Citation Nr: 21065268 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 13-16 343 DATE: October 25, 2021 REMANDED Entitlement to an initial compensable rating for left hip degenerative joint disease with limitation of extension under 38 C.F.R. § 4.71a, Diagnostic Code 5251 is remanded. REASONS FOR REMAND The Veteran had active duty from October 1968 to October 1990. He served in the Republic of Vietnam and was awarded the Air Medal. Entitlement to an initial compensable rating for left hip degenerative joint disease with limitation of extension under 38 C.F.R. § 4.71a, Diagnostic Code 5251 is remanded. The report of a December 2020 hip examination conducted for the Department of Veterans Affairs (VA) states that the Veteran complained of progressively worsening left hip pain for which he saw a chiropractor. On examination of the left hip, the Veteran exhibited extension to 20 degrees with pain and crepitus. The examiner commented that: the noted pain "does not result in/cause functional loss;" the examination was not being conducted during a flare up, but was "medically consistent with the Veteran's statements describing functional loss during flare up;" pain "significantly limits functional ability with flare ups;" estimated extension during flare-ups was 0 to 20 degrees; left hip passive range of motion was the same as active range of motion;" and there was "no objective evidence of pain on passive range of motion testing." The doctor did not indicate the degree at which the Veteran experienced pain on extension of the left hip. In light of that deficiency and given the inconsistent findings as to the left hip functional impairment, the Board finds that the functional loss associated with the service connected left hip disability is unclear and the examination report is of limited probative value. In the October 2021 Appellant's Post Remand Brief, the accredited representative asserts that "the Veteran argues that his disability is more severe than as represented by VA in that VA did not discuss flares that are productive of near falls, and imbalance when ambulating and when standing, warranting a rating in excess of 0 percent." VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the cited deficiencies in the December 2020 VA examination report and the Veteran's contentions as to functional impairment associated with flare ups, the Board of Veterans' Appeals (Board) finds that further VA left hip evaluation is needed, Clinical documentation dated after December 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider, including any chiropractor, who treated him for the service connected left hip disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA clinical documentation not already of record, including treatment records dated after December 2020. 3. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of left hip degenerative joint disease. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight-bearing and nonweight-bearing and passive and active motion of the left hip. The examiner should specifically indicate the degree at which the Veteran experiences pain on motion of the left hip. (b) State whether there is any additional loss of function of the left hip, due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.