Citation Nr: 21066431 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 09-04 436 DATE: November 1, 2021 REMANDED The issue of service connection for a left ankle disability is remanded. The issue of service connection for a bilateral hip disability is remanded. The issue of a total disability rating due to individual unemployment (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1964 to December 1965. This case comes before the Board of Veterans' Appeals (Board) from a December 2016 rating decision from a Department of Veterans Affairs (VA) regional office (RO). This case was remanded in May 2021 for additional development. A supplemental statement of the case was issued in August 2021. It is now before the Board. 1. The issue of service connection for a left ankle disability is remanded. 2. The issue of service connection for a bilateral hip disability is remanded. 3. The issue of a TDIU is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR: In May 2021, the Board remanded the above issues for additional development. Specifically, the RO was ordered to obtain new examinations and nexus opinions on whether the Veteran's alleged left ankle disability and bilateral hip disabilities were related to his active service. The Board directed that the Veteran's symptoms and reported history must be considered; and "[i]f the medical professional [providing the opinions] rejects the Veteran's reports, he or she must provide an explanation for such rejection." The examiners' opinions obtained by the RO on both the left ankle disability and the bilateral hip disability do not address the Veteran's statements about the history of the condition and only provide a rationale based on medical records. No explanation is provided for why the Veteran's statements were not considered in forming the nexus opinions. Therefore, substantial compliance with the remand order was not achieved and a remand is necessary to obtain addendum opinions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of entitlement to a TDIU is inexplicably intertwined with the issues of service connection. Since a TDIU would be based on all service-connected disabilities, adjudicating the TDIU prior to determining whether the claimed disabilities of the left ankle and bilateral hips are service connected would be judicially inefficient. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, the issue of entitlement to a TDIU must be remanded with the claims for service connection. THE REMAND DIRECTIVES FOLLOW. 2. Return the claims file to the July 2021 VA clinician who provided an opinion on the Veteran's left ankle disability, and request s/he again review the entire claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriately-qualified VA examiner to provide an addendum medical opinion to determine the etiology of the Veteran's left ankle disability. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must provide an opinion as to whether the Veteran's degenerative arthritis of the left ankle is related to his active service, to include multiple falls. The examiner's opinion MUST specifically address the Veteran's lay statements regarding the timing and severity of his symptoms. The examiner must address if the Veteran's account of sustaining any current left ankle disability is consistent with medical knowledge and the evidence. THE EXAMINER MUST REVIEW THE ENTIRE RECORD INCLUDING: A January 1964 service treatment record (STR) for a fall sustained in service. An April 1965 STR for a fall sustained in service. An April 1994 VA examination report noting weakness in the left ankle. A November 2020 Compensation and Pension (C&P) Examination report in which the Veteran stated he fell three times in service and hurt his ankle, resulted in swelling and pain, and required the use of a brace and medication for pain. An August 2018 VA treatment record noting ankle pain. An October 2018 VA treatment record noting ankle pain. A July 2021 C&P Examination report in which the Veteran stated his ankle injury began with a fall in service, required using a bandaged for a long time, and continued to cause pain. 3. Return the claims file to the July 2021 VA clinician who provided an opinion on the Veteran's bilateral hip disabilities, and request s/he again review the entire claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriately-qualified VA examiner to provide an addendum medical opinion to assist in determining the etiology of the Veteran's bilateral hip disabilities. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must provide an opinion as to whether the Veteran's bilateral hip disabilities are related to his active service, to include multiple falls. The examiner's opinion MUST specifically address the Veteran's lay statements regarding the timing and severity of his symptoms. The examiner must address if the Veteran's account of sustaining any current left ankle disability is consistent with medical knowledge and the evidence. THE EXAMINER MUST REVIEW THE ENTIRE RECORD INCLUDING: A January 1964 service treatment record (STR) for a fall sustained in service. An April 1965 STR for a fall sustained in service. An October 1992 Social Security Administration (SSA) record noting an MRI of the back and hips suggestive of muscle spasms. A July 1993 SSA record where the Veteran states he has suffered lower-back pain since 1983. A June 2002 VA records noting worsening left hip pain. June 2003 hearing testimony where the Veteran states he had tremendous back pain and received an injection in the hip. A September 2005 VA treatment record noting left hip pain radiating to the left leg. A July 2021 C&P examination report in which the Veteran reports his hip pain began after falls in service and it has continued since. 4. Thereafter, readjudicate the issues on appeal. If the determinations remain unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Reed, Counsel The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.