Citation Nr: 21071126 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 18-20 058 DATE: November 29, 2021 REMANDED Entitlement to service connection for right leg condition is remanded. Entitlement to a rating in excess of 10 percent for traumatic arthritis, right hip painful motion is remanded. Entitlement to a compensable rating for traumatic arthritis, right hip limitation of flexion is remanded. REASONS FOR REMAND The Veteran served in the Army National Guard from January 2005 to June 2008. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. 1. Entitlement to service connection for right leg condition is remanded. The Veteran contends she has a right leg condition that is related to service. An April 2016 VA examination shows the Veteran is diagnosed with degenerative arthritis of the right leg. The examiner stated that the Veteran reports some pain in the right leg which is attributable in part to the right hip condition. Additionally, the examiner stated while there is evidence on radiographic studies of degenerative arthritis in the right knee, the Veteran denies pain in that knee and review of service treatment records (STRs) in VBMS does not reveal any evaluation or treatment for a right knee condition during active service. The examiner opined it is less likely than not that the Veteran's right leg pain is incurred in or caused by an event or injury in service. The Board notes the Veteran is service connected for a right hip condition. The examiner did not opine on whether the Veteran's right leg condition was caused or aggravated by her right hip condition. The Veteran's reserve STRs include a report noting the Veteran fell during a drill in April 2008 and the following day, during a second day of drill, reported her leg was hurting and she was taken to see a physician. An April 2008 statement of medical examination and duty status indicated the Veteran was injured in the line of duty. The Veteran's April 2008 Medical Eligibility Verification notes the Veteran fell at drill on her right hip. A February 2013 physician note indicates the Veteran complained of right legged numbness. At the July 2021 Board hearing, the Veteran stated during drill she slipped and fell on her right side. She stated that she has been having a lot of pain that disables her from working and sleeping, and she walks with a cane. The Veteran also stated, "I strongly believe they're all intertwined because falling on one side, hitting your hip, I mean, these are joints, they're all together, they're all connected, including my back." The Veteran has not been afforded a VA examination to determine whether her right leg is caused by or aggravated by any service-connected conditions. In addition, the April 2016 VA examiner did not address the Veteran's reserve line of duty injury where she complained of leg pain. The claim must be remanded so that a VA examiner can opine on whether it is at least as likely as not that a right leg condition is a manifestation of or etiologically related to her military service, to include secondary to a service-connected condition. 2. Entitlement to an initial rating in excess of 10 percent for traumatic arthritis, right hip painful motion is remanded. 3. Entitlement to a compensable rating for traumatic arthritis, right hip limitation of flexion is remanded. At the Veteran's July 2021 Board hearing, the Veteran stated that due to her hip pain she cannot cross her leg and has to put both legs down because it is very hard to do that. She also stated she uses a cane when walking, suffers constant pain every day and cannot get to her activities. The record reflects that the Veteran's most recent VA examination for her increased rating claims was in February 2017, which was more than four years ago. The Board finds that there is insufficient evidence of record to evaluate the Veteran's disabilities for the entire appeal period. Thus, an updated VA examination is needed to fully and fairly evaluate the Veteran's claims for increased disability ratings. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal the current state of claimant's disability, fulfillment of statutory duty to assist requires a contemporaneous medical examination). The matters are REMANDED for the following action: 1. Obtain all VA treatment records not currently associated with the claims file. 2. Schedule an examination to evaluate the Veteran's claimed right leg/knee condition After a review of the claims file, the examiner should opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability): the Veteran's right leg/knee condition had an onset during service, or was causally or etiologically due to service, to include the documented line of duty injury in April 2008 during drills; or, that the Veteran's right leg/knee condition, is caused or aggravated (beyond a natural progression) by her service-connected right hip condition. In formulating an opinion, the examiner should specifically consider and address: (1) the Veteran's July 2021 hearing testimony that she believes "they're all intertwined because falling on one side, hitting your hip, I mean, these are joints, they're all together, they're all connected." A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Schedule a new examination to evaluate the current severity of the Veteran's right hip condition. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail, including ranges of motion of the hips and the degree at which pain begins (i.e., 0 to 130 degrees with pain at 115 degrees). Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion testing for pain on BOTH active and passive motion AND in weight-bearing and non-weight-bearing. If the hips cannot be tested on "weight-bearing," then the examiner must specifically indicate that such testing cannot be done. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. Regarding flare-ups (pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017), if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding her flares, the examiner is requested to provide an estimate of the Veteran's functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Daley, Associate Counsel 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.