Citation Nr: 21071565 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 14-28 108 DATE: November 30, 2021 REMANDED Entitlement to service connection for a right hip disability, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for tremors, to include as secondary to service-connected acquired psychiatric disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1972 to July 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The issues were last before the Board in December 2020. The Board remanded the issues on appeal for addendum medical opinions. However, as discussed below, the Board finds that remand is necessary for further development. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the Board's prior December 2020 decision, the Board also addressed and granted the issue of entitlement to service connection for an acquired psychiatric disability. As such, the decision represents a full grant of the benefit sought and the issue is no longer on appeal. Entitlement to service connection for a right hip disability, to include as secondary to service-connected right knee disability is remanded. The Veteran seeks service connection for a right hip disability. See April 2008 VA 21-526; December 2011 statement in support of claim. The Veteran contends that his right hip disability is related to an in-service accident while moving furniture and a motor vehicle accident. The Veteran was afforded VA examinations in May 2019 and August 2021. When VA undertakes to provide an examination in a service connection claim, it must ensure that the examination is adequate for decision-making purposes. See 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For a medical examination and opinion to be adequate, it must be: (1) based upon sufficient facts or data; (2) be the product of reliable principles and methods; and (3) be the result of principles and methods reliably applied to the facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). At the May 2019 VA examination, the Veteran reported he injured his right hip in 1982 while moving furniture in service and experience intermittent dislocation since that injury. See May 2019 VA examination. The VA examiner also acknowledged the Veteran's statement that he has had right hip pain since a motor vehicle accident in 1986 during service. Id. The VA examiner diagnosed the Veteran with osteoarthritis of the bilateral hips. Id. I The VA examiner opined that the Veteran's bilateral hip osteoarthritis is less likely than not incurred by the claimed in-service injury. Id. As rationale, the VA examiner noted the Veteran's service treatment records were silent as to any claims of a hip injury, that his right hip pain was only first documented almost 20 years after service, and that a finding of degenerative joint disease is appropriate for his age. Id. However, the Board, in its December 2020 decision, noted the Veteran's service treatment records include a diagnosis of pain in the right sacroiliac (SI) joint in November 1982 characterized as low back pain. The Board noted the Veteran's SI joint is considered a part of both the lower back and the hip. Additionally, the Board noted the Veteran's service treatment records include a July 1986 motor vehicle accident and a follow up treatment record that notes the Veteran suffered multiple strains and felt sore all over. See July 1986 service treatment records. As such, the Board remanded for an addendum medical opinion. The Veteran was afforded a second VA examination in August 2021. The VA examiner noted the Veteran's report of dislocating his right hip while in service. See August 2021 VA examination. The VA examiner opined that it was less likely than not that the Veteran's bilateral hip degenerative arthritis was incurred in or caused by an in-service injury, event, or illness. Id. As rationale, the VA examiner noted there was one record noting right SI joint pain; no other records available to show where Veteran continued to complain of or be treated for this condition while in service or immediately after separation; and there was no mention of hip pain within the records related to the in-service motor vehicle accident. Id. However, the VA examiner did not address the Veteran's statements regarding dislocating his right hip and experiencing pain since service resulting in an implication that the VA examiner rejected the Veteran's lay statements. The VA examiner did not provide a reason for rejecting the Veteran's lay statements as directed by the Board in its December 2020 remand directives. As such, remand is necessary to comply with the Board's prior remand directives. Stegall, 11 Vet. App. at 271. Additionally, the examiner should provide a rationale that is not based solely on the absence of complaints or findings of hip pain in the Veteran's service treatment records. The Board notes that it is required to consider all theories of entitlement to service connection. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004); Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (explaining that the Board must consider all potential theories of entitlement raised by the evidence.). The Veteran is currently service connected for a right knee strain. The Veteran, through his representative, contends that the Veteran's right hip condition is linked to his service-connected right knee disability. See October 2021 Appellate Brief. As such, remand is necessary in order to obtain an addendum medical opinion addressing secondary service connection. Entitlement to service connection for tremors, to include as secondary to service-connected acquired psychiatric disorder is remanded. The Veteran seeks service connection for tremors. See December 2011 statement in support of claim. In the December 2020, the Board previously remanded the issue of entitlement to service connection for tremors for a VA examination addressing whether it is at least as likely as not that the Veteran's tremors are secondary to his service-connected acquired psychiatric disability. The Veteran was initially afforded a VA examination in May 2019. However, the Board determined the May 2019 VA examination was insufficient for decision making purposes. As such, the Veteran was afforded a second VA examination in August 2021. The VA examiner noted the Veteran's report that his tremors began in 1987 while in service. See August 2021 VA examination. The VA examiner opined that the Veteran's bilateral hand tremors were less likely than not related to the Veteran's psychiatric disability. Id. As rationale, the VA examiner noted that tremors associated with psychiatric disorders have a sudden onset, mostly occur at rest, have short duration, and spontaneous remission of tremor. Id. The VA examiner noted the Veteran's tremor is located in his bilateral hands and are more chronic in nature. Id. The VA examiner also opined that it was less likely than not that the Veteran's tremors were aggravated beyond its natural progression by his psychiatric disorder. Id. As rationale, the VA examiner provided the same rationale provided for secondary causation. Id. The Board finds the August 2021 VA examination inadequate for decision making purposes. See Nieves-Rodriguez, 22 Vet. App. at 302. First, no VA examiner has adequately addressed whether it is at least as likely as not that the Veteran's tremors are etiologically related to an in-service event, injury, or disease. In that regard, neither the May 2019 nor August 2021 VA examiner addressed the Veteran's service treatment records noting the Veteran's report of withdrawal tremors in November 1988. See November 1988 service treatment records. Second, the VA examiner noted the Veteran's tremors are more consistent with essential tremor and involves tremor that emerges with action. Id. However, it is still unclear as to whether the Veteran's tremors were caused by, or aggravated by, his psychiatric disability. In that regard, private treatment records document the Veteran's treatment for a psychiatric disability and his reports of experiencing shakes. See February 2007, March 2007, April 2008, and December 2011 private treatment records. At an initial PTSD VA examination in June 2012, the VA examiner noted the Veteran had noticeable shakes. See June 2012 VA examination. Additionally, the VA examiner merely provided the same rationale for aggravation as provided for secondary causation. As such, the Board finds the August 2021 VA examination inadequate for decision making purposes and remand is necessary for additional development. See Nieves-Rodriguez, 22 Vet. App. at 302. Finally, the Veteran's representative cited to a study created by eHealthMe which noted tremors found among people with PTSD who take medication Seroquel and have depression and contends that the Veteran's chronic stress is responsible for conditions associated with tremors. See October 2021 Informal Hearing Presentation. On remand, the examiner should also address the eHealthMe study. The matters are REMANDED for the following action: 1. Forward the record and a copy of this Remand to the examiner who provided the August 2021 examination and medical opinion, or, if that examiner is unavailable, to another qualified clinician, for completion of an addendum opinion to determine the nature and etiology of the Veteran's right hip disability. If the examiner determines that another examination of the Veteran is necessary, such an examination should be scheduled. The examiner should address the following: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's right hip disability is etiologically related to an in-service injury, event, or disease, to include the November 1982 service treatment record documenting pain at the right SI joint, and the July 1986 service treatment record documenting the motor vehicle accident and assessment for "multiple strains." A complete rationale should be given for all opinions and conclusions expressed. The examiner must address and consider the Veteran's lay statements regarding experiencing intermittent hip dislocation and pain since injuring his hip in November1982 while moving furniture in service. If the examiner rejects the Veteran's lay statements, he or she must provide a reason for doing so. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's right hip disability is proximately due to, or the result of, the Veteran's service-connected right knee disability. (c.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's right hip disability is aggravated (worsened) by the Veteran's service-connected right knee disability. A complete rationale should be given for all opinions and conclusions expressed. If the opinion cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. 2. Forward the record and a copy of this Remand to the examiner who provided the August 2021 examination and medical opinion, or, if that examiner is unavailable, to another qualified clinician, for completion of an addendum opinion to determine the nature and etiology of the Veteran's tremors. If the examiner determines that another examination of the Veteran is necessary, such an examination should be scheduled. The examiner should address the following: (a.) Whether is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's tremors are etiologically related to an in-service event, injury, or disease. A complete rationale should be given for all opinions and conclusions expressed. The examiner must address the Veteran's November 1988 service treatment records noting the Veteran's report of withdrawal tremors. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's tremors are proximately due to, or the result of, the Veteran's service-connected acquired psychiatric disorder. (c.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's tremors are aggravated (worsened) by the Veteran's service-connected acquired psychiatric disorder. (Continued on the next page) A complete rationale should be given for all opinions and conclusions expressed. The examiner must consider and address the Veteran's private treatment records noting the Veteran's shakes during treatment for his acquired psychiatric disorder. In addition, the examiner should address the eHealthMe study concerning tremors found among people with PTSD (as discussed in the October 2021 Informal Hearing Presentation). If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Carlin 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.