Citation Nr: 21072079 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 12-21 893 DATE: December 2, 2021 ORDER Entitlement to service connection for a left buttock shrapnel wound is denied. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) (except for a period when a temporary total rating was in effect) is denied. REMANDED Entitlement to service connection for a bilateral hand disability, other than left hand scars, to include arthritis, is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for bilateral neurological disabilities of the lower extremities, to include sciatica, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a current disability of the left buttock, to include any residuals of an in-service shrapnel wound such as a muscle injury or a scar. 2. The Veteran's PTSD has resulted in occupational and social impairment with reduced reliability and productivity; but has not resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; and has not resulted in total occupational and social impairment CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left buttock shrapnel wound have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to February 1971; he is the recipient of the Combat Action Ribbon, Purple Heart, and Vietnam Cross of Gallantry medal related to his service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2009 and May 2011 rating decisions issued by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). The Veteran was scheduled for a Board hearing with a Veterans Law Judge in October 2021, but he did not appear as scheduled. He has not provided any good cause for his absence. Therefore, the Board considers the request for a hearing withdrawn. 38 C.F.R. § 20.603(d). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Entitlement to service connection for left buttock shrapnel wound The Veteran is currently service connected for residual scarring of the right buttock due to a shrapnel wound. An August 1969 service treatment record (STR) indicates wound cleaning of the buttocks, implying that the left side was also injured. The Veteran contends that he is entitled to service connection for residuals of a left buttock shrapnel wound. The Veteran attended an April 2001 examination for scars which found multiple scars, to include on the right buttock. An October 2013 VA examination only identified two shrapnel injuries on the left palm and the right thigh, however, the examiner did not address whether there was residual scarring of the left buttock. The Board remanded this appeal for a new VA examination to clarify whether the Veteran had a disability of the left buttock. The Veteran attended May 2019 scars and muscle injury VA examinations. The examiner did not find any discernable scar of the left buttock and did not find any signs or symptoms to support a diagnosis of a muscle injury to the left buttock. The examiner noted the in-service incident and treatment for shrapnel injury to the buttocks in service, but stated that the claimed condition was less likely than not related to service because there is no current condition. During the pendency of the claim, no VA examiner has identified a current left buttock disability, to include a muscle injury or scar. The Veteran's medical records do not indicate any treatment for a left buttock condition during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As the Veteran has no current disability of the left buttock, the Veteran is not entitled to service connection for a left buttock disability. The preponderance of the evidence is against a grant of service connection; there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Entitlement to a rating in excess of 50 percent for PTSD (except for a period when a temporary total rating was in effect) The Veteran's PTSD is currently rated at 50 percent disabling. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran had a temporary 100 percent rating from August 26, 2009, to October 31, 2009. The Veteran contends he is entitled to a higher rating. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Veteran's PTSD has resulted in occupational and social impairment with reduced reliability and productivity. However, it has not resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or in total occupational and social impairment. Therefore, the Veteran's PTSD most closely approximates the criteria for a 50 percent evaluation for the period on appeal. The Veteran attended a VA examination in April 2009 to establish service connection for PTSD. The examiner stated the Veteran was alert and oriented, with stable affect but with a decrease in range and intensity. His thought process was normal with no delusions, hallucinations, obsessive-compulsive tendencies, or suicidal or homicidal ideation. The examiner identified symptoms of PTSD to include sleep disturbances, nightmares, flashbacks, and irritability. The Veteran reported he recently renovated a building for his wife and son, who plan to operate a deli and pizza shop. The examiner found the Veteran had severe to moderate occupational and social functioning. The examiner noted the Veteran worked as a pipe fitter, which he was able to do as long as he worked alone, but the Veteran reported he had been fired or quit jobs in the past. The examiner stated that the Veteran would have more difficulty if he had an occupation where he had to work with more people on a regular basis. The Veteran attended a VA examination in August 2009 with the same examiner. The examiner stated the Veteran was alert and oriented, with stable affect but with a decrease in range and intensity. His thought process was normal with no delusions, hallucinations, obsessive-compulsive tendencies, or suicidal or homicidal ideation. The examiner identified symptoms of PTSD such as sleep disturbances, nightmares, flashbacks, hypervigilance, and irritability. The examiner stated he believed the Veteran would have a difficult time returning to competitive employment. Shortly after this examination, the Veteran entered in-patient treatment for his PTSD, during which time he is in receipt of a 100 percent rating. On discharge, the doctor noted symptoms of isolation, anger, and alcohol abuse. The doctor reported no suicidal thoughts throughout the hospitalization and moderate progress in the program. The Veteran was then incarcerated from May 2010 to May 2013. The Veteran attended a VA examination in May 2019. The recent history indicated the Veteran was married and resided with his wife, but he reported no socialization outside the home. The Veteran continued to receive treatment at a VA medical center and there were no recent suicide attempts or psychiatric hospitalizations. The Veteran reported no work or school since the last examination. The examiner identified symptoms of PTSD to include anxiety, depression, panic attacks, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory, or stereotyped speech, disturbances of motivation and mood, and difficulty in maintaining and establishing effective work and social relationships. The examiner found the Veteran had occupational and social impairment with reduced reliability and productivity. Throughout the period on appeal, other than during his incarceration, the Veteran has had consistent treatment at a VA medical center for his PTSD. The Veteran has consistently denied suicidal thoughts and hallucinations or delusions. Mental status examinations generally show logical thought process, normal thought content, good judgement, and insight. His treatment records indicate continued symptoms of sleep difficulty and hypervigilance, especially in social settings. However, several treatment notes indicate that he goes to, and volunteers at, church and has been busy with projects in the home setting. While he is retired, he reported that he owns a deli and helps his wife out there. The Veteran applied for Social Security Administration (SSA) disability benefits in 2008. His application stated that his physical impairments were the primary impairments that prevented him from working. When asked if he had ever been fired or laid off from a job because of problems getting along with other people, he responded "no." He was awarded disability based on a primary diagnosis of osteoarthritis and secondary diagnosis of discogenic and degenerate disorder of the back. The Veteran submitted an independent medical provider disability benefits questionnaire (DBQ) by Dr. C. in January 2014. The doctor found that the Veteran had total occupational and social impairment. The examiner identified symptoms of depression, anxiety, suspiciousness, chronic sleep impairment, flattened effect, impaired judgement, disturbances of motivation and mood, difficulty adapting to stressful circumstances, including a worklike setting, and inability to establish and maintain effective relationships. The Veteran submitted an additional independent medical provider opinion from Dr. A. in October 2016. The doctor examined the Veteran and the mental status examination showed fair concentration, short attention span, increased psychomotor activity, hesitant, but coherent speech patterns, judgment and insight normal, and affect in normal limits. The Veteran reported that he began feeling depressed when he got back from Vietnam and started feeling like killing himself years ago. He further stated that last winter he felt like killing himself, however, he denied any intent or plan at the time of the assessment. The examiner identified symptoms of PTSD to include flashbacks, insomnia, anxiety, irritability, and anger. The examiner noted the Veteran reported he left employment due to PTSD symptoms. The doctor stated that the Veteran was unemployable and had impairments in excess of his 50 percent rating. The Veteran submitted two DBQs and a check-box form indicating levels of impairment, all prepared by Dr. A. The DBQ box for suicidal ideation was checked on one form, but it was not checked on the second DBQ form. The examiner also indicated marked difficulty relating to co-workers, dealing with the public, maintaining attention and concentration, understanding and carrying out complex job instructions, and marked difficulty in the Veteran's ability to complete a normal workweek. The Board finds the Veteran's treatment records the most probative evidence of record. The Veteran's consistent history of mental health treatment and treatment records throughout the period on appeal provide the most complete picture of the Veteran's symptoms and level of functioning. This evidence is more probative than the one-time examination by an independent medical provider or VA examiner, as it documents the Veteran's symptoms over a long period of time and contains numerous mental status examination and contemporaneous descriptions of activities and levels of impairment. In addition, the Board notes that the 2009 VA examiner and the independent medical examiner Dr. A indicated that the Veteran reported he stopped working due to his PTSD symptoms. However, this is contradicted by his application for SSA benefits, which stated that his primary reason for being unable to work was his physical impairments. In addition, the 2009 VA examiner stated that the Veteran had been fired from jobs or had left jobs due to his social impairment; however, this is also contradicted by the Veteran's application for SSA benefits. Therefore, the Board finds the 2009 VA examiner's opinion and the independent medical providers opinions less probative as to the Veteran's total occupational and social functioning. Although the Board finds them less probative, it has still considered the independent provider and VA examiner opinions in evaluating the Veteran's level of functioning. While the independent medical providers stated that the Veteran had total occupational and social impairment or marked functioning, the symptoms identified by the independent medical providers are not symptoms typically indicative of this level of functioning. In addition, these reports are inconsistent with the Veteran's treatment records, which while they show difficulty in social and occupational functioning, do not support total impairment. The Veteran's treatment records indicate symptoms and a level of functioning consistent with the 50 percent rating. The Veteran has consistently endorsed symptoms such as disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, as well as symptoms listed in the 30 percent criteria, such as chronic sleep impairment, depressed mood, anxiety, and suspiciousness. The treatment records show that while the Veteran does have difficulty with occupational and social functioning, he is married, attends church, and assists his wife at their deli. The Board acknowledges the Veteran's reports of past suicidal ideation in the narrative report from Dr. A. The Veteran reported that he began feeling depressed when he got back from Vietnam and started feeling like killing himself years ago. In addition, he stated that last winter he felt like killing himself. The Board has considered this narrative report and acknowledges suicidal ideation during the period on appeal. However, as outlined above, the Veteran has consistently denied suicidal ideation during his many years of VA medical treatment visits, and he did not report suicidal ideation to either VA examiner. The Veteran's significant history of mental health treatment where he denies suicidal ideation is more probative of the frequency and duration of this symptom than a single report to an independent medical evaluator. As such, considering the evidence of record as a whole, the Board finds that the frequency and duration of the Veteran's suicidal ideation to be low. While the Veteran has presented with some symptoms described in the criteria for 70 percent disability rating, namely suicidal ideation as reported in his history to Dr. A, his symptoms have not caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. Although he has reported some difficulties at work and with relationships with his family, he is married, attends church, and has reported assisting his wife at their deli. In addition, his treatment records consistently indicate intact thought process and content, and no hallucinations or delusions. After a thorough review of the evidence, although the symptoms associated with the Veteran's service-connected PTSD have fluctuated in severity to some degree through the appeal period, they most closely parallel the type of symptoms described in the criteria for the 50 percent disability rating. The Veteran has exhibited occupational and social impairment with reduced reliability and productivity as a result of symptoms such as nightmares, difficulty sleeping, anxiety, irritability, and disturbances of mood. 38 C.F.R. § 4.130, Diagnostic Code 9411. Considering the Veteran's record as a whole, his symptoms have not caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as discussed in detail above. A higher rating of 100 percent is not warranted, as the Veteran did not have symptoms or overall impairment more closely approximating the criteria for a 100 percent rating. The Veteran is married and has some relationships and interactions with his family. In addition, he reported attending church and helping his wife at the deli that they own. Therefore, the record does not show total occupational and social impairment, as required for the 100 percent schedular rating. Based on the foregoing evidence, the Veteran's PTSD most closely approximates the criteria for a 50 percent rating for the entire period on appeal. The preponderance of the evidence is against the assignment of a rating in excess of 50 percent. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral hand disability, other than left hand scars, to include arthritis, is remanded. The Veteran contends he has a bilateral hand disability, to include arthritis. He contends this is related to service, to include as a result of shrapnel wounds sustained during service. The Veteran attended an October 2013 hand and finger VA examination. The examiner found a diagnosis of polyarthropathy of the bilateral hands. At the examination, the Veteran reported bilateral hand stiffness over the past several years, most prominently in the morning. However, the VA examiner did not offer an opinion as to whether the Veteran's hand condition was related to service. The Board remanded in August 2018 for a new VA examination and opinion. The Veteran attended a May 2019 hand and finger VA examination. The examiner identified a diagnosis of left hand synovitis, but he did not identify a right hand condition. The examiner found that the Veteran's left hand synovitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, the examiner did not provide any rationale for the differing diagnosis to the October 2013 VA examination. The "current disability" required for service connection includes a disability at the time of filing or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Bilateral polyarthropathy was diagnosed during the pendency of this claim, and the May 2019 VA examiner did not address the discrepancy in the diagnosis, specifically, if the Veteran ever had a right hand disability during the pendency of the claim. Therefore, the Board finds that this opinion is inadequate a new VA opinion is required to determine whether any diagnosis the Veteran had during the pendency of the claim, to include polyarthropathy of the bilateral hands, is related to service. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for a right knee disability is remanded. In the December 2009 claim, the Veteran alleged that he has arthritis of the right knee that was "likely caused by the traumatic wounds" incurred during combat. He also alleged that his right knee could be related to a knee injury sustained during his service in Vietnam. The Veteran attended an October 2013 VA examination, but no service connection opinion was provided at that time. The Board remanded the claim in August 2018 for an opinion on whether the Veteran's right knee disability was related to his in service right knee injury. The August 2018 remand noted an in-service injury documented in the Veteran's service treatment records (STRs) and post-service VA treatment records from January 2009 that show the Veteran reported he had right knee discomfort for greater than 30 years. In addition, the Board notes that the December 2008 VA treatment record states that the Veteran gave a history strongly suggestive of a meniscal tear in his right knee many years ago that had led to noticeable degenerative changes. The Veteran attended a May 2019 VA examination. The examiner found the Veteran had a diagnosis of knee arthritis, but found that this was less likely than not incurred in or caused by the claimed in-service injury. The examiner discussed the in-service injury for a right knee abscess, which he acknowledged untreated can affect a local joint, but stated that there was no indication that this occurred. He stated that an uncomplicated skin infection would not have contributed to arthritic changes to the joint found 40 years later. However, the examiner did not discuss the Veteran's reports to a medical care provider that he had had knee pain for 30 years. In addition, he did not discuss the medical record stating that the history the Veteran provided was strongly suggestive of a meniscal tear many years ago, which has led to noticeable degenerative changes. Therefore, the Board finds that this opinion is inadequate and that a new medical opinion must be obtained on remand. See Barr, 21 Vet. App. 303. 3. Entitlement to service connection for a right hip disability is remanded. The Veteran claims he developed a right hip condition as a result of carrying heavy equipment while out in the field. See December 2009 claim. He also alleges that his right hip condition had onset as a result of his right knee and low back conditions, for which service connection is also claimed. The Veteran attended an October 2013 VA examination, but no opinion was provided. The examiner found that the Veteran had a right hip sprain and strain, which were temporally related to right knee pain and have been slowly progressive since onset in 1990. In August 2018, the Board remanded this appeal for direct and secondary service connection opinions. The Veteran attended a May 2019 VA examination. The examiner found that the Veteran did not have a current right hip disability. However, the examiner found the Veteran had abnormal range of motion for the right hip and did not provide and explanation to reconcile a reduced range of motion with no current disability. In addition, even if the Veteran did not have a diagnosis at the 2019 VA examination, he has had an identified right hip condition since he filed his compensation claim. The "current disability" required for service connection includes a disability at the time of filing or during the pendency of the claim. McClain, 21 Vet. App. 319. Therefore, the Board finds that this opinion is inadequate and that a new medical opinion must be obtained on remand. See Barr, 21 Vet. App. 303. 4. Entitlement to service connection for a back disability is remanded. In the December 2009 claim, the Veteran alleged that he had a back disorder that was caused by wear and tear sustained during service when he carried heavy equipment in the field. In a separate portion of the Veteran's claim, he alleged that his right knee exacerbated his low back disorder, raising a secondary theory of entitlement. The Veteran attended a VA examination in October 2013, but no opinion for service connection was given. Therefore, in August 2018, the Board remanded the claim for a VA examination and opinion and remanded the claim as intertwined with the claim of service connection for a right knee disability. The Veteran attended a May 2019 VA examination. The examiner found a diagnosis of degenerative arthritis of the lumbar spine, but he stated that this was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also found that the back disability was less likely than not due to or the result of the right knee arthritis, or aggravated beyond its normal progression by the right knee disability. The examiner stated that the right knee arthritis does not cause significant gait alteration, and in order for a knee condition to cause the level of degenerative changes and pain of the back the Veteran experiences, the knee condition would have had to cause alteration in gait. The examiner found that this alteration in gait was not observed for this Veteran. The examiner raised the issue of secondary service connection due to a hip condition, but did not offer an opinion as he found no current hip disability. However, the October 2013 VA examination showed that the Veteran had abnormal gait due to his knee and hip pain. The examination specifically showed a subtle antalgic gait favoring the right side. The May 2019 VA examiner did not address the notation of antalgic gait, which is significant as the rationale for the opinion is primarily based on finding no gait disturbance. Therefore, the Board finds that this opinion is inadequate and that a new medical opinion must be obtained on remand. See Barr, 21 Vet. App. 303. 5. Entitlement to service connection for bilateral neurological disabilities of the lower extremities, to include sciatica, is remanded. In his December 2009 claim, the Veteran reported that he had received a diagnosis of three ruptured discs in his back, which had caused pain to develop that would shoot down both legs. The Veteran's claim is inextricably intertwined with his claim of entitlement to service connection for a back disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Development undertaken for the Veteran's back will bear directly on the question of whether there is sciatica that is related to a service-connected disability present. Therefore, a decision on this matter is deferred pending development on the back claim. 6. Entitlement to a TDIU is remanded. The Board finds that the claim of entitlement to TDIU is inextricably intertwined with the claims for service connection for a back, hip, and knee disabilities. All issues "inextricably intertwined" with the issues certified for appeal are to be identified and developed prior to appellate review. Harris, 1 Vet. App. 180. The issue of entitlement to TDIU is intertwined with the service connection claims because a decision on the latter claims may have an impact on the former claim. Thus, the claim of entitlement to TDIU must be remanded for the appropriate development, as well as contemporaneous adjudication. Id. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a VA examiner regarding the nature and etiology of the Veteran's hand condition. The claims file, including a copy of this Remand, must be made available to the examiner for review. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the record, the examiner is asked to provide a response to the following (each opinion must be supported by rationale): (a.) Identify any hand conditions diagnosed during the pendency of the claim. The examiner should specifically address the October 2013 VA examiner's diagnosis of polyarthropathy of the bilateral hands. (b.) For each hand condition diagnosed during the pendency of the claim, is it at least as likely as not (a 50 percent or greater probability) that the disorder onset in, or is otherwise related to, service, to include the Veteran's verified combat and shrapnel injuries sustained to the upper extremities? 2. Obtain an addendum opinion from a VA examiner regarding the nature and etiology of the Veteran's right knee condition. The claims file, including a copy of this Remand, must be made available to the examiner for review. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the record, the examiner is asked to provide a response to the following (each opinion must be supported by rationale): (a.) Is the Veteran's knee condition at least as likely as not (a 50 percent or greater probability) related to service, to include the Veteran's verified combat and shrapnel injuries sustained to the right lower extremity? The examiner must address the Veteran's reports to a medical care provider in January 2009 that he had had knee pain for 30 years, as well as a December 2008 medical record stating that the history the Veteran provided was strongly suggestive of a meniscal tear many years ago, which has led to noticeable degenerative changes 3. Obtain an addendum opinion from a VA examiner regarding the nature and etiology of the Veteran's hip condition. The claims file, including a copy of this Remand, must be made available to the examiner for review. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the record, the examiner is asked to provide a response to the following (each opinion must be supported by rationale): (a.) Identify any hip condition diagnosed during the pendency of the claim. The examiner should address the October 2013 VA examination, which found that the Veteran had a right hip sprain and strain. In addition, the examiner should also address the abnormal range of motion found on the May 2019 VA examination. If no current disability is found, the examiner should provide an explanation for the abnormal range of motion to reconcile this finding with no current disability. (b.) For each hip condition diagnosed during the pendency of the claim, is it at least as likely as not (a 50 percent or greater probability) that the disorder had onset in, or is related to, service? he examiner must specifically address the Veteran's assertions of an in-service wear and tear on his right hip due to carrying heavy objects while out in the field. (c.) For each hip condition diagnosed during the pendency of the claim, is it at least as likely as not caused by his right knee condition? (d.) For each hip condition diagnosed during the pendency of the claim, is it at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his right knee condition? (e.) For each hip condition diagnosed during the pendency of the claim, is it at least as likely as not caused by his back condition? (f.) For each hip condition diagnosed during the pendency of the claim, is it at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his back condition? 4. Obtain an addendum opinion from a VA examiner regarding the nature and etiology of the Veteran's back condition. The claims file, including a copy of this Remand, must be made available to the examiner for review. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the record, the examiner is asked to provide a response to the following (each opinion must be supported by rationale). The examiner should address the October 2013 VA examination that showed that the Veteran had abnormal gait due to his knee and hip pain. (a.) Is the Veteran's back condition at least as likely as not (a 50 percent or greater probability) caused by his right knee condition? (b.) Is the Veteran's back condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his right knee condition? (c.) Is the Veteran's back condition at least as likely as not (a 50 percent or greater probability) caused by his right hip condition? (Continued on the next page) (d.) Is the Veteran's back condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his right hip condition? Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Patrick, 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.