Citation Nr: 21073326
Decision Date: 12/08/21	Archive Date: 12/08/21

DOCKET NO. 16-23 343
DATE:  December 8, 2021

REMANDED

Entitlement to service connection for a left hip disability, to include as secondary to service-connected disabilities, is remanded.

REASONS FOR REMAND

The Veteran had active military service from June 1973 to June 1985. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in October 2019. A transcript of that hearing has been associated with the record.

This case was previously before the Board, most recently in August 2021, and remanded for additional development. In an October 2021 rating decision, the RO granted entitlement to service connection for lumbar spine fusion L4-5 with L2-3 retrolithiasis residuals and degenerative disc disease (DDD) ("back disability"). This constitutes a full grant of the benefit previously sought on appeal and hence, the matter is no longer in appellate status. The issue currently on appeal has been returned to the Board for further appellate action.

The Veteran has contended that his left hip disability is related to his active service, or alternatively, secondary to service-connected disabilities. He was diagnosed with left trochanteric bursitis/pain syndrome. The Veteran was last afforded a VA examination in April 2021. However, the examiner found that the Veteran did not have a left hip disability. The examiner stated that the Veteran's left hip complaints were solely related to his service-connected back disability and sciatic radiculopathy.

The Board finds that the April 2021 VA medical opinion is inadequate for adjudication purposes. In this regard, the examiner did not address whether the Veteran's left trochanteric bursitis/pain syndrome was caused or aggravated by the Veteran's service-connected back disability and/or left lower extremity radiculopathy. As the precise etiology of the Veteran's left hip disability remains unclear, the Board finds that an additional VA examination is warranted. 

The matter is REMANDED for the following action:

1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 

2. Then, schedule the Veteran for an examination to determine the nature and etiology of any currently present left hip disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. 

Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present left hip disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. 

Additionally, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present left hip disability was caused or aggravated (chronically worsened) by the Veteran's service-connected left ankle instability, back disability, and/or left lower extremity radiculopathy, to specifically include any altered gait and/or body mechanics resulting from such. 

The rationale for all opinions expressed must be provided. 

3. Confirm that the VA examination report and all medical opinions provided comport with this remand and undertake any other development determined to be warranted.

4. Then, readjudicate the appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board.

 

 

Kristin Haddock

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Ware, 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.