Citation Nr: 21009886 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 11-05 746 DATE: February 23, 2021 REMANDED Service connection for a joint or orthopedic disability of the right leg is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1977 to July 1981 in the United States Army, with additional National Guard service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Offices (ROs). 1. Service connection for a joint or orthopedic disability of the right leg is remanded. Under 38 C.F.R. § 19.31, the VA Regional Office will provide a supplemental statement of the case (SSOC) to the appellant when there are any material changes in or additions to the information included in the SOC or any prior SSOC, to include receipt of additional pertinent evidence. In December 2020, the Board sent the Veteran a letter asking him whether he waived his right to have the case remanded to the VA Regional Office (RO) for the initial review of pertinent evidence associated with the claims file by VA since the RO’s last readjudication of the claim. The Veteran and his attorney were advised that the Board would remand the appeal if a response was not received within 45 days. As such, no response was received, the Board must proceed with the remand. Additionally, in July 2018, the Board remanded the claim for further development. The Board noted that current degenerative arthritis of the right knee was shown on x-ray in February 2015, and service treatment records documented a May 1981 injury to the right leg. The Board sought a VA medical opinion addressing both direct service connection, and also whether the current right leg disability is secondary to the already-service connected right leg muscle disability or disability of the lumbar spine. A VA examination was conducted in May 2019, but the examiner limited his opinion to current right hip arthritis, without mention of the current right knee disability. He additionally failed to address the matter of whether the service-connected right leg muscle disability has aggravated the current right leg disability. As such, the Board cannot find there has been substantial compliance with the remand directives, and a further opinion must be obtained. Stegall v. West, 11 Vet. App. 268 (1998). Additionally, as the Veteran has since been awarded service-connection for a neurological disability affecting the right leg, the examiner should address this disability as well in rendering the requested opinions. The matters are REMANDED for the following action: 1. Provide the Veteran's electronic claims file to the May 2019 VA examiner, or if not available, to another appropriately qualified examiner, for an addendum opinion. Unless determined otherwise by the VA examiner, an actual examination of the Veteran is not required. The examiner is advised that in addition to the right hip arthritis documented on VA examination in May 2019, the Veteran was diagnosed with degenerative arthritis of the right knee on x-ray in 2015. Please address both disabilities in responding to the questions below. (a.) Is it at least as likely as not that any joint or orthopedic disability of the right leg (including right knee arthritis and right hip arthritis) is related to an in-service injury, event, or disease, including the May 1981 injury to the right leg? Why do you say so? (b.) Is it at least as likely as not that any joint or orthopedic disability of the right leg (including right knee arthritis and right hip arthritis) is: (i.) proximately due to any service-connected disability (including the right leg muscle disability, radiculopathy of the right leg, and/or lumbar spine disability), or (ii.) aggravated beyond its natural progression by any of these service-connected disabilities (including the right leg muscle disability, radiculopathy of the right leg, and/or lumbar spine disability? Why do you say so? Please address each of the service-connected disabilities in rendering these opinions. 2. Thereafter, readjudicate the appeal, considering all evidence added to the claims file since the June 2020 Supplemental Statement of the Case. If service connection is granted, the RO must consider the amputation rule set forth at 38 C.F.R. § 4.68 and the provisions in 4.55 in assigning any rating. If the benefit sought is not granted, provide the Veteran and his representative with an updated Supplemental Statement of the Case. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.