Citation Nr: 21011566 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 16-00 941 DATE: March 2, 2021 REMANDED Entitlement to service connection for a left hip disability is remanded. REASONS FOR REMAND The Veteran served in the U.S. Marine Corps Reserves from May 1984 to April 1988 and in the U.S. Marine Corps from April 1988 to April 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by a VA Regional Office (RO). The Board previously remanded the Veteran’s claim for service connection in October 2018 to afford the Veteran a VA examination for his claimed left hip condition. A review of the claims file now shows that there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). However, as will be discussed in greater detail below, the Board finds that a further remand is warranted to properly develop the Veteran’s claims. Entitlement to service connection for a left hip disability is remanded. The Veteran contends his left hip disability began in service and that he has experienced symptoms including pain since service. Specifically, the Veteran asserts that he suffered injuries to his hip in March 1988 after a fall during a training exercise and again in October 1989 while playing football. The Veteran was afforded a VA examination in September 2019 for his claimed left hip disability. The examiner opined that the Veteran’s left hip disability was less likely than not incurred in or caused by service. Furthermore, the examiner opined that any back conditions did not cause or aggravate his left hip condition. The examiner noted that there were no reports of chronic hip pain in the Veteran’s separation examination. It was further noted that there was no report of hip pain until 2018, approximately 30 years after service. In addition, the examiner noted that X-rays of the Veteran’s hips in 2018 indicated “mild degenerative changes in bilateral hips”. He further reported that “this is not an unusual finding for someone that is 55 years of age”. Ultimately, the examiner explained that “if the left hip had been injured significantly, one would see worsening of the degeneration of the left hip as compared to the right on X-ray findings, but this is not the case”. On October 5, 2020, the Veteran’s representative submitted new VA medical evidence consisting of an MRI of the Veteran’s left hip conducted in September 2020. The Board notes that this evidence was not considered by the RO when it issued the August 2020 supplemental statement of the case continuing the denial of service connection for a left hip disability. However, this information was not available at that time and was therefore never considered by the September 2019 examiner. The MRI indicates degenerative left hip labral tearing with adjacent paralabral cyst formation and mild to moderate osteoarthrosis. This was not noted by the September 2019 examiner. In fact, the examiner noted the Veteran’s hips were basically the same with mild to moderate degenerative changes. The new evidence of record indicates a more severe condition in the left hip. The Veteran’s representative now contends this new evidence of labral tearing in the hip joint can be caused by acute injuries such as those sustained by the Veteran during service, as well as by degenerative osteoarthritis. In support of this contention, the Veteran’s representative referenced two medical articles. See Correspondence dated September 25, 2020. The Board notes, the September 2019 VA examiner did not have an opportunity to review the significance of the findings in the September 2020 MRI nor consider the referenced medical articles. As such, the Board finds an addendum medical opinion is required. 38 U.S.C. § 5103A(d)(1). See also Colvin v. Derwinski, 1 Vet. App. 171 (1991) (holding that the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment). In addition, at the time of the September 2019 VA examination, the Veteran was not service connected with a back condition. Nonetheless, the examiner provided a negative nexus opinion for a secondary theory of service connection for any back condition. After multiple addendum medical opinions in September 2019, the Veteran was eventually diagnosed and service-connected for degenerative disc disease (DDD) of the lumbar spine with a history of compression fractures by a rating decision dated in April 2020. The Veteran has since also been service-connected for bilateral lower extremity radiculopathy as secondary to his DDD. The Board notes, that no VA examiner has specifically considered the now service-connected condition of DDD of the lumbar spine with compression fractures and whether or not it caused or aggravated the Veteran’s left hip disability. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a claim is determined by the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). As such, the Board finds that a new VA addendum medical opinion is warranted to consider the new medical evidence now of record and to provide a direct and secondary opinion as to service connection for the Veteran’s claimed left hip disability. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records up to the present. 2. After completing the records development indicated above, obtain an addendum opinion by an appropriate clinician to identify and determine the nature and etiology of any left hip disability. The clinician is asked to address the following: (a.) Whether it is at least as likely as not (probability of 50 percent or better) that the Veteran's left hip disability had its onset in or is otherwise related to his active service. The examiner should specifically address the MRI conducted in September 2020 indicating a labral tear with adjacent paralabral cyst formation and mild to moderate osteoarthrosis. The examiner should also consider reports in the Veteran’s service treatment records (STRs) of injuries sustained to his left hip to include a fall from 8 feet during training exercises in March 1988 and a football injury sustained in October 1989. (b.) If not incurred in or otherwise due directly to service, whether it is at least as likely as not (probability of 50 percent or better) that the Veteran’s left hip disability was caused or aggravated (i.e., worsened beyond natural progression) by a service-connected disability, including degenerative disc disease (DDD) of the lumbar spine with arthritis and history of compression fractures. In determining whether his claimed conditions are aggravated by any service-connected disability, discuss a baseline level of severity of the claimed condition established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.