Citation Nr: 21013521 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 14-39 300 DATE: March 9, 2021 REMANDED 1. Entitlement to service connection for left hip arthritis is remanded. 2. Entitlement to service connection for right knee arthritis is remanded. 3. Entitlement to service connection for left knee arthritis is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from August 1966 to April 1969. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision. In October 2017, a Travel Board hearing was held before the undersigned; a transcript is in the record. In March 2018 and May 2020, the case was remanded for further development. [The May 2020 Board decision also remanded the matter of service connection for degenerative arthritis of the spine. A November 2020 rating decision granted service connection for degenerative arthritis of the spine, rated 20 percent rating effective April 5, 2010, and 40 percent effective October 18, 2020. Accordingly, that matter is no longer before the Board.] 1., 2., 3. Entitlement to service connection for degenerative arthritis of the left hip and right and left knees. The Board regrets the further delay inherent with another remand, but, finds that the May 2020 remand instructions were not adequately fulfilled. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran claims that his left hip and bilateral knee disabilities are related to his service, to include as secondary to his service-connected left ankle disability or to his recently service-connected back disability. He has also established service connection for diabetes with peripheral neuropathy of both upper and lower extremities. On October 2020 VA hip examination, the examiner opined that the Veteran’s left hip disability was less likely than not related to an incident in service or caused or aggravated by a service-connected disability. He explained that the Veteran had a well-documented history of left hip arthritis status-post arthroplasty as noted in the medical records; however, there were no active duty service treatment records (STRs) that indicate a relationship between his left hip disability and peripheral neuropathy and/or a healed left foot fracture. The examiner also noted that low back disabilities technically do not alter hip mechanics so significantly as to require a hip arthroplasty. The opinion is inadequate because the rationale was cursory and did not address aggravation, or identify an alternate etiology for the left hip disability. Therefore, remand for a fully adequate medical advisory opinion is necessary. On October 2020 VA knee examination, the examiner opined that the Veteran’s right and left knee disabilities are less likely than not related to his service or caused or aggravated by a service-connected disability. The examiner noted that the Veteran reported that he started experiencing bilateral knee pains in Vietnam on carrying and lifting objects and prolonged walking on rugged terrain, and that after service he received treatment for his knees, to include a right knee replacement in 2007 and a left knee replacement in 2010. The examiner explained that there are no active duty STRs that indicated a relationship between the right and left knee disabilities and peripheral neuropathy and/or a healed left foot fracture. The examiner also noted that lower back disabilities technically do not alter knee mechanics so significantly as to require bilateral knee replacements. He also opined that the Veteran’s age was the predominant risk factor for his degenerative changes. The opinion is inadequate because the rationale was cursory and did not address aggravation, and an alternate etiology for the right and left knee disabilities was not clearly identified (that age was the predominant risk factor for development does not preclude that another factor may have contributed to caused or aggravated the disability). Therefore, remand to obtain a fully adequate medical advisory opinion regarding the etiology of the Veteran’s right and left knee disabilities is necessary. The matters are REMANDED for the following: Arrange for the Veteran’s record to be forwarded to an appropriate clinician (in orthopedics) to determine the nature and likely etiology of his left hip, and right and left knee disabilities. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should: (a) Identify (by diagnosis) each left hip, and right and left knee disability entity shown by the record. (b) Identify the likely etiology for each diagnosed left hip, and right and left knee disability entity diagnosed. Specifically, is it at least as likely as not (a 50 % or better probability) that each disability (i) is related directly to the Veteran’s service (was incurred therein), to include as due to a documented lifting injury therein and his reports of substantial heavy lifting (unloading, carrying and storing food supplies; lifting, carrying, and cleaning heavy pots and pans and food containers; etc.) or (ii) was caused or aggravated [the opinion must address aggravation] his service-connected left ankle, lower extremity peripheral neuropathy, and/or low back disabilities? (c) If a diagnosed left hip, right knee, and left knee disability is found to not be directly related to the Veteran’s service/injury therein, or to have been caused or aggravated by a service-connected disability, identify the etiology for the left hip, right knee, and left knee disability considered to be more likely, and explain why that is so. All opinions must include complete explanation of the rationale. The rationale should acknowledge that, in his occupation as a cook in service in service, the Veteran engaged in substantial heavy lifting (unloading, carrying and storing food supplies; lifting, carrying, and cleaning heavy pots and pans and food containers; etc.) Citation to supporting factual data and medical principles would be helpful. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bayles, 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.