Citation Nr: 21013807 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 15-37 207 DATE: March 10, 2021 REMANDED Entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran had active service from February 2003 to May 2004. She also had additional active duty for training (ADT) from February to June 2001. This matter comes before the Board of Veterans Appeals (Board) on appeal from a January 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a right hip disability is remanded. The Veteran contends that she is entitled to service connection for a right hip disability because she first experienced right hip pain and a hairline fracture during active service and it has progressed since. See January 2014 Notice of Disagreement (NOD); October 2015 Veteran’s correspondence. In October 2020, the Board remanded the matter to obtain a medical opinion regarding the etiology of the Veteran’s claimed right hip disability. The Veteran was afforded a VA examination in December 2020. The Board finds that the December 2020 VA examination report is inadequate for adjudication purposes and that a remand is necessary to obtain an addendum medical report. In that regard, the examiner opined that there was “no objective evidence on exam to warrant a diagnosis for the claimed right hip condition/right hip pain, to include right hip degenerative changes/arthritis.” The examiner did not acknowledge the Veteran’s current lay statements of pain which were corroborated by her husband. Evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (2018). Further, the examiner did not address whether the Veteran suffered from an undiagnosed illness as a result of her Persian Gulf service. Service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifested either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Iraq, where the Veteran served, is included in the Southwest Asia theater of operations. 38 C.F.R. § 3.317(e)(2). On remand, the examiner should address all theories of entitlement. The matters are REMANDED for the following action: Obtain an addendum medical opinion from the December 2020 VA examiner (or a suitable substitute if that examiner is not available). The Veteran’s electronic claims file, including a copy of this remand, must be made available to the examiner for review in connection with the opinion. If the examiner finds that another examination is warranted, another examination should be scheduled. The examiner is requested to offer an opinion as to the following: (a) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran suffers from a right hip disability. Evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (2018). (b) In the case that no diagnosis can be made, opine whether it is at least as likely as not (50 percent probability or greater) the Veteran's symptom or symptoms are related to an undiagnosed illness or related to a medically unexplained chronic multi symptom illness. The examiner’s attention is directed to evidence that the Veteran served in Iraq (Persian Gulf) while on active duty from March 2003 to April 2004. If the examiner is unable to provide an opinion as to the matter, the RO is requested to schedule the Veteran for an examination with a clinician who is qualified to make such an opinion. Service connection may be established for a chronic disability resulting from an undiagnosed illness that became manifested either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). (c) If the Veteran suffers from a diagnosed right hip disability, whether it is clear and unmistakable that the right hip disability preexisted the Veteran's active service in February 2003; and if so, whether it clearly and mistakably was not aggravated by her active service from February 2003 to May 2004. The examiner’s attention is directed to the Veteran’s statements that she injured her right hip during her active duty for training in 2001. See also March 2001 service treatment records which indicate complaints of sudden pain in right hip following road march. (d) If the disability did not preexist service, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran suffers from a right hip disability that was incurred in or is otherwise related to service, to include due to marching with a ruck sack, driving a Humvee, and being in combat situations in Iraq. (e) If the Veteran has a diagnosis of arthritis, the examiner should opine whether it manifested within one year of the Veteran's separation from service in May 2004; or, whether it was noted in service with continuity of symptomatology since service. The examiner’s attention is directed to the following: (i) October 2005 private chiropractic treatment records showing treatment for the back after complaints of pain centered around the right hip; (ii) November 2008 VA chiropractic treatment records noting the Veteran had a right leg that was shorter than her left leg; (iii) December 2013 private chiropractic treatment records noting complaints of hip pain for 8 years in the same right hip area that was circled in October 2005; (iv) January 2014 VA treatment records noting complaints of pain in the right gluteus radiating down the posterior upper thigh; (v) May 2016 VA treatment records where a physician found the Veteran was complaining of pain that was not actually in the hip area instead it was in the right lower back SI joint area. A complete rationale for all opinions reached must be provided. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Baskerville, LaRita 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.