Citation Nr: 21015691 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 14-10 751A DATE: March 18, 2021 REMAND Service connection for a bilateral hip disorder. Service connection for a low back disorder. REASONS FOR REMAND The Veteran served on active duty from August 1969 to March 1971. The case is on appeal from an August 2010 rating decision. In September 2014, the Veteran testified at a Board hearing. Most recently, in July 2020, the Board remanded the case for additional development. 1. Service connection for a bilateral hip disorder. 2. Service connection for a low back disorder. Pursuant to the Board’s July 2020 remand, a VA addendum opinion was obtained later that same month. The Board finds the opinion is not completely adequate. In that respect, and although the opinion notes onset of a lumbar condition in approximately 2004, the opinion does not address the Veteran’s lay statements regarding back and hip symptoms during service, particularly in association with duties of a cannoneer and his involvement in combat during service in Vietnam, or heavy lifting, see January 2020 Board decision, with worsening low back symptoms in 1998. See March 2020 & January 2016 VA examinations. The Veteran’s service personnel records (SPRs) show participation in combat in Vietnam. The Board notes that a medical opinion based solely on the absence of documentation in the service treatment records (STRs) or that fails to consider lay statements is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner’s opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury but relied on the service medical records to provide a negative opinion). This is particularly so when records would not be expected such as during combat service. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). In addition, and even though no evidence of a gait abnormality that would have potentially altered the lumbar spine or hip mechanics over the years was noted, the opinion does not address the Veteran’s constant use of a cane reported on VA examination in March 2020. Further, and although no medical literature showing a causal effect between ankle conditions and lumbar or hip degeneration, or trochanteric syndrome, was reported, the January 2016 VA examination report reflects a diagnosis of intervertebral disc syndrome. As such, a new opinion is warranted. In view of the remand, VA treatment records since the issuance of the September 2020 supplemental statement of the case (SSOC) should be obtained. The matters are REMANDED for the following action: 1. Obtain VA treatment records since September 2020. 2. After obtaining any outstanding records, provide the claims file to an appropriate medical professional to render the requested opinions. The need for another examination for the bilateral hip and low back conditions is left to the discretion of the medical professional offering the addendum opinions. The clinician is asked to presume the Veteran had hip and back pain and swelling during service, and furnish an opinion with respect to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that any hip or low back disorder, to include arthritis, had its onset during, or is otherwise related to, active service, including hip and back symptoms during service in Vietnam while deployed with an artillery unit, and in association with his specialty of cannoneer, as well as heavy lifting. See January 2020 Board remand. (b.) Whether it is at least as likely as not (50 percent or greater probability) that a hip or low back disorder was caused by service-connected lateral collateral ligament sprain with osteoarthritis of the left ankle. (c.) Whether it is at least as likely as not (50 percent or greater probability) that a hip or low back disorder was aggravated by service-connected lateral collateral ligament sprain with osteoarthritis of the left ankle. Aggravation is an increase in severity beyond the natural progress of the disease. In rendering the opinions, consideration should be given to the Veteran’s reports of symptoms during and following service. Rationale for all opinions expressed should be provided. If the clinician is unable to provide the requested opinions without resort to speculation, it must be so stated, and he or she must provide the reasons why an opinion would require speculation. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Taylor 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.