Citation Nr: 21022084 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 18-31 854 DATE: April 14, 2021 REMANDED Entitlement to service connection for a left hip disability, to include avascular necrosis, (excluding left hip strain, limitation of flexion, abduction, adduction, and rotation) is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right hip disability is remanded. Eligibility for specially adapted housing is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance or housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1995 to February 1996. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November 2017 and December 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Offices (RO). In January 2019, the Veteran presented testimonial evidence at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In August 2019, the Board remanded the case for additional development. While on remand, in a June 2020 rating decision, the RO granted service connection for left hip strain, limitation of abduction, adduction, and rotations, limitation of flexion, and scars of the left hip. However, a finding of avascular necrosis of the left hip was noted on a January 2020 VA examination and the examiner found that such was not related to the Veteran’s military service. As such, this matter has not been resolved and the issue service connection for a left hip disability other than left hip strain, limitation of flexion, abduction, adduction, and rotation is before the Board. The issue is listed on the title page. Additionally, the Board acknowledges that the Veteran also seeks SMC and as SMC based on housebound status is part and parcel of her claim, this issue will also be addressed on appeal. The other issues listed on the title page have been returned to the Board for further appellate review. 1. Entitlement to service connection for a left hip disability, to include avascular necrosis, (excluding left hip strain, limitation of flexion, abduction, adduction, and rotation). In accordance with the August 2019 Board remand, the Veteran was afforded a VA examination in January 2020. As stated in the Introduction, the January 2020 VA examiner found that the Veteran’s left hip avascular necrosis was less likely than not to have arose during or otherwise related to military service. As rationale, the examiner explained that avascular necrosis was related to the Veteran’s frequent steroid use associated with sarcoidosis. The examiner further concluded that it was less likely than not that the Veteran’s avascular necrosis was proximately caused by the service-connected left knee disability. In this regard, the examiner explained that avascular necrosis had several risk factors, but a knee injury was not a noted risk factor. The examiner further noted that risk factors for developing avascular necrosis included trauma and injuries to the hip, steroid use, bisphosphonate use, excessive alcohol use, and certain medical treatments. With regards to the aggravation prong, the examiner found that it was less likely than not that the Veteran’s avascular necrosis was aggravated beyond its natural progression due to her left knee disability. The examiner stated that there was no evidence of aggravation and the Veteran’s current avascular necrosis was not associated with IT band syndrome, her military service, or her service-connected left knee disability. In Ward v. Wilkie, 31 Vet. App. 233 (2019), the United States Court of Appeals for Veterans Claims (Court) held that secondary service connection is warranted for “any incremental increase in disability—any additional impairment of earning capacity—in non-service-connected disabilities resulting from service-connected conditions…regardless of its permanence.” Id. at 240. Thus, the appropriate standard in the context of 38 C.F.R. § 3.310 (b) is “any increase” in disability; rather than “aggravated beyond its natural progression.” Id.; see also Allen v. Brown, 7 Vet. App. 439 (1995). In order to ensure that the appropriate standard is used, an addendum opinion is needed. Additionally, the Board notes that the is Veteran now service connected for several other left hip disabilities that may have caused or aggravated the Veteran’s left hip avascular necrosis. Thus, an addendum opinion is needed in this regard. 2. Entitlement to service connection for a right knee disability. With regards to the right knee disability, the January 2020 VA examiner concluded that the Veteran’s right knee arthritis was less likely than not proximately caused by the service-connected left knee disability. While there may have been some compensation for left knee condition, the examiner explained that the Veteran’s right knee would have been resolved once knee replacement was completed. The examiner noted that the Veteran had a very mild arthritis noted on MRI and not found on X-ray. Therefore, the examiner found that it was likely that her right knee disability was related to basic aging process and not related to compensation for left knee disability. The examiner further explained that the Veteran’s current avascular necrosis of left hip was the cause for compensation. With regards to the aggravation prong, the examiner found that it was less likely than not that the Veteran’s right knee disability was aggravated beyond its natural progression due to her left knee disability. As rationale, the examiner explained that only very mild arthritis was noted on MRI and not visualized on X-ray. The examiner further explained that the Veteran’s right knee pain did not start until 2014 when she injured her knee in the shower and it did not appear to be related to a left knee condition or compensation. The examiner stated that mild arthritis was related to aging and risk factors are associated with weight, sex, and aging. The examiner also stated that there was no evidence that the Veteran had compensatory gait following knee replacement until right knee pain occurred and with the left hip complaint for avascular necrosis. As noted, the appropriate standard in the context of 38 C.F.R. § 3.310 (b) is “any increase” in disability; rather than “aggravated beyond its natural progression.” Ward, supra.; Allen, supra. In order to ensure that the appropriate standard is used, an addendum opinion is needed. Additionally, the Veteran reported that she had pain due to compensating the weight from her left side to her right side of her body. In this regard, as noted above, the Veteran is now service connected for a left hip disability. Thus, an addendum opinion is need in this regard. 3. Entitlement to service connection for a back disability. The Veteran was afforded a VA examination in January 2020. At such time, the examiner noted that the Veteran’s January 1996 service treatment record that showed an antalgic gait, listing mildly to the right, and documenting tenderness to palpation L5/S1, left greater than right. The examiner also noted an August 1997 statement from the Veteran describing lower back pain, and a November 1998 VA treatment record documenting complaints of back spasm and low back pain. Based on a review of the record, the examiner opined that the Veteran’s back disability less likely than not arose during or was otherwise related to her military service. As rationale, the examiner explained that there was no diagnostic condition noted on examination and the Veteran had myofascial pain, called lumbar strain on the VA examination. The examiner concluded that it was more likely than not the Veteran’s back disability was related to fibromyalgia and sarcoidosis which caused muscle pain with movement and radicular type symptoms, as noted in the records. The examiner also concluded that the Veteran’s back disability was less likely than not proximately caused by the service-connected left knee disability, to include reported altered gait and weight bearing. The Veteran had a knee replacement in 2003 and the knee replacement was done to alleviate pain and correct an altered gait. The examiner noted that the Veteran had long standing back complaints, but all diagnostics were normal with no indication of a back disability. However, the examiner explained that, given fibromyalgia and sarcoidosis, records show that pain was suspected to be associated with these conditions, which were not service connected. With regards to the aggravation prong, the examiner found that it was less likely than not that the Veteran’s back disability was aggravated beyond its natural progression due to her left knee disability. The examiner noted that the Veteran continued to have normal ROM. The examiner noted the Veteran’s report that she had pain due to compensating the weight from her left side to her right side of her body. While some discomfort was noted on examination, it was due to fibromyalgia and sarcoidosis and not associated with left knee disability as imaging was normal with the exception of mild edema noted on MRI in 2017 which is found to be associated with obesity. An October 2017 X-ray revealed a normal appearance of the lumbar spine. As noted, the appropriate standard in the context of 38 C.F.R. § 3.310 (b) is “any increase” in disability; rather than “aggravated beyond its natural progression.” Ward, supra.; Allen, supra. In order to ensure that the appropriate standard is used, an addendum opinion is needed. Additionally, the Veteran is now service connected for a left hip disability. Thus, an addendum opinion is needed in this regard. 4. Entitlement to service connection for a right hip disability. In January 2020, the examiner opined that the Veteran’s right hip disability was less likely than not proximately due to or the result of her service-connected left knee disability. The examiner also concluded that it was less likely than not aggravated beyond its natural progression due to her service-connected left knee disability. As rationale, the examiner explained that the Veteran had no right hip complaints associated with her left knee disability prior to replacement and the knee replacement resolved gait abnormality. However, current avascular necrosis of left hip will cause a gait abnormality and excess pressure on right trochanteric bursa, resulting in bursitis. The examiner concluded that the avascular necrosis was not related to service or service-connected left knee disability. As noted, the appropriate standard in the context of 38 C.F.R. § 3.310 (b) is “any increase” in disability; rather than “aggravated beyond its natural progression.” Ward, supra.; Allen, supra. In order to ensure that the appropriate standard is used, an addendum opinion is needed. Moreover, at the Veteran’s October 2017 VA examination, the Veteran reported that due to her left knee and left hip injury, she compensated while walking and applied her body weight mostly to right hip. In this regard, as noted above, the Veteran is now service connected for a left hip disability. Thus, an addendum opinion is need in this regard. 5. Eligibility for specially adapted housing. The Veteran contends that she is entitled to specially adapted housing due to her service-connected disabilities. In this regard, the Veteran is currently service connected for several disabilities, to left total knee replacement, left hip strain, limitation of flexion of the left hip, and limitation of abduction, adduction, and rotations of the left hip. The Veteran has been granted a disability rating of 100 percent due to her service-connected disabilities. As an initial matter, the Board finds that the claims for entitlement to specially adapted housing is inextricably intertwined with the remanded claims. Thus, the adjudication of this matter is deferred. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision in the matter).   6. Entitlement to special monthly compensation based on the need for regular aid and attendance or housebound status. As a decision on the remanded issues could significantly impact a decision on the issue of entitlement to special monthly compensation, the issues are inextricably intertwined. A remand of this claim is also needed. The matters are REMANDED for the following actions: 1. Return the record to the January 2020 VA examiner for an addendum opinion for the Veteran’s claims. The record and a copy of this Remand must be made available to, and reviewed by, the examiner. If the January 2020 examiner is not available, the record should be provided to an appropriate examiner so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should offer an opinion as to the following inquiries: (A) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left hip avascular necrosis, right knee disability, right hip disability, and/or back disability: (i) is proximately due to or the result of the Veteran’s service-connected left hip strain, limitation of flexion, abduction, adduction, and rotation, or (ii) is aggravated by the service-connected left hip strain, limitation of flexion, abduction, adduction, and rotation? (B) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left hip avascular necrosis, right knee disability, right hip disability, and/or back disability is proximately due to, the result of, or is aggravated by the service-connected left knee disability? The term “aggravation” in the above context refers to “any incremental increase in disability - any additional impairment of earning capacity -in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence.” In formulating the above opinions, the examiner must consider and discuss all lay statements and assertions provided by the Veteran. A complete rationale must be provided for any and all opinions offered. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence or information might allow for a more definitive opinion. 2. Complete any additional development deemed necessary, readjudicate the claims on appeal, including the claims of entitlement to specially adapted housing and special monthly compensation. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brennae L. Brooks, Associate 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.