Citation Nr: 21024039 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 17-01 996 DATE: April 21, 2021 REMANDED Entitlement to service connection for a left hip condition, to include as secondary to degenerative disc disease at L5-S1 (previously rated as chronic lumbar strain) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corp from August 1972 to December 1974. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issue for further development in August 2019. The case has been returned to the Board for appellate review. Direct Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Secondary service connection Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). The Veteran contends that his left hip condition is secondary to his service-connected back and left knee conditions. See November 2013 VA Form 21-4138 Statement in Support of Claim. The Veteran has also contended that his left hip condition is secondary to injuries sustained after falling off a cliff during service. See November 2016 VA Form 9. Pursuant to the August 2019 Board Remand, an addendum medical opinion was obtained to determine whether the Veteran has a current hip condition, and whether any left hip condition is related to his active service, to include falling from a cliff during training. The January 2020 VA examiner noted that the Veteran’s diagnosis for his left hip is left hip strain, based upon the March 2014 VA examination and a review of the medical records. However, the March 2014 VA examination does not list a diagnosis for left hip strain. The examiner also opined the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service-connected condition. The rationale is that the medical records do not contain any evidence of an altered gait or other stress/anatomical changes resulting from the service-connected right knee injury that could be attributed to, or result in, a left hip condition. The Board finds the January 2020 VA medical opinion to be inadequate because the examiner based its rational upon an inaccurate medical history. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. Accordingly, the most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examiner based a negative nexus opinion largely on a factual error that the Veteran has no altered gait that could result in a left hip condition. This is contradicted by the March 2014 VA examination which notes that the Veteran has guarding or muscle spasm of the thoracolumbar spine severe enough to result in an abnormal gait. As such, the Board affords the January 2020 VA examiner’s opinion no probative weight, as it was not based upon a factual medical history. Lastly, a remand is required to afford the Veteran an examination that complies with the requirements of joint testing during active, or passive range of motion testing, as well as during weight bearing and non-weight bearing movements. The United States Court of Appeals for Veterans Claims (Court) held in Correia v. McDonald, 28 Vet. App. 158 (2016), that the final sentence of 38C.F.R. §4.59 (2017) requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia established additional requirements for examinations regarding musculoskeletal disabilities. After reviewing the examinations of record, the Board finds that they are incomplete in this regard, and requires further medical guidance in light of the holding in Correia. The matters are REMANDED for the following action: 1. Attempt to obtain outstanding relevant private or VA treatment records. 2. After obtaining all outstanding records, schedule the Veteran for a VA examination from an appropriate clinician to determine the nature and etiology of the Veteran’s claimed left hip condition. The claims folder must be made available to and reviewed by the examiner. All indicated tests and studies should be performed, including range of motion studies in degrees, and the results reported. The clinician should address the following: (a.) Identify all medical conditions of the left hip by diagnosis(es). If no current left hip condition is diagnosed, determine whether the Veteran had a left hip disability at any point during the pendency of the claim. (b.) Whether it is at least as likely as not that the Veteran’s left hip condition is related to his active service, to include falling from a cliff. (c.) Whether it is at least as likely as not that the Veteran’s left hip condition is proximately due to or the result of the Veteran’s service-connected right knee injury. (d.) Whether it is at least as likely as not that the Veteran’s left hip condition is proximately due to or the result of the Veteran’s service-connected lumbar spine condition. (e.) Whether it is at least as likely as not that the Veteran’s left hip condition is proximately due to or the result of any other of the Veteran’s service-connected disabilities. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion testing for the left hip on both active and passive motion and in weight-bearing and non-weightbearing. If the left hip cannot be tested on “weight-bearing,” then the examiner should specifically indicate that such testing cannot be done. All opinions provided must be fully explained. If any requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Nelson, 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.