Citation Nr: 21026115 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-29 192A DATE: April 29, 2021 REMANDED Entitlement to service connection for a right hip disability, to include a right hip strain and as due to the service-connected lumbar spine degenerative joint disease and residuals of coccyx fracture is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from March 1981 to July 1981 and from April 1983 to March 1984. This matter comes before the Board of Veterans’ Appeals on appeal from an August 2010 rating decision issued by the Boston Department of Veterans Affairs (VA) Regional Office (RO). In the August 2020 rating decision, the Veteran was granted service connection for residuals of his coccyx fracture, claimed as a broken tailbone and back condition. The rating decision also denied the Veteran’s claim of service connection for his right hip condition. This matter was previously before the Board in September 2018. The Board remanded the issue of service connection for the right hip for additional development and a new VA examination. Caffrey v. Brown, 6 Vet. App. 377 (1994); 38 C.F.R. § 3.327(a). The matter returned to the Board in December 2020 and was remanded again after the VA examination was found to be inadequate and the Veteran through his representative raised new theories of entitlement that must be addressed. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c). 1. Entitlement to service connection for a right hip disability, to include a right hip strain and as due to the service-connected lumbar spine degenerative joint disease and residuals of coccyx fracture is remanded. The Veteran contends that he is entitled to service connection for a right hip disability, to include a right hip strain, due to the service-connected disabilities of degenerative joint disease in the lumbar spine and residuals of his coccyx fracture. The Veteran claims that he injured his right hip during an in-service motorcycle crash. The VA has conceded the in-service motorcycle crash. The Veteran underwent a VA examination in September 2019 to examine the nature and etiology of the right hip disability. The examiner noted that the Veteran suffers from bilateral lumbar paraspinal muscle spasms that result in an antalgic gait and abnormal sitting posture. The examination also noted that the Veteran began reporting right hip pain in 2018 and was diagnosed with right hip sprain in 2019. The examiner found the right hip to have an abnormal and limited range of motion (ROM). The Veteran claimed that the hip was “always painful” and that he could not walk more than 10 minutes without bad hip pain. The examiner also found that the Veteran suffered functional loss due to the right hip in the form of pain, fatigue, and weakness. However, the examiner opined that the right hip condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner rationale stated that the Veteran’s medical records are silent as to hip pain from the time of discharge until 2018. The examiner also noted that x-rays in May 2014 revealed no significant degenerative joint disease in the hip. In February 2020, the Veteran’s representative submitted a letter stating that the VA examiner failed to address whether the Veteran’s antalgic gait and abnormal posture caused, contributed to, or aggravated the hip condition. Additionally, the Veteran’s representative stated that the examiner failed to address whether the physical impact of the in-service motorcycle accident contributed to the development of the Veteran’s hip condition. Finally, the representative claimed that it was inappropriate for the examiner to make findings based on x-rays from 2014. The Veteran’s attorney stated that new x-rays were warranted before an opinion should be rendered on the issue. The August 2020 Board remand decision noted the inadequacy of the September 2019 exam in failing to specifically address whether the impact of the in-service motorcycle accident could have contributed to the development of the Veteran’s hip condition. The Board also noted the Veteran’s representative correspondence and her raising of a new theory of entitlement. Specifically, entitlement to secondary service connection due to the Veteran’s lumbar spine degenerative joint disease and residuals of the coccyx fracture which the September 2019 examiner stated led to an antalgic gait and abnormal posture. The Board also noted that the September 2019 examiner failed to discuss relevant in-service medical evidence. The Veteran’s service treatment records (STRs) from February 1984 show that the Veteran suffered from right lateral femur head area swelling and a retroperitoneal hematoma in his right groin following the motorcycle crash. The Veteran received a new VA examination in January 2021. The VA also issued an addendum opinion in January 2021. The examination noted the Veteran’s complaint of right hip pain and the diagnosis of a right hip sprain in 2019. The examination also discussed the Veteran’s functional impairment. The examiner opined that it was less likely than not that the Veteran’s hip disability was incurred in or caused by the claimed in-service injury. The examiner also opined that that it was less likely than not that the Veteran’s current hip condition was secondary to the service-connected back condition. The examiner finally opined that it was less likely than not that the Veteran’s hip condition was proximately due or aggravated by the service-connected back condition and residuals of the coccyx fracture. The Board finds after a thorough review that the January 2021 opinions are inadequate. While the examiner offered opinions and rationale for the Veteran’s claim for direct and secondary service connection, the examiner did not adequately address the Board’s remand directives. Specifically, the examiner failed to discuss the Veteran’s relevant STRs and the medical evidence showing a right femur head swelling and a right groin hematoma when offering an opinion on the theory of direct service connection. The examiner also did not address whether new imaging studies or x-rays would be required. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, in accordance with Stegall, remand for full compliance with the Board’s prior remand is warranted. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran’s right hip disability. The claims file and a copy of this remand must be made available to the examiner, and the examiner shall indicate in the addendum that the claims file was completely reviewed. The need for another VA examination is left to the discretion of the medical professional drafting the addendum opinion. However, the examiner must consider and address whether a new x-ray or imaging studies of the Veteran’s right hip are necessary to decide the claim. The examiner must offer an opinion as to whether the Veteran’s right hip disability is at least as likely as not related to an in-service injury, event, or disease. In offering this direct service connection opinion, the examiner must specifically address records from the Veteran’s in-service February 1984 motorcycle accident. In particular. The examiner must discuss the February 1984 STR notes that indicate right femoral head swelling and a retroperitoneal hematoma in the right groin. (Continued on the next page)   A complete rationale for all opinions is required. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.L. Aumiller, 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.