Citation Nr: 21027865 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 18-43 411 DATE: May 7, 2021 REMANDED Entitlement to a disability rating exceeding 10 percent for a right hip disability, limitation of abduction. Entitlement to a compensable disability rating for a right hip disability, limitation of flexion. Entitlement to a disability rating exceeding 10 percent for a right knee tibia stress fracture. Entitlement to service connection for a left hip disability, claimed as secondary to right hip disability. Entitlement to service connection for a back disability. Entitlement to service connection for left lower extremity radiculopathy. REASONS FOR REMAND The Veteran served on active duty from March 2016 to May 2017. This appeal comes to the Board from a July 2017 rating decision. The Veteran testified at a November 2020 hearing. She identified outstanding records from a private chiropractor. She noted prior VA examination findings indicating she did not have a current back and left hip disability were inadequate. After the hearing, VA received treatment records noting back pain and impairment. VA should obtain a new VA examination to consider this evidence. Additionally, VA examinations of the right knee tibia fracture and right hip disability are several years old. Rating criteria for certain orthopedic disorders changed effective February 7, 2021. VA should obtain current VA examinations using both the older criteria and the newer criteria to the extent that it supports a higher rating. VA should also obtain new examinations to evaluate whether the service-connected disabilities caused or aggravated left hip and back disabilities. The Board REMANDS for the following actions: 1. VA should request the Veteran identify outstanding relevant records, including any outstanding chiropractic records, and VA should add them to the file. 2. After adding records to the file, VA should obtain a VA examination of the current severity of the right hip disabilities and right knee tibia fracture. The examination should also address the service connection claims for left hip, back, and left lower extremity radiculopathy. With the right hip and right knee, the examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. The examiner should use the most up-to-date Disability Benefits Questionnaire. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge, a deficiency in the record, or the examiner. VA should ensure that the examinations evaluate the Veteran's disabilities under both the older rating criteria and the new criteria effective February 7, 2021 to the extent newer criteria supports a higher disability rating. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). With the left hip, back, and left lower extremity radiculopathy claims. VA should ensure the examinations address the following: (a.) The VA examiner should identify all current disabilities associated with the Veteran's left hip, back, and left lower extremity radiculopathy. The examiner should consider functional loss of earning capacity, including as due to pain, to be a disability for the purpose of the examination. (b.) For each disability, the examiner should opine whether the disability at least as likely as not (50 percent or greater probability) began during or was otherwise caused by the Veteran's service. The examiner should explain why or why not with adequate rationale citing relevant evidence in the record. For example, April 2017 records from John Randolph Medical Center show the Veteran received an MRI scan based on indications including low back pain and radiculopathy. (c.) In regard to diagnoses of arthritis, the examiner should opine whether it is at least as likely as not the arthritis manifested to a compensable degree (for example, any limitation of motion due to pain) within one year of the Veteran's separation from active duty. (d.) The examiner should opine whether the Veteran's service-connected disabilities including a right hip disability, a right knee tibial stress fracture, and complex regional pain syndrome at least as likely as not caused or aggravated each left hip and back disability to include radiculopathy. The aggravation does not have to be permanent. Temporary aggravation is sufficient. See Ward v. Wilkie, 31 Vet. App. 233 (2019). A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Duffy, 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.