Citation Nr: 21031294 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-12 669 DATE: May 21, 2021 REMANDED Entitlement to service connection for a bilateral hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2000 to July 2002. The matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in November 2018 for further development by the RO. The case has been returned to the Board for further appellate action. Entitlement to service connection for a bilateral hip disability is remanded. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. The Veteran contends that his bilateral hip condition began in service and has continued to the present. He contends that the condition is secondary to his antalgic gait, which in turn is attributable to his service-connected bilateral plantar fasciitis. The Veteran underwent a VA examination in June 2013, noting possible mild sacroiliac joint dysfunction bilaterally. In November 2018, the Board remanded the claim to obtain an addendum medical opinion on whether the claimed bilateral hip disability was caused or aggravated by one or more service-connected disabilities. Pursuant to the remand directives, the RO obtained a June 2020 medical opinion. The examiner opined against a finding of secondary service connection. However, this medical opinion is inadequate. It concludes that the Veteran's hip condition is not causally related to or aggravated by his service-connected conditions, to include bilateral plantar fasciitis or iliotibial band syndrome. In the explanation, the examiner states that that the physical examination of the hips is essentially normal, with the exception of a mildly positive Patrick's sign bilaterally, indicating possible mild sacroiliac joint dysfunction. The examiner opines that the Veteran's possible mild sacroiliac joint dysfunction is at least as likely as not causally related to the Veteran's mildly antalgic gait. The Veteran's mildly antalgic gait is caused by the Veteran's non-service-connected right foot bi-partite sesamoiditis, a congenital malformation not known to be causally related to plantar fasciitis. However, regarding aggravation, the examiner stated that "no documentation is noted in the provided records for evidence associated with aggravation" secondary to his service-connected disabilities. The Board notes that a lack of documentary or "objective" evidence is not the evidentiary standard. Thus, the case must be returned for an addendum opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA undertakes an examination, it must provide an adequate one). Moreover, following the issuance of the most recent supplemental statement of the case (SSOC) dated June 2020, the Veteran submitted private medical treatment records indicating multiple possible right hip diagnoses that were not noted in the prior examination report or opinions of record. Such medical findings include osteoarthritis, labral tear, cam lesion, and femoral ace tabular impingement. See September 2020 private medical treatment records. On remand, the examiner will be asked to consider these records in the addendum medical opinion. Additionally, the Veteran's representative submitted an appellate brief in April 2021 citing a review of medical literature indicating that plantar heel pain is commonly associated with gait-related disabilities. The representative also stated that the examiner failed to consider whether the Veteran's bilateral hip disability is "otherwise etiologically related to the Veteran's service," to include, "a rigorous exercise program." Liberally construed, the Board takes this to mean that no medical opinion of record has adequately considered direct service connection. On remand, the examiner will be asked to consider these contentions in the addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, obtain an addendum opinion from an appropriate medical professional to determine the nature and etiology of the Veteran's bilateral hip disability. After reviewing the claims folder in its entirety, the examiner should address the following: (a) Is the Veteran's bilateral hip disability at least as likely as not related to an in-service injury, event, or disease in service? (b) In the alternative, is the Veteran's bilateral hip disability at least as likely as not (50 percent or greater probability) caused by any of his service-connected disabilities; and (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's bilateral hip disability has been aggravated by any of his service-connected disabilities? In rendering this opinion, the examiner should address the medical records and medical literature submitted by the Veteran. See September 2020 private medical treatment records (noting findings of right hip osteoarthritis, labral tear, cam lesion and femoral ace tabular impingement); April 2021 appellate brief (citing Phillips A, McClinton S., Gait deviations associated with plantar heel pain: A systematic review.). If, and only if, the examiner determines that another VA examination is necessary to provide an informed opinion, such an examination should be scheduled. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and must state whether there is additional evidence that would permit the necessary opinion to be made. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.