Citation Nr: 21041794 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 09-18 287 DATE: July 10, 2021 ORDER Entitlement to an evaluation in excess of 30 percent for a left hip total replacement from March 1, 2010, through July 9, 2018, is denied. REMANDED Entitlement to an evaluation in excess of 10 percent for right hip degenerative changes with enthesopathic changes in the pelvis based on a limitation of extension is remanded. Entitlement to a compensable evaluation for right hip degenerative changes with enthesopathic changes in the pelvis based on limitation of flexion is remanded. Entitlement to a compensable evaluation for right hip degenerative changes with enthesopathic changes in the pelvis based on impairment of the thigh is remanded. Entitlement to service connection for a kidney disability, to include as secondary to a left hip disability, is remanded. Entitlement to service connection for a low back disability, to include as secondary to a left hip disability, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to a left hip disability, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to a left hip disability, is remanded. Entitlement to specially adapted housing is remanded. Entitlement to a special home adaption grant is remanded. FINDING OF FACT From March 1, 2010, through July 9, 2018, the left hip total replacement was not characterized by moderately severe residuals of weakness, pain, or limitation of motion. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for a left hip total replacement from March 1, 2010, through July 9, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1977 to September 1981 and from March 1984 to May 1984. In an August 2019 decision, the Board denied entitlement to service connection for a kidney disability. The Veteran subsequently appealed the decision to the United States Court of Appeals for Veterans Claims (Court), and while that case was pending at the Court, the Veteran's attorney and the VA Office of the General Counsel filed a joint motion to vacate this part of the Board's decision and remand the Veteran's claim for readjudication. In a May 2020 Order, the Court granted the motion, vacated the Board's August 2019 decision as it pertains to this issue, and remanded this case to the Board for readjudication. The claim was again before the Board in October 2020. Additional development is needed before the claim can be decided on the merits. The other issues listed above were remanded for additional development by the Board in August 2019. The requested development has been completed as related to an increased rating for the left hip disability, and the claim is properly before the Board for appellate consideration. Additional development is needed on the issues of increased ratings for the right hip disabilities, service connection for a low back disability, left knee disability, and right knee disability, specially adapted housing, and a special home adaption grant. Increased Rating Entitlement to an evaluation in excess of 30 percent for a left hip total replacement from March 1, 2010, through July 9, 2018 Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not specifically contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and also weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Normal ranges of motion of the hip are from hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. The Veteran's left hip was rated under Diagnostic Code 5054, hip replacement, which during the applicable period provided a 30 percent rating as the minimum rating; a 50 percent rating for moderately severe residuals of weakness, pain, or limitation of motion; a 70 percent rating for markedly severe residual weakness, pain, or limitation of motion following implantation of prosthesis; a 90 percent rating following implantation of prosthesis with painful motion or weakness such as to require the use of crutches; and a 100 percent rating for one year following the implantation of prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5054. Diagnostic Code 5250 provides for rating the hip on the basis of ankylosis. Favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction is to be rated 60 percent disabling; intermediate ankylosis of the hip is to be rated 70 percent disabling; and extremely unfavorable ankylosis, with the foot not reaching ground, crutches necessitated, is to be rated 90 percent disabling, and is entitled to special monthly compensation. 38 C.F.R. § 4.71a. Diagnostic Code 5251 provides a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5253 provides a 10 percent evaluation for limitation of rotation of the affected leg (with an inability to "toe-out" more than 15 degrees) or limitation of adduction causing an inability to cross legs, and a 20 percent evaluation for limitation of abduction resulting in motion lost beyond 10 degrees. 38 C.F.R. § 4.71a. The Veteran underwent a left hip replacement in January 2009, and had a 100 percent rating from that date through February 28, 2010. There was no hip pain upon range of motion at April 2010 VA orthopedic treatment. At April 2010, June 2010, September 2010, and November 2010 VA physical therapy the Veteran rated the left hip and back pain as at least seven out of ten in intensity. The Veteran reported not having left hip pain at January 2011 VA treatment. The Veteran had a VA examination in April 2011 at which there was pain, stiffness, weakness, and decreased speed of joint motion. There was no instability, giving way, incoordination, episodes of dislocation or subluxation, locking episodes, and effusions. Symptoms of inflammation were warmth, swelling, and tenderness. There were no left hip flare-ups. The Veteran was unable to stand for more than a few minutes or walk more than a few yards. He used two crutches or a walker. On examination range of motion was flexion to 90 degrees, extension to 15 degrees, left extension to 15 degrees, and left abduction to 25 degrees. The left leg could not cross over the right, and toes could out over 15 degrees. There was objective evidence of pain with active motion. On repetitive motion there was pain and no additional loss of motion. There was no ankylosis, and there was tenderness to palpation at the posterior hip and gluteus left side along the lateral upper femur to mid-shaft. The Veteran had another VA examination in March 2017 at which range of motion was flexion to 80 degrees, extension to 30 degrees, abduction to 40 degrees, and adduction to 25 degrees. Adduction was not limited such that the Veteran could not cross his legs. External rotation was to 45 degrees and internal rotation was to 40 degrees. No pain was noted on examination, including with weightbearing. There was not objective evidence of localized tenderness or pain on palpation of the left hip or associated soft tissue. There was no additional loss of function or range of motion after three repetitions. The examiner wrote that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during flare-ups. Pain, weakness, fatigability, or incoordination could limit the functional ability of an individual who has a musculoskeletal pathology during a flare-up. However, the examiner felt that to classify the functional limitation in the absence of a flare-up as mild, moderate, or severe would be mere speculation. There was no left-sided ankylosis or malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The functional impairment was that prolonged sitting and standing was prevented. The record does not show the flexion was limited to 45 degrees or extension to 5 degrees, and the Veteran could cross his legs and toe-out more than 15 degrees. Furthermore, there was no ankylosis of the left hip, flail joint, or malunion or nonunion of the femur. Therefore, the Veteran would not qualify for compensable evaluations under Diagnostic Codes 5250, 5251, 5252, 5253, 5254, or 5255. See 38 C.F.R. § 4.71a. The treatment records and April 2011 VA examination report show complaints of pain. The Veteran did not report hip pain at the March 2017 VA examination, and there was no localized tenderness or pain noted by the examiner upon examination. There was weakness of the left hip at the April 2011 VA examination, and weakness was not noted to be present at the March 2017 examination. Under 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca, the Board is required to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation of motion diagnostic codes. The Veteran had pain and weakness of the left hip at the April 2011 VA examination. However, there were no flare-ups or additional limitations of motion after repetitive use testing, and the Veteran used assistive devices. At the March 2017 VA examination there was no additional loss of function or range of motion after three repetitions. The flare-ups that the Veteran reported appeared to pertain to the right hip based on that he reported pain related to the right hip and that the left hip was noted to not present a "problem." The examiner did not feel that there was functional loss or functional impairment, regardless of repetitive use. While the examiner indicated that he could not say without speculation regarding functional loss with flare-ups and repetitive use, the totality of the examination report indicates that there were no flare-ups or limitations with repetitive use. Overall, the record does not show that there were moderately severe residuals of weakness, pain, or limitation of motion of the left hip as required for a 50 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5054. Finally, in light of the holding in Hart, supra, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected left hip total replacement from March 1, 2010, through July 9, 2018, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. Because the evidence preponderates against the claim for an evaluation in excess of 30 percent for a left hip total replacement from March 1, 2010, through July 9, 2018, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). REASONS FOR REMAND 1. Entitlement to an evaluation in excess of 10 percent for right hip degenerative changes with enthesopathic changes in the pelvis based on a limitation of extension is remanded 2. Entitlement to a compensable evaluation for right hip degenerative changes with enthesopathic changes in the pelvis based on limitation of flexion is remanded 3. Entitlement to a compensable evaluation for right hip degenerative changes with enthesopathic changes in the pelvis based on impairment of the thigh is remanded The Veteran had a VA examination in July 2018. Under the holding in Correia v. McDonald, 28 Vet. App. 158 (2016), a VA examination of the joints must, wherever possible, include the results of range of motion testing on both active and passive motion, in weight-bearing and nonweight-bearing, and, if possible, with the range of the opposite undamaged joint in compliance with 38 C.F.R. § 4.59. The ranges of motion of the right hip were not measured in both active and passive motion. Therefore, the Board finds that the Veteran must be scheduled for a new examination before the claim can be decided on the merits because the examination did not comply with the requirements of Correia, 28 Vet. App. at 168. The Veteran reported daily flare-ups at the July 2018 VA examination. The examiner wrote that it could not be stated whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time and during any flare-ups. The examination report states that it would be speculative to state the additional limitations in range of motion. It is noted that "[B]efore the Board can accept an examiner's statement that an opinion cannot be provided without resorting to speculation, it must be clear that this is predicated on a lack of knowledge among the 'medical community at large' and not the insufficient knowledge of the specific examiner." See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017) (quoting Jones v. Shinseki, 23 Vet. App. 382, 390 (2010)). For the above reasons, the Veteran must be scheduled for a new examination before the claim can be decided on the merits. 4. Entitlement to service connection for a kidney disability, to include as secondary to a left hip disability is remanded. In October 2020 a VA examiner reviewed the record and opined that the Veteran's kidney disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. It was noted that the service treatment records are silent regarding a diagnosis or symptoms of bilateral nephrolithiasis during or within a year of active service. Per the Board's October 2020 remand, the examiner was to discuss the June 1981 medical history report in which the Veteran reported having had kidney stones or blood in the urine. While the examiner discussed risk factors for kidney stones, it is not clear if the possibility of kidney stones or blood in the urine during service was considered as part of the opinion. Furthermore, the examiner wrote that the medical literature did not support that medications to treat the left hip disability, including depomedrol, could be a cause for bilateral nephrolithiasis. The examiner did not provide an opinion regarding whether the kidney disability was aggravated by medication taken for the left hip disability. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. Therefore, a new medical opinion must be obtained before the claim can be decided on the merits. 5. Entitlement to service connection for a low back disability, to include as secondary to a left hip disability, is remanded. 6. Entitlement to service connection for a left knee disability, to include as secondary to a left hip disability, is remanded. 7. Entitlement to service connection for a right knee disability, to include as secondary to a left hip disability, is remanded. The Veteran had VA examinations in February 2020 at which he was diagnosed with lumbar degenerative disc disease/spondylosis and lumbar levoscoliosis. The examiner opined that the low back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. It was noted that the service treatment records are silent for a lumbar condition during or within a year of service and that the Veteran denied any signs or symptoms related to a lumbar condition at May 1983 and September 1983 examinations. The examiner also opined that the low back disabilities were less likely than not proximately due to or the result of the Veteran's service-connected left hip condition because the medical literature does not show a causal or aggravation relationship. There were different pathophysiological processes. The Veteran also had a VA examination for the knees in February 2020 at which he was diagnosed with bilateral knee osteoarthritis. The examiner opined that the bilateral knee disabilities were less likely than not incurred in or caused by military service or aggravated by the left hip disability. It was noted that the service treatment records are silent for bilateral knee osteoarthritis, and that there was no evidence it was present during or within a year of service. The examiner further wrote that medical literature does not show a causal relationship between the left hip disability and knee disabilities and that they were independent of one another. Regarding the low back disability, the examiner did not give proper consideration of the Veteran's reported back pain after falling during service in 1978. Furthermore, the March 2017 pelvis examination that found altered gait biomechanics and the April 2018 physical medicine consultation that found an antalgic gait with prolonged stance in the right lower extremity were not discussed in relation to the back and knee disabilities, as called for on the Board's August 2019 remand instructions. Compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A new opinion must be obtained before the claims are decided on the merits. 8. Entitlement to specially adapted housing is remanded. 9. Entitlement to a special home adaption grant is remanded. Specially adapted housing is available to a veteran who is entitled to compensation for permanent and total disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is additionally available to a veteran with a permanent and total disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities, such as to preclude locomotion; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which affect the functions of balance or propulsion as to preclude unaided locomotion. 38 U.S.C. § 2101(a); 38 C.F.R. § 3.809. If entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if the veteran has a service-connected disability that results in blindness in both eyes with 20/200 visual acuity or less in the better eye with the use of a standard correcting lens or a limitation in fields of his or her vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees; such a disability need not be permanent and total in nature. Additionally, a special home adaptation grant is available for a veteran who has a service-connected permanent and total disability which: (1) includes the anatomical loss or loss of use of both hands; (2) is due to deep partial thickness burns that have resulted in contracture(s) with limitation of motion of two or more extremities or of at least one extremity and the trunk; (3) is due to full thickness or subdermal burns that have resulted in contracture(s) of one or more extremities or the truck; or, (4) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease (COPD)). 38 C.F.R. § 3.809a. "Loss of use" is not specifically defined under 38 C.F.R. § 3.809 or 3.809a. Regulations pertaining to special monthly compensation for loss of use of a hand or foot state that loss of use is held to exist when no effective function remains other than that which would be equally well-served by an amputation with use of a suitable prosthetic appliance. The determination should be made on the basis of the actual remaining function, such as the ability to grasp, manipulate objects, balance, or propel oneself forward. See 38 C.F.R. §§ 3.350(a)(2), 4.63. The Court of Appeals for Veterans Claims has found that a "loss of use" exists when there is "deprivation of the ability to avail oneself" of that extremity, and functional impairment caused by pain, weakness, or incoordination should be taken into account when making that determination. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). The resolution of the claims for service connection for low back and knee disabilities may impact whether the Veteran satisfies the requirements for specially adapted housing and a special home adaption grant, as set forth in 38 C.F.R. § 4.16(a). As such, the claims are inextricably intertwined and must be considered together, and a decision by the Board on the Veteran's specially adapted housing and a special home adaption grants claims would, at this point, be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998). Per the Board's August 2019 remand, a VA examination was to be scheduled to obtain an opinion whether the Veteran has loss of use such that locomotion is precluded without the use of assistive devices due to service-connected disabilities. It does not appear from the record that such an opinion was provided by the February VA 2020 examiner. Compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall, 11 Vet. App. at 271. On remand, the Veteran must be scheduled for an examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the current severity of his service-connected right hip disabilities. The electronic claims file must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. The examiner should also indicate the ranges of the right hip both actively and passively and with weight-bearing and nonweight-bearing. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. If it is not feasible to do so to any degree of medical certainty without resorting to speculation, then the examiner must provide an explanation for why this is so. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups, regardless of whether the Veteran can be tested with repetitive use or is examined during a flare-up. The VA examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If it is not feasible to do so to any degree of medical certainty without resorting to speculation, the examiner must provide an explanation for why this is so. 2. Obtain an addendum to the October 2020 examiner's opinions regarding the kidney disability. The Veteran's claims folder should be provided to the reviewer prior to completion of the opinion. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney disability is related to service or was incurred within a year of service. The examiner should consider and discuss any relationship between the current kidney disability and the June 1981 notation in a medical history report that the Veteran had had kidney stones or urine in the blood. The examiner must also opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney disability is proximately due to or aggravated beyond its natural progression by medications taken for the service-connected left hip disability, specifically to include depomedrol. The examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. The examiner must discuss the medical rationale for all opinions expressed, whether favorable or unfavorable, and if necessary, citing to specific evidence in the file. If the examiner cannot provide his or her requested opinion without resorting to speculation, he or she should state why that is the case. 3. Obtain an addendum to the October 2020 examiner's opinions regarding the low back disability. The Veteran's claims folder should be provided to the reviewer prior to completion of the opinion. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability is related to service or was incurred within a year of service. The examiner must also opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability is proximately due to or aggravated beyond its natural progression by the service-connected left hip disability. The examiner should assume as credible the Veteran's report of experiencing back pain after falling in service in 1978 and having intermittent back pain since then. The examiner must also discuss the March 2017 pelvis examination that found that the Veteran had altered gait biomechanics and the April 2018 physical medicine consultation that found that the Veteran had an antalgic gait with prolonged stance in the right lower extremity. The examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. The examiner must discuss the medical rationale for all opinions expressed, whether favorable or unfavorable, and if necessary, citing to specific evidence in the file. If the examiner cannot provide his or her requested opinion without resorting to speculation, he or she should state why that is the case. 4. Obtain an addendum to the October 2020 examiner's opinions regarding the bilateral knee disability. The Veteran's claims folder should be provided to the reviewer prior to completion of the opinion. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral knee disability is related to service or was incurred within a year of service. The examiner must also opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral knee disability is proximately due to or aggravated beyond its natural progression by the service-connected left hip disability. The examiner must discuss the March 2017 pelvis examination that found that the Veteran had altered gait biomechanics and the April 2018 physical medicine consultation that found that the Veteran had an antalgic gait with prolonged stance in the right lower extremity. The examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. The examiner must discuss the medical rationale for all opinions expressed, whether favorable or unfavorable, and if necessary, citing to specific evidence in the file. If the examiner cannot provide his or her requested opinion without resorting to speculation, he or she should state why that is the case. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the severity of the service-connected disabilities as they relate to loss of use of the extremities. The Veteran's claims folder should be provided to the reviewer prior to completion of the opinion. The examiner should state whether the Veteran requires braces, crutches, canes, or a wheelchair in order to ambulate on at least an occasional basis, including the frequency with which any such assistive device is required. The examiner should also opine as to whether the Veteran's service-connected disabilities, including the left and right hip disabilities, cause: The loss of use of both lower extremities so as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. The loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. The loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. If there is loss of use due to nonservice-connected disabilities, the examiner is asked to identify such disabilities. As used here, the term "preclude locomotion" means the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. The examiner should fully describe the objective findings to support any conclusions (e.g., with respect to range of motion, instability, weakness, atrophy, tone, callosities, etc.), and should provide a complete rationale for all opinions expressed. If the examiner cannot provide his or her requested opinion without resorting to speculation, he or she should state why that is the case, including whether a new in-person examination in necessary. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott Shoreman, 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.