Citation Nr: 22010574 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 09-29 610 DATE: February 24, 2022 REMANDED Entitlement to service connection for a low back disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. Entitlement to service connection for a left hip disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to October 1971, and from July 1974 to December 1995. In July 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Most recently, in May 2021, the Board remanded these issues for additional development. Unfortunately, the Board finds that another remand is necessary in order obtain an adequate medical opinion. The Board notes that there appears to be an indication that the Veteran is also claiming that these disabilities are secondary to his bilateral foot disability. Thus, the Board has recharacterized the issues pertaining to the back and hips to reflect this claim. 1. Entitlement to service connection for a low back disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. 2. Entitlement to service connection for a left hip disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. 3. Entitlement to service connection for a right hip disorder, to include as secondary to the service-connected knee and feet disabilities, is remanded. These issues were most recently remanded to obtain an opinion as to whether the Veteran's low back, left hip and right hip disorders were secondary to his bilateral knee disability. The Veteran was afforded a VA examination with opinion in November 2021. The examiner opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition. The examiner provided the same rationale for each disability. In relevant part, the examiner found that the Veteran's right hip, lumbar and left hip disorders are less likely than not proximately due to or the result of the Veteran's service-connected conditions, including bilateral total knee replacements and bilateral pes planus. The examiner observed that there does not appear to be substantial changes in gait and or anatomical alterations which would affect proximal joints including the right hip, back, and left hip. The examiner also found that the disabilities were not aggravated beyond their natural progression by the service-connected conditions. The examiner provided the same rationale for aggravation as causation. Importantly, a secondary service connection claim has two prongs: causation and aggravation. 38 C.F.R. § 3.310. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Thus, the November 2021 opinion is inadequate as the examiner provided the same rationale for both causation and aggravation. Moreover, the crux of the rationale was that the Veteran did not show any substantial changes in gait that would affect proximal joints. However, VA clinical records show that the Veteran ambulated slow and used a cane. He also consistently wore knee braces and shoe orthotics. Prior VA clinical records also observed limping. Moreover, on numerous occasions, the Veteran reported trouble walking due to his feet and knees. Importantly, the June 2018 VA examination noted that the Veteran had pain in the low back due to compensation for knee pain and abnormal walking. Thus, it appears that the remaining medical evidence of record contradicts the examiner's rationale, and the examiner failed to rectify their finding with this evidence. Further, the examiner indicated that the Veteran's disabilities were not aggravated beyond their natural progression by the service-connected disabilities. Importantly, the United States Court of Appeals for Veterans Claims (Court) has held that any incremental increase in nonservice-connected disability by service-connected conditions warrants secondary service connection regardless of permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Thus, in light of the above, the Board finds that an addendum opinion is needed as to whether the Veteran's service-connected knee and feet disabilities cause or aggravate his low back, left hip and right hip disorder, to include any incremental increase, even transient, regardless of permanence. 4. Entitlement to a TDIU is remanded. The matter of entitlement to a TDIU is inextricably intertwined with the remaining issues on appeal. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate examiner to determine the nature and etiology of any low back disorder, left hip disorder and right hip disorder. The examiner must review the entire claims file. The need for another examination is left to the discretion of the examiner. The examiner is asked to address the following: (a) Is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's currently diagnosed back disorder, left hip disorder and right hip disorder are caused by the service-connected bilateral knee and foot disabilities, to include any impaired gait caused by such disabilities? (b) Is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's currently diagnosed back disorder, left hip disorder and right hip disorder are aggravated (any incremental increase regardless of permanence) by the service-connected bilateral knee and foot disabilities, to include any impaired gait caused by such disabilities? All opinions are to be accompanied by a rationale consistent with the evidence of record. The examiner must provide different, separate rationales for both causation and aggravation. The examiner must discuss the evidence that shows the Veteran has walked with a limp as well as used a cane, knee braces and foot inserts to ambulate. The examiner must also consider the statements made by the Veteran indicating trouble walking, especially the June 2018 VA examination that showed pain was present in the low back due to compensating for knee pain and abnormal walking. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.N. Moats 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.