Citation Nr: 22017496 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 19-08 811 DATE: March 25, 2022 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a right hip disability, to include as secondary to a lumbar spine disability, is remanded. Entitlement to service connection for a left hip disability, to include as secondary to a lumbar spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1988 to January 1995. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for a lumbar spine disability is remanded. The Veteran contends that his lumbar spine disability is due to overuse injuries incurred during service. The Veteran testified that his low back pain had its onset in service and was related to repetitively lifting heavy cables on aircraft carrier catapult equipment along with performing physically demanding activities as an aviation storekeeper, like driving forklifts, lifting heavy equipment, and moving boxes. See Hearing Transcript at 3-5, 12 (July 2021). To ensure that VA has met its duty to assist, remand is required for an addendum medical opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the medical evidence of record is inadequate to decide the claim on appeal. A VA medical opinion, dated in January 2018, reflects that the Veteran's lumbar spine disability, diagnosed as degenerative disc disease, was less likely than not incurred in or caused by an in-service injury, event or illness. The Board finds the VA medical opinion inadequate for adjudicative purposes. First, the negative opinion primarily relied on the absence of medical documentation in the STRs of low back injury or symptoms from lifting heavy cable. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). The rational lacked any explanation as to how the absence of such supported the negative conclusion reached. Second, the opinion does not reflect consideration of relevant STRs. For instance, a December 1988 STR reflects that the Veteran complained of low back pain and muscle spasms and was assessed with resolving lower back pain. An August 1991 STR reflects that he was diagnosed with muscular low back strain after lifting a 30 to 35 pound child. A December 1994 Report of Medical History at separation reflects history of swollen or painful joints when exercising. Similarly, the opinion does not reflect consideration of other relevant evidence. While the opinion reflects that a June 2000 private x-ray report first documented degenerative changes of the lumbar spine, the opinion does not reflect consideration of a corresponding private medical record, dated in June 2000, noting (1) the Veteran had a history of intermittent back pain in the past, going back to the days when he was in the Navy, and (2) an April 2001 lumbar spine x-ray report showing findings compatible with old minimal compression injuries at T12, L1 and L2. See Medical Treatment Record Non-Government Facility (July 2017). Given the absence of any meaningful discussion of this evidence in the rationale suggests a lack of awareness of seemingly relevant facts and, therefore, casts doubt on the medical opinions' foundation. Third, the opinion's rationale does not reflect any meaningful consideration of the Veteran's lay statements. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) ("the VA examiner's failure to consider [a veteran's] testimony when formulating her opinion renders that opinion inadequate."). Indeed, the Veteran has stated that he was responsible for maintaining and inspecting all launch bridle assemblies and holdback cables which weighed between 10 pounds and 140 pounds and performed other duties related to flight operations. He also indicated that, during service, he was referred for a lumbar spine x-ray in Meridian, Mississippi, and was told that his back was not in good shape. See NOD (December 2018). Likewise, at his Board hearing, the Veteran testified to experiencing low back pain from lifting heavy cables and performing physically rigorous activities related to his duties as an aviation storekeeper. See Hearing Transcript (July 2021). Although the clinician is not required to accept the Veteran's theory that his military service caused his disability, or that he had symptoms associated with the disability during or following military service if this is incongruous with the record; however, the clinician is required to fully explain why he or she disagrees with the Veteran's theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). If another etiology is the more likely cause, the clinician must provide a complete explanation of his or her reasoning. Given the above deficiencies, the Board finds the opinion is inadequate for decision-making purposes and remand is necessary. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for a right hip disability is remanded. 3. Entitlement to service connection for a left hip disability is remanded. Issues 2 & 3. The Veteran testified that his right and left hip disabilities are secondary to his lumbar spine disability. See Hearing Transcript at 17 (July 2021). Specifically, the Veteran contends that his bilateral hip disabilities are the result of gait abnormalities caused by his lumbar spine disability. See Hearing Transcript at 4, 15-16 (July 2021). First, the Board finds that the claims of entitlement to service connection for right and left hip disabilities are inextricably intertwined with the claim of service connection for a lumbar spine disability. Therefore, the Board must defer consideration of the claims at this time. See Harris v. Derwinski, 1 Vet. App. 181 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Second, the Board finds that a January 2018 VA medical opinion addressing the etiology of the Veteran's right and left hip disabilities is inadequate. See Barr, 21 Vet. App. at 311. The examination report reflects diagnoses of bilateral total hip arthroplasties. By history, bilateral hip pain began in 2010 and gradually worsened. He attributed the bilateral hip pain to walking abnormally due to low back pain. The associated opinion reflects that: It is less likely than not that the hip conditions are secondary to the back pain. Based on available records, the back and hip pain started in the same timeframe. There is no explanation for how the back pain resulted in altered gait that would lead to the advanced degenerative changes that eventually occurred in the hips. Further, x-ray imaging shows that there was probable impingement of the hip joints that likely lead to his arthritis and eventual hip replacements. Simply stated, the opinion is conclusory and does not contain a reasoned explanation for the negative conclusion reached. More specifically, it is unclear how the examiner arrived at the conclusion that the low back and bilateral hip conditions began at the same time. In this regard, the record contains private medical evidence, dated in June 2000, reflecting the Veteran's report of intermittent low back pain going back to his time in service. In addition, the Veteran testified that his bilateral hip pain began around 2010 which is corroborated by a July 2011 MRI report of the bilateral hips, noting a clinical history of low back pain radiating to the bilateral hips, left greater than right. The opinion is therefore inadequate because it does not contain a clear conclusion with supporting data, nor a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Moreover, the examiner provided no opinion on whether the Veteran's bilateral hip disabilities are aggravated beyond their normal progression by the lumbar spine disability. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to, "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). As such the opinion is inadequate because it does not provide a rationale that deals with causation and aggravation as separate concepts. See Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018). Thus, the Board finds that only if the agency of original jurisdiction (AOJ) finds that the Veteran has a lumbar spine disability linked to his military service, then another VA medical opinion must be obtained to address whether the Veteran's bilateral hip disabilities are secondary to the lumbar spine disability. See El Amin, supra. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for signs or symptoms of his lumbar spine and bilateral hip disabilities, to include from Asante Physicians Partners Family Medicine and Southern Oregon Orthopedics. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's lumbar spine disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinicians. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with a lumbar spine disability. The clinician should specifically address whether the in-service low back symptoms reflect onset of or an early manifestation of later diagnosed degenerative disc disease of the lumbar spine. The clinician must opine on: Whether any low back disability at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran's theory that it stems from repetitive-use and over-use related to lifting of heavy cables and his duties as an aviation storekeeper. See Hearing Transcript at 3-5, 12 (July 2021) & NOD (December 2018). The opinion, at a minimum, should reflect consideration of the following: (1) STRs showing complaints and diagnoses in December 1988 and August 1991, related to the lumbar spine and the December 1994 report of medical history at separation in which the Veteran marked he had painful joints when exercising, (2) a private medical record dated in June 2000 noting the Veteran had a history of intermittent low back pain since his time in the Navy, and (3) buddy statements provided by the Veteran's spouse and coworkers. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): The opinion should reflect consideration of the pertinent evidence of record (e.g., the Veteran's documented relevant history and assertions). In other words, consider and expressly address the Veteran's theory that his lumbar spine disability stems from his in-service duties and activities. NOTE (3): The clinician is not required to accept the Veteran's theory that his military service caused his lumbar spine disability, or that he had symptoms associated with a lumbar spine disability during or following military service if this is incongruous with the record; however, the clinician is required to fully explain why he or she disagrees with the Veteran's theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). 3. ONLY IF the above development shows that a lumbar spine disability is related to service, then obtain an addendum opinion from an appropriate clinician addressing whether the Veteran's right and/or left hip disabilities are at least as likely as not (1) proximately due to a service-connected lumbar spine disability, or (2) aggravated beyond the natural progression by a service-connected lumbar spine disability. Provide a rationale that deals with causation and aggravation as independent concepts. Explain. 4. Ensure that the medical opinion(s) obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Krunic, 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.