Citation Nr: 22040111 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 15-46 373 DATE: July 13, 2022 REMANDED Entitlement to service connection for a left hip disability, to include avascular necrosis and degenerative arthritis, is remanded. Entitlement to an initial compensable rating for residuals of stress fracture, right inferior and superior pubic ramus, limitation of extension, is remanded. Entitlement to an initial rating in excess of 10 percent for residuals of stress fracture, right inferior and superior pubic ramus, limitation of flexion, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active duty service from August 2006 to December 2006 and from March 2009 to September 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in May 2013. The RO, in relevant part, denied service connection for a left hip disability and continued an initial rating of 10 percent for limitation of flexion of the right thigh and a noncompensable rating for limitation of extension of the right thigh. These matters were previously before the Board in September 2018, at which time they were remanded for further evidentiary development. The Board also found that the issue of entitlement to a total disability rating based on individual unemployability (TDIU) was reasonably raised by the evidence per Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), and remanded the issue for development. In a June 2021 rating decision, the RO increased the rating for limitation of extension of the right thigh from noncompensable to 10 percent, effective February 23, 2021. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing in March 2022. A copy of the hearing transcript has been reviewed and associated with the claims file. 1. Entitlement to service connection for a left hip disability, to include avascular necrosis and degenerative arthritis, is remanded. When VA undertakes the effort to provide an examination, the examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Inadequate medical examinations include those that provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr, 21 Vet. App. at 311. It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez, 22 Vet. App. at 304. VA must consider all lay and medical evidence of record. 38 U.S.C. §§ 1154(a), 5107; 38 C.F.R. § 3.303. The Veteran has claimed entitlement to service connection for a left hip disability. VA examinations have revealed diagnoses of avascular necrosis and degenerative arthritis of the left hip. She asserts that these disabilities are caused by an injury incurred after falling during a basic training exercise. The service treatment records indicate that the Veteran fell into a hole in October 2016 and subsequently reported hip pain. She was assessed in October 2016 with a left sacroiliac joint stress fracture. The Veteran underwent a VA examination in July 2012, wherein she was diagnosed with a left sacroiliac joint stress fracture. The examiner opined that it is less likely than not that the Veteran's claimed left hip disorder was related to service because there are no complaints in her service treatment records for an acute injury or chronic complaints of left hip pain. The examiner issued an addendum opinion in November 2012, wherein he clarified that the sacroiliac joint is a separate joint from the left hip and reiterated his negative nexus opinion based on a lack of left hip complaints in the Veteran's service treatment records. Another VA medical opinion was issued in November 2018. The examiner opined that it is less likely than not that the Veteran's avascular necrosis and degenerative arthritis of the left hip are directly related to service, as there are no service treatment records indicating treatment for a left hip disability during service. She also opined that it is less likely than not that the Veteran's left hip disabilities were caused or aggravated by her service-connected right hip disability. She stated that there is no known physiologic mechanism whereby a prior right hip stress fracture could cause degenerative arthritis or impede the blood supply to the left hip to cause avascular necrosis. The examiner also indicated that there is no medical evidence demonstrating that the avascular necrosis or degenerative arthritis were aggravated beyond their natural progression. Another VA opinion was issued in October 2020. The examiner opined that it is less likely than not that the Veteran's avascular necrosis and degenerative arthritis of the left hip are directly related to service, as they were diagnosed seven years after her separation from service and no service treatment records show concerns of avascular necrosis or degenerative arthritis. She also opined that it is less likely than not that the Veteran's left hip disabilities were caused by her service-connected right hip disability because there is no medical literature or pathophysiology to support a finding that the right hip disability causes or increases the risk of developing left hip avascular necrosis or degenerative arthritis. An addendum medical opinion was issued in January 2021, in which the examiner opined that the Veteran's avascular necrosis and degenerative arthritis of the left hip are less likely than not caused by or incurred during service, as they were not detected until seven or eight years after her separation from service. He also stated that the complaints of hip pain during service were due to the left sacroiliac joint stress fracture and the service-connected right hip disability. In January 2021, the RO issued a rating decision which granted service connection for residuals of a left sacroiliac joint stress fracture. The Board finds the VA medical opinions on direct service connection to be inadequate. In this regard, the examiners relied on a lack of treatment for left hip problems during service and the period of seven years between her separation from service and diagnosis of avascular necrosis and degenerative arthritis of the left hip. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (examination inadequate where the examiner relied on the lack of evidence in service treatment records to provide a negative etiology opinion). Therefore, a new medical opinion is warranted on the issue of whether the Veteran's left hip disabilities were incurred during service or are caused by an in-service injury, event, or illness. Additionally, the January 2021 rating decision granted service connection for residuals of a left sacroiliac joint stress fracture. The Veteran claims that her current hip problems resulted from the same in-service injury that caused her service-connected sacroiliac joint disability. Therefore, it is reasonable to conclude that her claimed disabilities may be secondary to the service-connected sacroiliac joint disability, and a medical opinion is warranted to address this issue. 2. Entitlement to an initial compensable rating for residuals of stress fracture, right inferior and superior pubic ramus, limitation of extension, is remanded. 3. Entitlement to an initial rating in excess of 10 percent for residuals of stress fracture, right inferior and superior pubic ramus, limitation of flexion, is remanded. In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion (ROM) measurements of the opposite undamaged joint where applicable. Simply noting whether the Veteran exhibited pain on weight-bearing and non-weight-bearing is insufficient under Correia; VA examiners are to record the ROM testing results for both active and passive motion, as well as both weight-bearing and non-weight-bearing. See 28 Vet. App. at 170. The Veteran asserts that she is entitled to higher ratings for her service-connected residuals of stress fracture, right inferior and superior pubic ramus. She is currently in receipt of a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5252, for limitation of flexion. She is in receipt of a noncompensable rating prior to February 25, 2021, and a 10 percent rating thereafter, under Diagnostic Code 5251 for limitation of extension. The Veteran underwent a VA hip examination in July 2012. Her initial range of motion (ROM) measurements in the right hip were flexion to 90 degrees with pain and extension to 20 degrees with pain. The Veteran was unable to perform repetitive use testing. She reported flare-ups causing difficulty with driving, exercising, and sexual relations due to hip pain. The Veteran underwent another VA examination in October 2015. She was unable to perform ROM testing due to instability on her feet. However, the examiner noted pain with weight-bearing. He also indicated that the Veteran had additional functional loss with repeated use over time and during flare-ups but could not provide ROM estimates for the additional functional loss. Another VA examination was conducted in October 2020. Her initial ROM measurements for the right hip were flexion to 65 degrees and extension to 10 degrees. She had no additional ROM loss with repetitive use testing. The examiner opined that the Veteran had flexion to 60 degrees and extension to 10 degrees with repeated use over time and during flare-ups. the examiner noted pain with weight-bearing and non-weight-bearing, as well as with active and passive ROM testing. The Veteran underwent another VA examination in February 2021. Her active and passive ROM measurements for the right hip were flexion to 60 degrees and extension to 8 degrees, both with pain. The examiner also noted pain with weight-bearing and non-weight-bearing, as well as on rest/non-movement. She indicated that the Veteran's right hip ROM after repetitive use, with repetitive use over time, and during flare-ups is flexion to 45 degrees and extension to 5 degrees. The Board finds that the VA examinations of record do not comply with the requirements of Correia, 28 Vet. App. at 158. In this regard, while the October 2020 and February 2021 examiners noted pain with weight-bearing and non-weight-bearing, they did not provide ROM measurements indicating the point at which pain was experienced with weight-bearing and non-weight-bearing. Additionally, the October 2021 examination does not include passive ROM measurements. While the other VA examinations were conducted prior to the Correia decision, they also do not include ROM measurements for passive motion, weight-bearing, and non-weight-bearing. Accordingly, an addendum medical opinion is needed to estimate the Veteran's prior ROM measurements with passive motion, weight-bearing, and non-weight-bearing. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Veteran is currently service connected for the following disabilities: residuals of left sacroiliac joint stress fracture, rated as 10 percent disabling; residuals of stress fracture, right inferior and superior pubic ramus, limitation of flexion, rated as 10 percent disabling; residuals of stress fracture, right inferior and superior pubic ramus, limitation of extension, rated as noncompensable prior to February 25, 2021 and 10 percent disabling from that date; and residuals of stress fracture, right inferior and superior pubic ramus, impairment of the thigh, rated as noncompensable from November 2, 2018 and 20 percent disabling from October 22, 2020. Her combined disability rating is 20 percent prior to October 22, 2020, and 40 percent from that date. Thus, she does not currently meet the schedular criteria for a total disability rating based on individual unemployability (TDIU). The issues of entitlement to service connection for a left hip disability and increased ratings for limitation of flexion and extension of the right thigh remain on appeal. Should they be awarded, the Veteran may be eligible for a schedular TDIU award. As a decision with respect to the pending claims regarding the hips will affect the Veteran's claim of entitlement to a TDIU, these claims are inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Consequently, the claim for entitlement to a TDIU must be remanded. The matters are REMANDED for the following actions: 1. Obtain an addendum medical opinion from the examiner who issued the January 2021 VA left hip medical opinion or, if that examiner is unavailable then another similarly qualified examiner may respond instead. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. A new VA examination is only necessary if deemed so by the examiner. The examiner should respond to the following: (a.) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran's left hip avascular necrosis and/or degenerative arthritis had its onset during active duty service or is otherwise related to an in-service injury, illness, or event? (b.) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran's left hip avascular necrosis and/or degenerative arthritis was caused or aggravated beyond its natural progression by her service-connected residuals of a left sacroiliac joint stress fracture? Aggravation can include temporary worsening or flare-ups. (c.) If aggravation is found, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the left hip avascular necrosis and/or degenerative arthritis prior to aggravation? If so, please identify. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. A negative nexus opinion may not rely solely on a lack of complaints or treatment for a left hip disability during service. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 2. Obtain an addendum medical opinion from the examiner who conducted the February 2021 VA hip examination or, if that examiner is unavailable then another similarly qualified examiner may respond instead. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. A new VA examination is only necessary if deemed so by the examiner. The examiner should respond to the following: (a.) Please provide range of motion (ROM) estimates for the degree at which the Veteran experienced pain with weight-bearing at each prior VA examination. (b.) Please provide range of motion (ROM) estimates for the degree at which the Veteran experienced pain with non-weight-bearing at each prior VA examination. (c.) Please provide range of motion (ROM) estimates for the degree at which the Veteran experienced pain with passive motion at each prior VA examination. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. After completion of #1 and #2, readjudicate the issues on appeal, to include consideration of the additional VA examination reports and treatment records since the last Supplemental Statement of the Case (SSOC) in June 2021. If the benefits sought on appeal are not granted in full, issue the Veteran and her representative an SSOC and provide the Veteran an opportunity to respond. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.