Citation Nr: 24018024 Decision Date: 04/26/24 Archive Date: 04/26/24 DOCKET NO. 17-01 793 DATE: April 26, 2024 REMANDED Service connection for left hip arthritis, to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran had active duty for training (ACDUTRA) from October 2009 to June 2010, with additional subsequent periods of Reserve training until April 2014. This matter comes before the Board of Veterans' Appeals (Board) from a September 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in July 2023 when it was remanded for additional development. It has since been returned to the Board for further appellate consideration. 1. Service connection for left hip arthritis, to include as secondary to a service-connected disability is remanded. Although the Board regrets additional delay, additional development is required prior to adjudicating the claim for service. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran contends that he injured his left hip during INACDUTRA on January 12, 2013, and that it caused his left hip arthritis. See July 2017 statement. In the alternative the Veteran argues that his left hip disability is related to his service-connected back condition. See June 2022 statement. The Veteran received an April 2023 VA examination. The examiner opined that the left hip arthritis was less likely than not aggravated beyond its natural progression by his service-connected condition. The examiner reasoned his service treatment records (STRs) from entry in October 2009 to separation June 2010 did not show evidence of aggravation of a left hip condition beyond its natural progression. Pursuant to the November 2022 Board remand the Veteran received a June 2023 VA examination. The examiner opined that the left hip disability was less likely than not incurred in or caused the claimed in-service, injury, event, or illness. The examiner acknowledged that "the 2019 radiology findings do reflect left hip pathology beyond what would be expected given age and general health." The examiner explained, "it is likely the veteran did suffer chronic repetitive trauma from activities which resulted in pathology of left hip beyond what would be expected, but no evidence suggests the process was specifically related to the veterans 8 months of active-duty service." Rather, the examiner reasoned that the available clinical evidence does not indicate that an active-duty related task contributed to the pathology of his left hip condition. First, the Board finds the June 2023 opinion is inadequate. The examiner's opinion is couched in speculative terms, "no evidence suggests the process was specifically related" to his active-duty service, making the examiner's degree of certainty to the conclusions rendered unclear. See, e.g., Bloom v. West, 12 Vet. App. 185, 187 (1999). Next, the Board acknowledges that the Veteran received a June 2023 VA examination, and the examiner provided an opinion regarding direct service connection. However, as discussed above the claim also includes a secondary theory of entitlement. It is noted that in the November 2022 remand the Board did not request the June 2023 VA examiner address a secondary theory of entitlement. Nevertheless, the April 2023 VA examiner did not provide an opinion that addressed all theories of entitlement. Specifically, the April 2023 failed to provide an opinion regarding whether the Veteran's left hip arthritis is proximately due to (caused by) the service-connected back disability. Additionally, the examiner's aggravation opinion does not contain adequate rationale as the examiner largely relied on the absence of evidence of aggravation in his STRs. The rationale provided does not help the Board understand why the Veteran's condition was not aggravated by his service-connected back condition. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Accordingly, there is no adequate medical opinion of record upon which the Board can rely to decide the claims. Thus, remand is required to adequately address all theories of entitlement. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities on appeal. 2. Following the receipt of any outstanding records, obtain an addendum opinion regarding the etiology of any diagnosed left hip disability from an appropriate clinician. The Veteran's entire claims file, to include a copy of this remand, should be provided to the examiner. If an examination is deemed necessary, it shall be provided. Following a complete review of the record, the examiner is asked to provide the following opinion: First, please diagnose all left hip disabilities found on examination or based on a review of the medical records. All diagnostic findings (or lack thereof). If any previously documented diagnoses are no longer extant or otherwise not felt to apply, the examiner must explain why. Second, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed left hip disability had onset in service or is otherwise related to active service or incurred during a period ACDUTRA or INACDUTRA. If the answer is no, then is it at least at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed left hip disability is proximately due to or the result of the service-connected back disability. In rendering the requested rationale, the examiner must note that it is not required that the left hip disability is shown to be "predominantly" due to or result of the service-connected back disability, but whether there is any contributing degree of etiological relationship to the service-connected condition. If not, then is it at least at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left hip disability is aggravated beyond natural progression by the service-connected back disability. In rendering the requested rationale, the examiner must note that it is not required that the left hip disability is shown to be aggravated beyond natural progression "predominantly" by the back disability, but whether there is any contributing degree of aggravation beyond natural progression by his service-connected condition. If aggravation is found, is there medical evidence that shows a baseline of the Veteran's left hip disability. 3. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If lay assertions in any regard are discounted, the examiner should clearly state, and explain why. The examiner should not discount the Veteran's lay statements without explanation or rely on an absence of medical evidence in the record to support his or her conclusions. In addressing the above the examiner is asked to consider and address the following: 1) any relevant STRS, including the May 5, 2013, Adult Preventive and Chronic Care Flowsheet reflecting he reported taking Aleve for bulging discs and left hip arthritis and the May 13, 2013, Periodic Health Assessment that notes the Veteran reported that he had arthritis in his left hip due to "military backpack." 2) any relevant private treatment records, including the June 11, 2013, medical record that reflects the Veteran reported he takes over-the-counter medication for his back and hips "secondary to carrying heavy packs in the military", the October 2013 record noting the Veteran reported occasional left hip pain, and the October 2015 medical record notes that the Veteran reported a history of left hip and low back issue since service. (Continued on the next page) ? 3) the September 2023 VA examination. 4. A complete rationale must be provided for each opinion. Providing an opinion or conclusion without explanation will delay processing of the claim and require clarification. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Braxton, 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.