Citation Nr: 1538504 Decision Date: 09/09/15 Archive Date: 09/18/15 DOCKET NO. 09-49 022 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for osteoarthritis, status post left total hip replacement. 2. Entitlement to service connection for a low back disability, to include as secondary to service-connected osteoarthritis, status post left total hip replacement. 3. Entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected osteoarthritis, status post left total hip replacement. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Air Force from March 1987 to September 1990, from November 2001 to April 2002, from September 2004 to May 2005, and from July 2005 to February 2006. This case is before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which established service connection for osteoarthritis, status post left total hip replacement, and assigned a 30 percent disability rating. In February 2012, a Travel Board hearing was held before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In February 2013, the case was remanded for further development. The Board, in a November 2013 decision, denied the Veteran's claim for an initial disability rating in excess of 30 percent. In the November 2013 decision, the Board instructed the Agency of Original Jurisdiction (AOJ) to issue a Statement of the Case (SOC) relevant to the Veteran's claim for a higher initial disability rating for a right ankle disability, as the Veteran had submitted a timely notice of disagreement (NOD). See Manlincon v. West, 12 Vet. App. 238 (1999). In August 2015, the AOJ issued an SOC. The Veteran has not submitted a substantive appeal, and this issue is not before the Board at this time. The Veteran appealed the November 2013 Board decision to the U.S. Court of Appeals for Veterans Claims (Court). In a December 2014 Memorandum Decision, the Court vacated the November 2013 Board decision and remanded the issue for further adjudication. The claim now returns to the Board for such adjudication. In addition, while the RO has not adjudicated the issue of entitlement to a TDIU, the Court has held that a claim for a TDIU due to service-connected disability is part and parcel of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In the instant case, the Veteran alleged in his February 2013 hearing testimony that he was forced to resign from one job and take a less strenuous one, due to his hip disability. Therefore, in light of the Court's holding in Rice, the issue of entitlement to a TDIU has been raised by the record. As such, the Board has taken jurisdiction over this issue and has included it on the title page. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. The Board notes that, in addition to VBMS, there is a separate electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the documents in Virtual VA reveals that, with the exception of medical records dated from July 2011 to April 2013, the documents therein are either duplicative of those contained in the VBMS or irrelevant to the claim on appeal. The issues of entitlement to secondary service connection for a low back disability and for a bilateral knee disability, as well as entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. VA will notify the Veteran if any action on his part is required. FINDING OF FACT Throughout the entire appeal period, the Veteran's service-connected osteoarthritis, status post left total hip replacement, is productive of no more than moderately severe residuals of weakness, pain, and limitation of motion, without more severe residuals more nearly approximating markedly severe residuals or requiring crutches. CONCLUSION OF LAW The criteria for an initial 50 percent rating, but no higher, for osteoarthritis, status post left total hip replacement, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield, supra; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's rating claim arises from an appeal of the initial evaluation following the grant of service connection. The Board notes that once service connection is granted, the claim is substantiated and additional notice is not required. As such, any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA as to this issue. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file, to include the Veteran's electronic file, contains the Veteran's available service treatment records, post-service reports of VA, and private treatment and examination. Moreover, the Veteran's statements, to include testimony taken at the February 2012 Board hearing, in support of the claim are of record. The Board has carefully reviewed such statements and concludes that there is no available outstanding evidence pertinent to the claim decided below that must be obtained. Accordingly, the Board finds that all reasonable efforts have been undertaken by VA with respect to the instant appeal, and no further development is required under these circumstances. Additionally, the Veteran was afforded VA examinations in January 2007 and April 2013 to evaluate the severity of his left hip disability. The Board finds that the VA examinations are adequate because, as shown below, they are based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they describe his disability in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the April 2013 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination regarding the issue decided herein. As noted, the Veteran was provided with an opportunity to set forth his contentions during a hearing before the undersigned. The Board notes that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board, and a Veterans Law Judge has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that during the hearing the undersigned set forth the issue to be discussed at the hearing, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The Board also finds that there was substantial compliance with the February 2013 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to substantial compliance with a remand order. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board); see also Dyment v. West, 13 Vet. App. 141 (1999). In this case, the Board directed the agency of original jurisdiction (AOJ) to obtain and associate all outstanding VA treatment records, and then afford the Veteran a VA examination to determine the current severity of his left hip disability. A review of the claims file reveals all updated records have been associated with the claims file; and as noted, the Veteran was afforded a VA examination in April 2013. As stated above, and for reasons explained below, the Board finds that the VA examination is adequate. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Analysis In this case, the Veteran contends that his service-connected osteoarthritis, status post left total hip replacement, is more disabling than reflected in the current disability rating. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca, supra. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board finds that the 50 percent rating herein assigned represents the greatest level of severity throughout the entire course of the appeal. Consequently, "staged" ratings are not for consideration. In the August 2008 rating action, service connection was granted for status post total left hip replacement, and a 30 percent disability rating was assigned under Diagnostic Code 5054. The Veteran has disagreed with the evaluation assigned. Under DC 5054, replacement of the hip with prosthesis warrants a 100 percent rating for a one-year period following implantation of the prosthesis. Thereafter a minimum rating of 30 percent is warranted. A 50 percent rating is warranted for moderately severe residuals of weakness, pain, or limitation of motion. A 70 percent rating is warranted for markedly severe residual weakness, pain, or limitation of motion following implantation of the prosthesis. A 90 percent rating is warranted following implantation with painful motion or weakness such as to require the use of crutches. Normal range of motion for the hip is 0 degrees of extension to 125 degrees of flexion and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. The Board observes that the words "moderate," "moderately severe," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Evidence relevant to the severity of the Veteran's service-connected left hip disability includes, in addition to his assertions, private outpatient treatment notes, VA clinical records, and VA examination reports. A left hip arthroplasty was performed in November 2004. Service connection was granted for post-operative residuals of the left hip arthroplasty, and a 30 percent rating was assigned from February 9, 2006, the date of the Veteran's discharge from service. During a January 2007 VA examination, the Veteran reported pain, stiffness, fatigability, and lack of endurance. There was no noted weakness, swelling, and redness. He reported flare-ups occurring on average of one time a week, usually as a result of excessive walking. These flare-ups resulted in pain that he measured as 6 out of 10. The Veteran reported the flare-ups caused functional impairment in that he experienced difficulty walking, difficulty putting his clothes on, and difficulty getting out of a vehicle. The examiner noted the Veteran's grooming was severely adversely affected by his hip disability. The Veteran did not have a need for assistive devices, nor had he had any episodes of dislocation or recurrent subluxation. The examiner noted that the Veteran's joint problem moderately affected his walking and driving. It was further noted that the Veteran's recreational activities were moderately to severely adversely affected by his hip disability. On examination the Veteran had normal gait and posture; the left hip was not ankylosed; there was pain with motion, fatigue, and a lack of endurance; however, there was no noted weakness, incoordination, abnormal weight bearing, effusion, redness, or heat. Limitation of motion was indicated. The examiner found no need for a brace or crutches. Range of motion testing of the left hip revealed extension was to 30 degrees, flexion was to 100 degrees, abduction was to 40 degrees, adduction was to 20 degrees, internal rotation was to 30 degrees; and external was to 50 degrees. Range of motion testing after repetitive testing revealed some limitation in range of motion, as extension was to 25 degrees; flexion was to 95 degrees; abduction was to 35 degrees; adduction was to 15 degrees; internal rotation was to 25 degrees; and external rotation was to 45 degrees. There was no pain with extension, abduction, adduction, or internal rotation; pain was noted at 90 degrees of flexion, and at 45 degrees of external rotation. The examiner noted that functional limitations with regard to standing and walking were that the Veteran was unable to stand too long in one place, and he could not walk too long a distance. The diagnosis was osteoarthritis status post arthroplasty. In a January 2009 private medical record, the Veteran reported experiencing hip pain on an almost daily basis for over one year. He measured the pain at 3 out of 10 when at rest, and at 8 out of 10 with activity such as long walks or lifting objects that weighed over 20 pounds. Stiffness and a decreased range of motion were noted. The Veteran reported taking Mobic, a prescription pain reliever, 4 to 5 times a week for pain. A February 2009 private medical record indicated the Veteran had been experiencing left hip pain and reduced mobility ever since his hip replacement surgery. The Veteran reported taking Mobic every day, with some relief. Joint pain and a reduced range of motion were noted. In his April 2009 notice of disagreement (NOD), the Veteran contended that a 50 percent rating is warranted because he experienced moderately severe residuals of weakness, pain, or limitation of motion. He attached a copy of a February 2009 letter from his personal physician that documented his complaints of left hip pain, as well as the fact that he took Mobic on an almost daily basis for pain. The letter indicated that the Veteran had a limited range of motion with abduction, adduction, extension and flexion in the hip, and that he was not able to perform "strenuous activities" due to the affected hip. A December 2009 private treatment record notes left hip flexion "about 75 percent of full range"; and pain with extension, abduction, external rotation, and internal rotation passive ranges of motion. The examiner noted that the Veteran had left hip active flexor weakness with resistance and pain. A separate December 2009 private medical record revealed the Veteran continued to experience left hip pain, as well as pain in his lower back and left knee. He reported taking Mobic daily without much improvement. The Veteran rated his hip pain at 7 out of 10 while at rest and 9 out of 10 with activity. He reported that he was no longer able to carry anything that weighed over 20 pounds. The doctor noted that the Veteran's hip condition was affecting his knee and lumbar spine. Testing revealed the Veteran experienced a reduction in range of motion, as he was only able to raise his hip 10 degrees. In a December 2011 private medical record, the Veteran reported increased left hip pain with standing. Stiffness and a decreased range of motion were noted. During the February 2012 Travel Board hearing, the Veteran testified that he experienced increased pain and stiffness, as well trouble with sitting, stooping, or standing for long periods of time. The Veteran testified that he had to take frequent breaks while at work, in order to move around and prevent stiffness in the joint. The Veteran indicated that taking long walks, such as in a park or while shopping, caused pain and that he had to take Mobic for pain relief. He reported that a weakness in his left leg caused an inability to bend down without assistance. The Veteran testified that he was no longer able to do things he used to do, such as spend time outdoors, due to the pain. He indicated that his mobility was very limited and he had had to hire a lawn service because he was no longer able to mow his grass or climb ladders. The Veteran reported experiencing flare-ups on a weekly basis, as well as weakness and trouble sleeping due to the pain. He testified that any stress put on the hip resulted in pain that lasted for days. He characterized the pain as severe. An October 2012 private treatment record notes that the Veteran had a one-half inch limb length discrepancy. On April 2013 VA examination, the Veteran reported that his service-connected left hip disability was stable. He stated that during flare-ups he experienced reduced range of motion but otherwise was functioning well. Range of motion testing revealed flexion to 125 degrees or greater with no objective evidence of painful motion; extension was to 5 degrees or greater with no objective evidence of painful motion; abduction was not lost beyond 10 degrees; adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited in that the Veteran could not toe-out more than 15 degrees. The Veteran was able to perform repetitive-use testing with 3 repetitions. The examiner noted that there was no additional limitation in range of motion of the left hip. The examiner also noted that the left hip experienced functional impairment, as there was less movement than normal and there was pain on movement. Range of motion testing was reported again (page 6 of the examination report); flexion was 0 to 100 degrees; abduction was 0 to 30 degrees, with pain at 30 degrees; extension was 0 to 30 degrees; external rotation was 0 to 15 degrees active; the examiner noted that the Veteran takes the lower leg and brings it up over the opposite leg when putting on shoes and socks (notably exceeding 0 to 60 degrees normal range). Muscle strength testing revealed normal left hip flexion, abduction, and extension. There was no ankylosis present. There was no noted malunion, nonunion of the femur, flail hip joint or leg length discrepancy. The examiner noted that the Veteran utilized shoe inserts to even out his gait. He indicated that the Veteran's left hip disability impacted his ability to work in that the Veteran should avoid prolonged walking, standing, and should not run. The objective medical evidence shows left hip limitation of motion, pain and weakness, and the Veteran's competent and credible statements regarding consistent pain show a disability that more nearly approximates moderately severe residuals. See 38 C.F.R. §§ 4.7, 4.71a, Code 5054; see also Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, the Board finds that the Veteran's left hip disability most nearly approximates a 50 percent disability rating. The medical evidence of record and the Veteran's statements indicate that the predominant symptom of his left hip disability is hip pain. The Veteran's medical records are replete with reports of pain that limits his ability to perform activities such as walking long distances, driving, or sitting for too long. He consistently sought medical treatment for hip pain. The Veteran reported taking pain medication on a regular basis for relief. The Veteran was unable to lift heavy objects or stand for long periods of time. He reported some problems staying asleep due to pain. In addition, as will be explained below, the Veteran's hip pain moderately interferes with his ability to work. Further supporting this finding, the Veteran's medical record and testimony both indicate the presence of weakness and limitation of motion of a moderately severe nature. To this end, the February 2007 VA examination showed limitations in the Veteran's range of motion as a result of repetitive motion. December 2009 private medical reports revealed an inability to raise his left hip to 10 degrees. Weakness of the hip was shown in multiple records, a finding supported by the Veteran's February 2012 testimony that he had "no strength" in his hip. Private medical records dated January 2009, February 2009, and December 2011, as well as the February 2009 letter from his personal physician, all indicate a reduction in range of motion in his hip. To this end, as noted by the Court in its December 2014 remand, the February 2007 and April 2013 VA examiners recorded different objective range of motion results. For example, range of motion testing in 2007 indicated left hip flexion of 100 degrees; in 2013, flexion was measured at 125. Post-test range of motion in 2007 was measured at 95 and in 2013 it was 100. Post-test abduction was measured at 35 degrees in 2007 and 30 degrees in 2013. These results, which show some improvement and some worsening of the Veteran's hip disability, indicate to the Board that the objective findings of the examiners have remained somewhat consistent. Such a results support a finding that the Veteran's symptoms have been stable so that a staged rating, pursuant to Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007), is not required in this appeal. Even when considering any functional loss due to pain or flare-ups under 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, the Board finds that the Veteran's arthritis of the left hip with total hip replacement has not met the criteria for a 70 percent rating under Diagnostic Code 5054. That code requires symptoms that are characterized as markedly severe. While some of the evidence shows that the Veteran's disability severely affects his ability to perform daily activities of living, such as grooming, the evidence as whole does not reflect functional impairment congruent with a higher rating than that already assigned. As discussed in detail above, the bulk of the record, to include the Veteran's statements, reflects only moderate limitations due to his service-connected hip disability. Thus, while the Veteran has reported symptoms such as pain in the left hip after walking long distances, such limitation has already been taken into consideration in the assigned 50 percent rating for moderately severe residuals; the Veteran's left hip has not been shown to be so disabling as to result in a higher rating. In an effort to determine whether a higher evaluation may be assigned to the left hip disability, the Board also considered rating criteria based on limitation of motion and hip joint disabilities found in DCs 5250 through 5255, also under 38 C.F.R. § 4.71a. The medical evidence shows that the Veteran's hip replacement residuals do not indicate evidence of actual ankylosis of the hip, flail hip joint or fracture of the shaft or anatomical neck of the femur as contemplated by DCs 5250, 5254 and 5255. Id. Under DCs 5251 and 5253, the maximum ratings for limitation of motion or impairment of the thigh are 10 percent and 20 percent respectively. Thus, those codes would not provide a basis for a higher rating. Id. Also, considering the evidence of record, even if the Board could find that the Veteran has experienced pain so disabling as to result in flexion limited to 10 degrees or less, it would only warrant a 40 percent disability rating under DC 5252, which is a lesser percentage than what is presently being awarded. Id. There is likewise no evidence that any loss of extension, flexion, or abduction could combine to support a higher rating under such diagnostic code. Therefore, the Board concludes that the overall level of disability is properly measured under DC 5054 for limitation of motion, weakness, and pain, and that the Veteran's disability most closely approximates a moderately severe level best represented by the 50 percent minimum rating. For the reasons established above, the criteria for the assignment of disability ratings of 70 or 90 percent for osteoarthritis, status post left total hip replacement, are not met. III. Extraschedular consideration In its December 2014 remand, the Court instructed the Board to reconsider its extraschedular determination in this case. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (2015). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Veteran's left hip symptoms primarily involve pain, limitation of motion, and weakness. These symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the hip provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5251-5253 (2015) (providing ratings on the basis of ankylosis and limited motion). The diagnostic codes in the rating schedule corresponding to hip replacements provide disability on the basis of the severity of the disability. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. See 38 C.F.R. § 4.40 (2013); Mitchell, supra. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. See 38 C.F.R. §§ 4.45, 4.59 (2013); see also Mitchell, 25 Vet. App. at 37. Notably, 38 C.F.R. § 4.59 specifically compensates for painful motion. The Board notes that, in the February 2007 VA examination report, the Veteran indicated he did not have the same level of mobility he once had, and that he experienced stiffness, fatigability, and a lack of endurance. A moderate impact on his ability to walk and to drive was noted, as was an inability to stand for long or walk very far. In January 2009, the Veteran indicated that he could no longer take long walks or lift in excess of 20 pounds. In his testimony before the Board in February 2012, the Veteran indicated he was "very limited [in regard to] mobility," could no longer do yardwork, and could not sit or stand for long periods of time. The April 2013 VA examination report indicated the Veteran wore inserts in his shoes to "even out" his gait. The Board finds that such symptoms are contemplated by the rating criteria, as they are examples of weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with activities such as sitting, standing, and weight bearing. See Mitchell, supra. In short, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. As such, there is no indication in the record that the average industrial impairment from the Veteran's osteoarthritis, status post left total hip replacement, would be in excess of that contemplated by the rating assigned, as the Veteran's disability picture is not shown to be exceptional or unusual. In addition, the Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, the appeal does not involve evaluation of multiple service-connected disabilities, and further discussion of Johnson is unnecessary. Consequently, as the Veteran's disability picture is not shown to be exceptional or unusual, the Board need not address whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 115-16. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER An initial disability rating of 50 percent, but no higher, for osteoarthritis, status post left total hip replacement, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). As concerns the Veteran's claims for secondary service connection, the Veteran contends that he has developed back and knee disabilities as a result of his service-connected left hip disability. In a December 2009 private medical record, the Veteran's doctor indicated that the Vetearn's left hip was affecting his knee and lumbar spine. In his testimony before the Board in February 2012, the Veteran described problems with his left knee due to the altered gait he developed as a result of his hip replacement. He also described back pain that he attributed to his hip disability. In an October 2012 treatment note, the Veteran was found to have early degenerative joint disease and instability in his foot and ankle, which was attributed to the shortening of his limb due to the hip replacement. In his April 2013 notice of disagreement, the Veteran noted that his hip replacement caused issues with his back, legs and ankles. In the April 2013 VA examination report, the VA examiner noted that the Veteran had a disturbance of locomotion that interfered with his sitting, standing or weight bearing in his right leg. The Veteran has not yet been afforded a VA examination with respect to these disabilities, and the Board finds that a medical opinion is necessary to decide the claims. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, a remand is required in order to afford the Veteran a VA examination so as to determine whether his low back and bilateral knee disabilities are secondarily caused or aggravated by the Veteran's service-connected left hip disability. Regarding TDIU, as noted in the Introduction, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for TDIU is part and parcel of the claim for benefits for the underlying disability. See Rice, supra. In the present case, the Veteran testified at the February 2012 hearing that he had to resign from one job and take another, less taxing one, due to his inability to climb in and out of a truck. In addition, the April 2013 examination report indicated that the Veteran's hip disability impacted his ability to work, in that he should avoid prolonged walking and standing, and should not run. Accordingly, the Board finds that the issue of entitlement to TDIU has been raised in this case. In this regard, the AOJ should conduct all appropriate development, to include: providing the Veteran with VCAA-compliant notice as to the issue of entitlement of a TDIU; be asked to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability); and be scheduled for a Social and Industrial Survey. The Board notes that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. See 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). However, the Board finds that the Veteran should be afforded a Social and Industrial Survey that provides a full description of the effects of his osteoarthritis, status post left total hip replacement on his ordinary activities, to include his employability. 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Finally, the Board notes that VA is required by the VCAA to assist claimants by gathering all pertinent records of VA treatment and all identified private treatment records. As this case is being remanded for additional development, the AOJ must again take appropriate steps to identify and gather any pertinent records and associate them with the claims file. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded an opportunity to submit or identify any additional evidence relevant to his service connection claims for a low back disability and bilateral knee disability, as well as the newly raised claim for a TDIU. With appropriate authorization from the Veteran, the AOJ should obtain and associate with the claims file any additional evidence pertinent to the Veteran's claim. 2. After obtaining any outstanding records, schedule the Veteran for the appropriate VA examination to address the nature and etiology of any currently manifested back disabilities. The claims file, to include all electronic records, must be made available to the examiner for review, and the examination report should reflect that such review was conducted. The examiner is asked to identify all back disabilities. Then, in regard to each such diagnosis, the examiner is asked to express an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's low back disability is caused or aggravated by his service-connected osteoarthritis, status post left total hip replacement? If aggravation is present, the examiner should indicate, to the extent possible, the approximate level of severity of the back disability before the onset of the aggravation. All opinions expressed must be accompanied by detailed supporting rationale. 3. After obtaining any outstanding records, schedule the Veteran for the appropriate VA examination to address the nature and etiology of any currently manifested disabilities of the bilateral knees. The claims file, to include all electronic records, must be made available to the examiner for review, and the examination report should reflect that such review was conducted. The examiner is asked to identify all disabilities of the Veteran's bilateral knees. Then, in regard to each such diagnosis, the examiner is asked to express an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's knee disability is caused or aggravated by his service-connected osteoarthritis, status post left total hip replacement? If aggravation is present, the examiner should indicate, to the extent possible, the approximate level of severity of the knee disability before the onset of the aggravation. All opinions expressed must be accompanied by detailed supporting rationale. 4. The Veteran should be provided with proper VCAA notice regarding the evidence and information necessary to substantiate his TDIU claim. He should also be requested to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). 5. After completing the aforementioned development, schedule the Veteran for a Social Industrial Survey to ascertain the impact of his service-connected osteoarthritis, status post left total hip replacement on his ordinary activities, to include his employability. The record must be made available for review. The VA Social Industrial surveyor is requested to describe the Veteran's employment history. In this regard, the surveyor should provide a full description of the effects, to include all associated limitations, of the osteoarthritis, status post left total hip replacement, on his ordinary activities, to include his employability, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. All opinions expressed must be accompanied by detailed supporting rationale. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs