Citation Nr: 1303170 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 08-26 518 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a higher initial disability rating for lumbar spine osteoarthritis, in excess of 10 percent prior to February 1, 2012, and in excess of 20 percent from February 1, 2012. 2. Entitlement to a higher initial disability rating in excess of 20 percent for limitation of abduction of the right thigh. 3. Entitlement to a higher initial disability rating for status post fracture of the right femur, in excess of 0 percent prior to February 1, 2012, and in excess of 10 percent from February 1, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Ganz, Associate Counsel INTRODUCTION The Veteran, who is the Appellant, had active service from June 1972 to April 1974. This matter is before the Board of Veterans' Appeals (Board) on appeal from August 2005 and October 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The August 2005 rating decision granted service connection for lumbar spine osteoarthritis, with a 10 percent initial rating, and for status post fracture of the right femur, with a 0 percent rating. The Veteran disagreed with the initial ratings assigned in the August 2005 rating decision. Following a January 2012 Board remand so that he could be provided with a new VA examination to assess the severity and manifestations of his service-connected disabilities, in an October 2012 rating decision, the Appeals Management Center (AMC) increased the disability rating for lumbar spine osteoarthritis to 20 percent, effective February 1, 2012, and increased his rating for status post fracture, right femur, to 10 percent, effective February 1, 2012, thus creating staged initial ratings. In the October 2012 rating decision, the AMC also granted a separate 20 percent rating for limitation of abduction of the right thigh, which was noted to be ancillary to the service-connected status post fracture of the right femur disability. Because the evaluations of the Veteran's disabilities do not represent the maximum ratings available for his disabilities under all of the potentially applicable diagnostic codes related to the spine, thigh, and hip (including limitation of abduction of the thigh under 38 C.F.R. § 4.71a, Diagnostic Code 5253), the Veteran's appeals for higher initial ratings remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. Prior to February 1, 2012, the Veteran's lumbar spine osteoarthritis was productive of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis. 2. At no point prior to or after February 1, 2012, even with consideration of limitation of motion due to pain, did the Veteran's lumbar spine osteoarthritis manifest forward flexion of the thoracolumbar spine of 30 degrees or less or favorable or unfavorable ankylosis of the entire thoracolumbar spine. 3. At no time during the pendency of the initial rating period on appeal, even with consideration of limitation of motion due to pain, has the Veteran's limitation of abduction of the right thigh manifested ankylosis of the hip; flexion functionally limited to 45 degrees or less; flail hip joint; or impairment of the femur manifesting malunion or fracture with nonunion or false joint. 4. Prior to February 1, 2012, the Veteran's status post fracture, right femur, disability was manifested by painful and limited motion of the hip or thigh. 5. At no time during the pendency of the initial rating period on appeal, even with consideration of limitation due to pain, did the status post fracture of the right femur manifest ankylosis of the hip; flexion functionally limited to 45 degrees or less; flail hip joint; impairment of the femur manifesting malunion or fracture with nonunion or false joint; or a discrepancy in the length of his lower extremities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, prior to February 1, 2012, the criteria for an initial rating of 20 percent, but no more, for lumbar spine osteoarthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5003, 5010, 5242 (2012). 2. At no time during the pendency of the initial rating period on appeal have the criteria for a rating in excess of 20 percent for lumbar spine osteoarthritis been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5003, 5010, 5242 (2012). 3. At no time during the pendency of the initial rating period on appeal have the criteria for an initial rating in excess of 20 percent for limitation of abduction of the right thigh been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5250-5255 (2012). 4. Resolving reasonable doubt in the Veteran's favor, prior to February 1, 2012, the criteria for an initial rating of 10 percent, but no more, for status post fracture of the right femur have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5003 (2012). 5. At no time during the pendency of the initial rating period on appeal have the criteria for a rating in excess of 10 percent for status post fracture of the right femur been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5250-5255 and 5275 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Concerning the appeal for higher initial ratings for lumbar spine osteoarthritis, status post fracture of the right femur, and limitation of abduction of the right thigh, because these are an appeal that arise from the Veteran's disagreement with the initial evaluations following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); 38 C.F.R. § 3.159(b)(3) (2012); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). See also 38 C.F.R. § 3.159(b)(3)(i) (there is no duty to provide VCAA notice upon receipt of a notice of disagreement). 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). VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A. VA has obtained service treatment records (STRs), post-service VA and private treatment records, and other records identified by the Veteran. The Veteran has not indicated he is in receipt of any benefits from the Social Security Administration (SSA) and has indicated as of his last VA examination that he is currently working. The Veteran has been afforded adequate examinations on the issues of higher initial ratings for his service-connected disabilities. The Veteran has been provided with VA examinations in April 2008 and February 2012, and a QTC examination on behalf of VA in June 2005. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA findings obtained in this case are adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. The VA examiners considered all of the pertinent evidence of record, to include STRs, VA and private treatment records, comprehensive physical examinations, including range of motion testing, and medical imaging, and the statements of the Veteran. Additionally, the most recent February 2012 VA examiner considered all of the above, and noted a review of the Veteran's claims file. Regarding the issues of limitation of abduction of the right thigh and status post fracture, right femur, during the most recent February 2012 VA examination assessing the severity of these disabilities, the examiner specified the point during range of motion testing where the Veteran's disabilities first manifested pain during initial range of motion testing and then conducted repetitive use range of motion testing. The examiner noted that the Veteran had additional limitation in the range of motion and functional loss or impairment of his hip and thigh following repetitive use testing. The examiner then specified that the Veteran had less movement than normal, swelling, instability, and disturbance in locomotion in the left hip and thigh, and weakened movement and pain on movement in both hips and thighs. Therefore, the examiner specified in his initial testing where painful motion began, and specified that after repetitive use testing his left hip and thigh had less movement than normal rather than his right hip and thigh. Given this the Board finds that this examination is adequate and fully addresses the requirement of DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). See Barr, 21 Vet. App. at 312. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Initial Ratings Legal Criteria for Initial Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of a Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 must be considered. See DeLuca, 8 Vet. App. at 202. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. §§ 4.45, 4.59. Ankylosis is immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is also defined as a stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Rating Lumbar Spine Osteoarthritis The Veteran claims his lumbar spine osteoarthritis warrants an initial evaluation in excess of 0 percent prior to February 1, 2012, and a rating in excess of 20 percent after February 1, 2012. The Veteran contended in his July 2008 VA Form 9 substantive appeal to the Board that he could function better then normal during the April 2008 VA examination because he had received an epidural injection in his back 12 days prior to the examination, and that his disability should be rated higher. The RO granted service connection for lumbar spine osteoarthritis, with a 10 percent evaluation, in the rating decision on appeal under 38 C.F.R. § 4.71a, DC 5010 (arthritis due to trauma). In its October 2012, rating decision, the AMC granted the Veteran's rating to 20 percent under this same diagnostic code; however, the AMC based its decision on the forward flexion of the Veteran's thoracolumbar spine being limited to 60 degrees, which is the General Rating Formula for Disease and Injuries of the Spine. The RO should have used the hyphenated Diagnostic Code 5010-5242 to reflect that the rating was now based on limitation of motion of the thoracolumbar spine to 60 degrees. The Veteran's service-connected lumbar spine osteoarthritis is more appropriately rated under DC 5242, degenerative arthritis of the spine, which is rated under the General Rating Formula for Diseases and Injuries of the Spine. Regardless, the Board will consider all applicable diagnostic codes under 38 C.F.R. § 4.71a. See 38 C.F.R. § 4.27 (2012). The General Rating Formula provides that diseases and injuries of the spine should be rated as follows: 5235, vertebral fracture or dislocation; 5236, sacroiliac injury and weakness; 5237, lumbosacral or cervical strain; 5238, spinal stenosis; 5239, spondylolisthesis or segmental instability; 5240, ankylosing spondylitis; 5241, spinal fusion; 5242, degenerative arthritis of the spine (see also Diagnostic Code 5003); and 5243, intervertebral disc syndrome. 38 C.F.R. § 4.71a. Under the general rating formula for diseases and injuries of the spine, ratings are assigned as follows: with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent disability evaluation is assigned when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. The Board notes that the Veteran is service connected for radiculopathy of the right and left lower extremities, which are each assigned separate 40 percent evaluations, effective February 1, 2012. The February 2012 rating decision granting these benefits found that they were related to his service-connected lumbar spine osteoarthritis. The Veteran has not disagreed with the assigned rating or effective date for these grants of service connection. Given that the rating or effective date assigned his left or right lower extremity radiculopathy disabilities are not issues before the Board, the current decision will not address the service-connected radiculopathy. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (2012) (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months warrants a 20 percent evaluation. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Initial Rating for Lumbar Spine Osteoarthritis prior to February 1, 2012 After a review of all of the evidence, the Board finds that, resolving reasonable doubt in the Veteran's favor, prior to February 1, 2012, the criteria for an initial rating of 20 percent, but no more, for lumbar spine osteoarthritis, have been met. For the period prior to February 1, 2012, the evidence shows that the Veteran's lumbar spine osteoarthritis was productive of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis. A review of the STRs do not show that the Veteran was treated for any back or spinal complaints or conditions during service. Service connection for the lumbar spine osteoarthritis disability was granted secondary to the status post fracture of the right femur. A March 2004 private treatment record noted that the Veteran complained of right arm numbness and tingling, and that a physical examination revealed that his spine had normal range of motion and that hyperflexion did not produce any pain. April 2004 private treatment records noted that the Veteran complained of low back and left leg pain and numbness and was given a diagnosis of L4 radiculopathy on the left. A December 2004 private treatment record noted that the Veteran reported chronic back pain that radiates from the right lumbar area down into the thigh. He reported that he fractured his femur in 1972, and it has always given him some problems, and sometimes interfered with his job since he is required to do very heavy lifting at times. A physical examination was conducted. The Veteran had a limping gait. His spine had some hint of scoliosis with spasms on the right side of the spine. His lower right and left extremities were of grossly normal size and equal to inspection. A pertinent diagnosis of mechanical low back pain, which could possibly be caused by the gait disturbance and unequal abilities of the right verus left leg, was given. It was noted that he would be sent for x-rays of the lumbosacral spine and right hip and femur. In June 2005 the Veteran was afforded a VA fee basis (QTC) medical examination to assess the nature and severity of his lumbar spine disability. He reported that, since sustaining a fracture during service, he has suffered from chronic pain in his right leg, low back, neck, and groin area, and that it has worsened with age and causes cramping in his leg and lower back. The Veteran reported that back pain occurred three times per month, lasted for 12 hour, and travels down the right leg. He reported that over the past year he had 1 incident of incapacitation for a total of 1 day and related incapacitating episodes as often as once per month. He reported that his private physician, Dr. S., recommended bedrest in December 2004 for two days, and reported that he missed about 80 hours or 10 days of work per year. A physical examination was conducted in June 2005 that revealed no complaints of radiating pain on movement. Muscle spasm was absent. There was tenderness noted on examination of the paravertebral muscles. There was negative straight leg raising on the right and left. There was no ankylosis of the spine. The thoracolumbar spine had 90 degrees of flexion, 15 degrees of extension, 30 degrees of right and left lateral flexion, 20 degrees of right rotation, and 30 degrees of left rotation. The examiner noted that pain occurred at the above noted degrees of motion, and that the joint function of the spine was not additionally limited by pain after repetitive use, fatigue, weakness, lack of endurance, or incapacitation. There were no signs of intervertebral disc syndrome (IVDS) with chronic and permanent nerve root involvement. Rectal and genital examinations were declined by the Veteran, neurologic examination revealed motor and sensory function within normal limits with bilateral lower extremity knee and ankle jerk reflexes of 2+. A copy of the June 2005 x-ray report conducted for the examination is of record. A diagnosis of lumbar spine osteoarthritis was given. February 2006 private treatment records noted that the Veteran continued to have low back pain as a result of the in-service injury. The Veteran reported that he could work three or four hours at the ranch clearing brush and then had to quit because of the pain. It was noted that he had no other joint pain besides nagging back pain. A physical examination was conducted, and his spine had a normal range of motion and no evidence of scoliosis, kyphosis, or lordosis. An assessment of chronic back pain was given. A May 2007 private medical letter that was addressed to the United States Department of Labor noted that the Veteran was working, but had severe segmental collapse at L4/5 and L5/S1, and that he needed a decompression and fusion at the two levels. It was suggested he do physical therapy. A June 2007 private medical letter that was addressed to the U. S. Department of Labor noted that his primary complaint was left lower extremity radiculopathy. He had very little low back pain. An August 2007 VA treatment record noted that the Veteran was seen to establish care at VA and that he had chronic low back pain and numbness and tingling in his left leg. August 2007 VA optometry treatment record noted that he had a past history of arthritis, medications as needed for pain. An August 2007 VA treatment record noted that the Veteran walks frequently, including outside at least twice a day and indoors at least once every two hours. A December 2007 VA treatment record noted an assessment of chronic back pain with L4 radiculopathy. A VA examination was conducted in April 2008. The VA examiner noted a review of the Veteran's medical records. It was noted that he worked in public works for the past 34 years. The Veteran reported low back pain every day, and present symptoms of fatigue, lack of endurance, and right lower extremity weakness. He denied incapacitating episodes in the last 12 months and reported that he had no bowel or bladder incontinence. He also reported a post-service on-the-job injury in August 2006, at which time he hurt his back. A physical examination was conducted in April 2008. The Veteran had an antalgic gait without ambulatory external aids. Lumbar lordosis was normal and he had no scoliosis. He could heel to toe walk 10 feet stably. Forward flexion was 0 to 90 degrees, extension was 0 to 20 degrees, and side bending, rotation, and flexion were symmetric and 0 to 40 degrees. The examiner noted that the Veteran performed active range of motion three times with no complaint of pain. The examiner found no additional limitation secondary to pain, fatigue, weakness, or lack of endurance following repetitive use. A neurologic examination was also conducted. An April 2008 x-ray examination of the lumbosacral spine noted an impression of multilevel degenerative changes and minimal spondylolisthesis. An April 2008 private medical statement that was addressed to the U. S. Department of Labor noted that the Veteran had a herniated L4/5 disc with severe segmental collapse at L4-5 and L5/S1. His primary complaint continues to be left lower extremity neuropathic type pain and occasional numbness in the right foot. He has undergone three injections. The physician opined that there was a measure of contributing factor between his in-service femur injury and his back problems. Initially, it has not been contended or shown at any time during the rating period that the Veteran has residuals of a fracture of the vertebra (DC 5235), sacroiliac injury and weakness (DC 5236), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), or spinal fusion (DC 5241). Accordingly, the diagnostic codes pertaining to those disabilities are not applicable in this case. The Board finds that, prior to February 1, 2012, the Veteran's lumbar spine osteoarthritis was productive of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis. The December 2004 private treatment record noted that a physical examination was conducted and that his spine had some hint of scoliosis with spasms on the right side of the spine and that he had a limping gait that could be a result of his back pain. Additionally, the April 2008 VA examination noted that the Veteran had an antalgic gait, but that although there was pain during palpitation, there was no muscular tension or spasm. Although the June 2005 QTC examination found muscle spasm was absent and the April 2008 VA examiner found that there was no scoliosis or muscle spasm, given the findings of the December 2004 private treatment record, which was based on a physical examination by a physician, that he had a hint of scoliosis, an abnormal gait, and spasms on the right side of his spine and other medical evidence of record showing he had an abnormal gait, the Board finds that the Veteran's lumbar spine disability more nearly approximates the criteria for an initial rating of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine prior to February 1, 2012. Additionally, a February 1, 2012 VA examination found that he had guarding or muscle spasm of the thoracolumbar spine, and there is no indication that his lumbar spine disability worsened the day of his February 1, 2012, examination; thus, this evidence indicates that he may have had muscle spasm prior to February 1, 2012. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that under 38 U.S.C.A. §38 C.F.R. § 4.71a, DC 5243, General Rating Formula for Diseases and Injuries of the Spine, prior to February 1, 2012, the criteria for an initial rating of 20 percent for lumbar spine osteoarthritis, have been met. 38 C.F.R. §§ 4.3, 4.7. Initial Rating in Excess of 20 Percent for Lumbar Spine Disability After a review of all of the evidence, the Board finds that at no time during the pendency of the initial rating period on appeal have the criteria for a rating in excess of 20 percent for lumbar spine osteoarthritis been met or more nearly approximated. At no time during the pendency of the initial rating period on appeal, even with consideration of limitation of motion due to pain, did the Veteran's lumbar spine osteoarthritis manifest forward flexion of the thoracolumbar spine of 30 degrees or less or favorable or unfavorable ankylosis of the entire thoracolumbar spine. A VA examination was conducted in February 2012. The examiner noted a review of the Veteran's claim file. The Veteran reported that flare-ups impact the function of his thoracolumbar spine in that increased activity causes increased pain. Initial range of motion testing of the spine was conducted in February 2012. Flexion ended at 60 degrees (painful motion was noted to begin at 60 degrees), extension ended at 15 degrees (painful motion began at 15 degrees), right lateral flexion ended at 20 degrees (painful motion began at 20 degrees), left lateral flexion ended at 15 degrees (painful motion began at 15 degrees), right lateral rotation ended at 20 degrees (painful motion began at 20 degrees), and left lateral rotation ended at 15 degrees (painful motion began at 15 degrees). The Veteran was able to perform repetitive use testing with three repetitions. The range of motion after a minimum of three repetitions was flexion to 60 degrees, extension to 15 degrees, and right and left lateral flexion and rotation to 20 degrees. The VA examiner noted that the Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive use testing. The examiner assessed that the Veteran's spine had functional loss and/or impairment consisting of weakened movement and pain on movement. Examination in February 2012 revealed that the Veteran had localized tenderness or pain to palpation for the joints and/or soft tissue of the thoracolumbar spine. The Veteran claimed pain from mid back T-7 to S-1, but was able to sit with his back against the chair. He had guarding or muscle spasm of the thoracolumbar spine, but it did not result in abnormal gait or spinal contour. He did not have muscle atrophy. The examiner also conducted reflex and sensory examinations and noted that the Veteran had bilateral severe radiculopathy, which, as the Board noted above, is service connected. The examiner found that the Veteran had no other neurologic abnormalities such as bowel or bladder problems. The examiner also noted that he had no IVDS of the thoracolumbar spine. The Veteran used a cane constantly for locomotion. The examiner noted that the Veteran's thoracolumbar spine disability impacted the ability to work in that it caused increased pain in his back, but that he was employed full time since 1974 and missed approximately 30 to 40 days of work with back problems. The examiner noted that the physical findings for his back at present are after a work-related accident in 2006, in which he injured his back. The February 2012 lumbar spine x-ray report was also included in the VA examination report. A diagnosis of degenerative disc disease (DDD), thoracolumbar spine, was given. It is observed that the Veteran was found to have osteoarthritis in his lumbar spine. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a. The evaluation of arthritis is conducted under DC 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. The lumbar vertebrae are considered a group of minor joints that is ratable on parity with a major joint. 38 C.F.R. § 4.45. Diagnostic Code 5003 allows for the assignment of a maximum 20 percent rating only where there is X-ray evidence of arthritis of two or more major joints or two or more minor joint groups. The lumbar spine may only be rated as one major joint. Accordingly, the evidence does not support a rating in excess of 20 percent for the service-connected lumbar spine disability under DCs 5003 and 5010. 38 C.F.R. § 4.71a. Based on a review of the competent and credible lay and medical evidence of record, the Board finds that, under the General Rating Formula, it is not shown that at any point during the appeal period (prior to and after February 1, 2012), the Veteran's lumbar spine ostearthritis has more nearly approximated the criteria of forward flexion of the thoracolumbar spine of 30 degrees or less, even with consideration of limitation due to pain, or favorable or unfavorable ankylosis of his entire thoracolumbar spine required for the next higher rating of 40 percent. See 38 C.F.R. § 4.71a. The March 2004 private treatment record noted that the spine had normal range of motion and that hyperflexion did not produce any pain. The June 2005 QTC examination found that the thoracolumbar spine had 90 degrees of flexion, that pain began at 90 degrees of flexion, and that joint function was not additionally limited by pain. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). It was also found by this examiner that there was no ankylosis of the spine. The February 2006 private treatment record noted that the Veteran's spine had a normal range of motion. The April 2008 VA examination found that his thoracolumbar spine had forward flexion of 0 to 90 degrees, and that he performed active range of motion three times with no complaint of pain. There is no additional limitation secondary to pain, fatigue, weakness, or lack of endurance following repetitive use. The February 2012 VA examiner found that range of motion testing revealed that flexion of the thoracolumbar spine ended at 60 degrees and painful motion began at 60 degrees initially and after three repetitions. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, supra. Therefore, the competent and credible lay and medical evidence of record shows that throughout the appellate period the Veteran's thoracolumbar spine has retained greater than 30 degrees of forward flexion and is not fixed in flexion or extension or otherwise manifests ankylosis. For these reasons, a rating in excess of 20 percent during any period during the pendency of his claim under the General Rating Formula is not warranted. See Id. Additional factors that could provide a basis for a higher rating have been considered; however, it is not shown that the Veteran has any functional loss beyond that being compensated. While the Veteran's reports recurring pain, the rating assigned contemplates such degree of impairment. In this Veteran's case, pain was specifically noted, and motion has been considered limited at the point where pain begins. See Id. The competent and credible lay and medical evidence, including the February 2012 VA examination, which specifically found he did not have IVDS of the thoracolumbar spine, also demonstrates that a rating in excess of 20 percent based on incapacitating episodes is not warranted based on the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. To receive a rating in excess of 20 percent requires evidence of bed rest having a total duration of at least 4 weeks during any 12-month time period. The only evidence of record indicating that the Veteran was prescribed bed rest for the lumbar spine disability is the June 2005 QTC medical examination in which he reported that his private physician Dr. S. recommended bedrest in December 2004 for two days. Therefore, because the evidence of record does not show, nor does the Veteran contend, that his service-connected lumbar spine disability required at least 4 weeks or more of bed rest as prescribed by a physician during any 12-month time period, a rating in excess of 20 percent would not warranted be under 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. The Board further finds that a separate disability rating is not warranted because the objective medical evidence does not demonstrate that the Veteran suffered from a separate neurological disability distinct from his service connected lumbar spine osteoarhritis or bilateral lower extremity radiculopathy. During the April 2008 and February 2012 examinations he denied any sort of bowel or bladder impairment. In short, the evidence of record does not identify any additional separate neurological findings or disability and therefore, the Board concludes, that the Veteran does not warrant any additional separate disability rating under the diagnostic codes pertinent to rating neurological disorders. See 38 C.F.R. § 4.71a, Codes 5237, 5239 Note (1). The Board acknowledges that the Veteran has chronic low back pain and thus, recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, supra. Nevertheless, higher compensation is not warranted under these provisions because the persuasive and credible evidence of additional functional loss due to pain, weakness, fatigue, or incoordination does not show limited motion or function to such a degree so as to warrant a rating in excess of 20 percent for any period of time. Additionally, the Board acknowledges the Veteran's statements regarding his pain and the impact on his work, which he reported; however, as the Veteran was already rated at 20 percent for the initial appeal period, some impact on his employment has been incorporated into his lumbar spine disability evaluation. Furthermore, the Board has considered the possibility for staged ratings. Fenderson, supra; Hart, supra. However, as the evidence does not show that the criteria for a rating in excess of 20 percent have been met at any time during the initial rating period, the Board concludes that staged ratings are inapplicable. In sum, the weight of the credible and competent evidence shows the orthopedic manifestations of the Veteran's low back disability do not warrant an initial rating in excess of 20 percent for any period of time during the appellate period. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.3, 4.7. Rating Limitation of Abduction of Right Thigh and S/P Fracture of the Right Femur The Veteran seeks an initial compensable rating for status post fracture of the right femur for the period prior to February 1, 2012, and in excess of 10 percent thereafter, and an initial rating for the separately rated disability of limitation of abduction of the right thigh in excess of 20 percent. The Veteran was originally granted service connection for status post fracture of the right femur, and this disability was rated under 38 C.F.R. § 4.71a, DC 5255 as non-compensable. In an October 2012 rating decision, the RO granted a higher initial rating for status post fracture of the right femur of 10 percent, under 38 C.F.R. § 4.71a, DC 5251, effective February 1, 2012, and granted a separate 20 percent rating for limitation of abduction of the thigh, effective February 1, 2012, under 38 C.F.R. § 4.71a, DC 5253. The hip and thigh can be rated under Diagnostic Codes 5250 to 5255. 38 C.F.R. § 4.71a. In this case, assigning multiple ratings for a veteran's limitation of abduction and status post fracture of the right femur based on the same symptoms or manifestations would constitute prohibited pyramiding. 38 C.F.R. § 4.14. However, as has been done in this case, separate ratings can be assigned if the service-connected disability causes distinct functional impairment or manifestations without violating the principles of pyramiding. The AMC granted a separate compensable rating for limitation of abduction of the right thigh under DC 5253 effective February 1, 2012; however, the Board will consider whether the service-connected disability manifested compensable ratings under any applicable diagnostic codes, to include DCs 5003, 5250-5255, throughout the pendency of the appellate period. A maximum 10 percent disability rating is warranted where extension of the thigh is limited to 5 degrees under Diagnostic Code 5251. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252 limitation of flexion of the thigh to 45 degrees warrants a 10 percent rating, to 30 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, and to 10 degrees warrants a maximum 40 percent rating. Under Diagnostic Code 5253, a 10 percent disability rating is warranted for limitation of rotation of the thigh if the affected leg cannot toe-out more than 15 degrees; a 10 percent rating is also warranted where adduction is limited such that legs cannot be crossed; and a maximum 20 percent rating is assigned for limitation of abduction of the thigh with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a. Normal ranges of motion of the hip include hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Under DC 5254 an 80 percent rating is warranted for flail hip joint. Id. Finally, Diagnostic Code 5255 provides ratings in excess of 10 percent for malunion of the femur with moderate knee or hip disability (20 percent); malunion of the femur with marked knee or hip disability (30 percent); fracture of surgical neck of femur with false joint; or fracture of shaft or anatomical neck of femur with nonunion, without loose motion, weight bearing preserved with aid of brace (60 percent); and fracture of shaft or anatomical neck of femur, with nonunion, with loose motion (spiral or oblique fracture) (80 percent). 38 C.F.R. § 4.71a. Compensable Evaluation prior to February 1, 2012 for S/P Right Femur Fracture After a review of all of the evidence, the Board finds that the criteria for an increased (compensable) rating of 10 percent have been more nearly approximated for the Veteran's service-connected status post right femur fracture disability for the period prior to February 1, 2012 under the criteria of 38 C.F.R. § 4.71a, DC 5003, and 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). Thus, if the Veteran's status post fracture, right femur, does not warrant a compensable rating under the appropriate diagnostic codes based on limitation of motion, in this case DCs 5251-5253, the minimum compensable rating (10 percent) may be assigned where there is satisfactory evidence of painful motion. 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 1. Having reviewed this evidence of record, the Board finds that the evidence is in relative equipoise as to whether the Veteran experienced limitation of motion of the right hip and/or thigh due to pain for the rating period prior to February 1, 2012, analogous to non compensable limitation of motion of the back (a major joint) due to arthritic pain to warrant a 10 percent rating under DC 5003. See 38 C.F.R. § 4.71a. A November 1972 STR noted that the Veteran had a fracture of the right femur, and a physical examination revealed moderately good range of motion in the hip joint and no pain or tenderness. An April 1974 separation examination form is of record, however it was not completed. A December 2004 private treatment record noted that the Veteran had chronic back pain that radiated from the right lumbar area down into the thigh. He reported that he fractured his femur in 1972, it has always given him some problems, and sometimes interfered with his job because he is required to do very heavy lifting at times. A physical examination was conducted. He had a limping gait. A December 2004 radiology report of the right hip noted that the reason for the examination was chronic pain from an old injury. It was noted that there was minimal narrowing of the acetabular joint space suggesting early degenerative changes. An acute osseous pathology was not seen. In June 2005 the Veteran was afforded a QTC medical examination to assess the nature and severity of his disability. The Veteran reported suffering a right femur fracture during training in 1972. The parts involved are the right leg, lower back, neck, and groin area. The Veteran reported intermittent symptoms as often as daily lasting 4 to 8 hours. He reported the ability to perform daily functions during flare ups is limited by pain. The current treatment is physical therapy and pain medication. A physical examination was conducted in June 2005. Gait was within normal limits and he did not require any assistive device for ambulation. The right hip had a normal general appearance. The range of motion on the right and left hip joints were flexion of 125 degrees, extension to 30 degrees, adduction to 25 degrees, abduction to 45 degrees, external rotation of 60 degrees, and internal rotation of 40 degrees. The examiner noted that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner noted that diagnostic x-ray testing of the right femur was within normal limits, the right hip x-ray showed calcification around the right hip, and surgical coils were present in the right pelvis. A copy of the June 2005 x-ray reports are of record. A diagnosis of status post femur fracture, no residual pathology, was given. It was noted that subjective factors were pain and that there were no objective factors. A VA examination was conducted in April 2008 to assess the severity of the Veteran's lumbar spine disability. An April 2008 MRI of the bilateral hips was conducted. The report noted an impression of moderate to severe osteoarthritis of the left hip and that the right hip joint was normal. The radiological report continued that there were only minimal degenerative changes at the right hip. The examiner noted that the current MRI of the hips showed a normal right hip and osteoarthritis of the left hip. Although the Board is determining whether the Veteran's status post fracture of the right femur disability manifested any painful or limited motion prior to February 1, 2012, a February 1, 2012 VA examination is somewhat probative as it has some tendency to refect the period prior to February 1, 2012, including by reported history and complaints. The February 2012 examiner noted a review of the Veteran's claim file. A diagnosis of femur fracture (old) was given. The Veteran reported that following service he did not get any medical attention until 2006, when he had a post-service work-related injury. He reported pain to the knees and quadriceps muscle areas. The Veteran reported flare ups impact the function of his hip or thigh. He reported further pain in his knee area, soreness, and that he was unable to move his leg. The Veteran also reported that with increased walking or standing his leg goes numb. Initial range of motion testing of his right hip was conducted. Flexion ended at 115 degrees and painful motion began at 115 degrees, extension ended at 5 degrees and painful motion began at 5 degrees, abduction was lost beyond 10 degrees, but abduction was not limited such that he could not cross his legs and rotation was not limited such that the Veteran could not toe-out more than 15 degrees. He was able to perform repetitive use testing with 3 repetitions. The range of motion after a minimum of three repetitions was flexion ended at 115 degrees, extension ended at 5 degrees or greater, abduction was lost beyond 10 degrees, but adduction was not limited such that the Veteran could not cross his legs, and rotation was not limited such that he could not toe-out more than 15 degrees. The VA examiner noted in February 2012 that the Veteran had additional limitation in range of motion and functional loss or impairment of the hip and thigh following repetitive use testing as discussed above. The examiner specified that the Veteran had less movement than normal, swelling, instability, and disturbance in locomotion in the left hip and thigh. He had weakened movement and pain on movement in both hips and thighs. He had normal 5/5 muscle strength during flexion, abduction, and extension testing of the hip. He did not have ankylosis of either hip joint or malunion or nonunion of he femur, flail hip joint, or leg length discrepancy. The Veteran reported using a cane constantly for his back and leg. Imaging studies of the Veteran's hips were performed and reviewed by the examiner. The examiner noted that the Veteran had no arthritic changes to the right hip. The examiner assessed that the hip or thigh condition impacted the ability to work due to reporting of increased pain during increased activity. It was also noted that the Veteran was employed full time and missed work due to his back. The Veteran's February 2012 imaging report of the hips is part of his VA examination report. The February 2012 VA examiner provided an addendum medical report in February 2012. The examiner reported that the Veteran's right hip and leg had abduction of 30 degrees, but pain at 25 degrees, adduction of 20 degrees, but pain at 15 degrees, adduction of 20 degrees, but pain at 15 degrees, internal rotation of 30 degrees, but pain at 25 degrees, and external rotation of 25 degrees, but pain at 20 degrees. The Board has considered the effective range of motion only to the point where pain sets in. VAOPGCPREC 9-98; Burton, supra; DeLuca, supra. Based on the above medical evidence, and the credible lay evidence provided by the Veteran, the Board finds that the evidence is in equipoise on the question of whether the Veteran's left hip disability was manifested by limitation of motion because of recurring pain to warrant a 10 percent rating due to pain under the requirements of DC 5003 and 38 C.F.R. § 4.59. The record does not clearly indicate that the Veteran had arthritis of the right hip prior to February 1, 2012; however, the December 2004 radiology report noted that there was minimal narrowing of the acetabular joint, space suggesting early degenerative changes. Similarly, the April 2008 MRI of the bilateral hips noted that the right hip joint was normal, but also that there were minimal degenerative changes at the right hip. Regardless of whether the Veteran had arthritis of his right hip prior to February 1, 2012, the Court has held that the application of 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton, supra. Although the June 2005 QTC examiner found that the Veteran had a normal range of flexion and abduction as indicated by 38 C.F.R. § 4.71, Plate II, it was noted that his status post femur fracture caused subjective pain, and during the February 1, 2012, and subsequent addendum opinion, he had decreased range of motion due to pain. Additionally, during December 2004 treatment, the Veteran had walked with a limp, which may or may not be attributable to the service-connected status post right femur fracture disability. The Veteran has consistently reported that his right hip and leg are painful. The Veteran is competent to report the symptoms and impairments associated with the right hip disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Given the consistency of his complaints, the Board finds him to be credible regarding his complaints of right hip and leg pain. Resolving reasonable doubt in the Veteran's favor, the Board finds that, for the period prior to February 1, 2012, his service-connected right hip disability manifested painful and thus limited motion to a compensable degree and a 10 percent rating is warranted for the rating period prior to February 1, 2012, under Diagnostic Code 5003 and 38 C.F.R. § 4.3, 4.7, and 4.59. See Powell, 13 Vet. App. at 34; Hicks, 8 Vet. App. at 417. Evaluation for S/P Right Femur Fracture and Limitation of Right Thigh Abduction Throughout the pendency of the appellate period, the Veteran has been able to move his right hip, albeit with some limitation, so it is not ankylosed. The February 2012 VA examiner specifically found that his right hip did not manifest ankylosis. Thus, the credible and competent lay and medical evidence of record does not show that a rating under Diagnostic Code 5250 is warranted. 38 C.F.R. § 4.71a. Under DC 5251, which is the rating code under which the Veteran's status post right femur fracture is currently rated, a maximum 10 percent disability rating is warranted where extension of the thigh is limited to 5 degrees. Thus, given that the Veteran's status post femur fracture was granted a 10 percent rating for painful motion prior to February 1, 2012, there is no period of time during the pendency of his claim that he could be granted a rating in excess of 10 percent under DC 5251. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252, limitation of flexion of the thigh to 45 degrees warrants a 10 percent rating, to 30 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, and to 10 degrees warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a. The June 2005 QTC examiner found that the Veteran's right hip joint had flexion of 125 degrees, and noted that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The February 2012 examiner found that pain limited his flexion of the right thigh to 115 degrees. The Veteran has not contended that the flexion of his thigh is limited to 45 degrees. Therefore, the credible and competent lay and medical evidence of record does not show that a compensable evaluation based on limitation of flexion of the thigh is warranted under DC 5252. 38 C.F.R. § 4.71a. Under Diagnostic Code 5253, limitation of adduction of the thigh such that the legs cannot be crossed or such that the effected leg cannot toe out more than 15 degrees warrants a 10 percent rating and a maximum 20 percent rating is assigned for limitation of abduction of the thigh with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a. The February 2012 VA examiner found that the Veteran's thigh had abduction lost beyond 10 degrees. Prior to this, the June 2005 QTC examiner found that he had adduction to 25 degrees, abduction to 45 degrees, external rotation of 60 degrees, and internal rotation of 40 degrees, which does not indicate that he could not cross his legs or not toe out less than 15 degrees. The Veteran has not contended that he could not cross his legs or toe out to 15 degrees prior to February 1, 2012. Therefore, the credible and competent lay and medical evidence of record does not show that a compensable evaluation based on limitation of adduction, abduction, or rotation of the right thigh under DC 5253 was warranted prior to February 1, 2012. Finally, Diagnostic Codes 5253 and 5255 provide respective ratings for flail hip and impairment of the femur manifesting nonunion, false joint, or malunion. The February 2012 VA examiner found that the Veteran did not have malunion or nonunion of the femur or a flail hip joint. There is no medical evidence indicating, nor does the Veteran claim, that his service-connected right femur disability has resulted in a flail hip joint or nonunion, false joint, or malunion of the femur; thus a compensable rating under DCs 5253 and 5255 is not warranted. 38 C.F.R. § 4.71a. Additionally, ratings can be assigned under DC 5275 based on shortening of the lower extremity. The February 2012 VA examiner found that the Veteran did not have leg length discrepancy, and there is no medical evidence of record indicating this. Nor does the Veteran claim his legs are of different lengths. Therefore, the credible and competent medical and lay evidence of record does not show that a compensable evaluation under DC 5275 is warranted. 38 C.F.R. § 4.71a. The Board notes that the Veteran's functional loss was considered. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. However, the evidence shows that there was no additional loss of range of motion due to pain, fatigue, weakness, or incoordination after repetitive motions during the June 2005 QTC examination and, while the examiner found objective evidence of pain at the February 2012 examination, that examiner also specified where painful motion began during range of motion testing. Regarding the examiner's statement that the Veteran had additional limitation in range of motion, it was noted that the Veteran's left thigh had less movement than normal rather than his right thigh, which indicates that he did not have additional range of motion loss of the right thigh beyond what was discussed in the examination report. In light of the foregoing, the Board concludes the Veteran's complaints of functional loss due to pain and limitation of motion are already compensated by the current 10 and 20 percent ratings. Additionally, the Board acknowledges the Veteran's statements regarding his pain and the impact on his work, which he reported; however, as the Veteran was already rated at separate 10 and 20 percent ratings for the initial appeal period, some impact on his employment has been incorporated into his right hip and thigh disability evaluations. In sum, the weight of the credible and competent evidence shows the orthopedic manifestations of the Veteran's right hip and thigh disability do not warrant initial ratings in excess of 10 and 20 percent for any period of time during the appellate period. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Furthermore, the Board has considered the possibility for additional staged ratings. Fenderson, supra; Hart, supra. However, as the evidence does not show that the criteria for ratings in excess of 10 and 20 percent have been met at any time during the initial rating period, the Board concludes that staged ratings are inapplicable. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for lumbar spine osteoarthritis, limitation of abduction of the right thigh, and status post fracture, right femur. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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 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) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). 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 the Compensation and Pension 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. In this case, comparing the level of the Veteran's lumbar spine disability and the symptomatology to the rating schedule, the degree of disability throughout the initial rating period under consideration is contemplated by the rating schedule; therefore, the schedular rating criteria is adequate to rate the Veteran's service-connected lumbar spine disability, and no referral for an extraschedular rating is required. In this regard, it is noted that the Veteran's symptoms-such as limitation of motion and pain motion-are fully detailed in the rating schedule under the General Rating Formula for Disease and Injuries of the Spine, and there are no factors causing additional disability. In this decision, the Board considered functional loss due to pain and weakness as well as weakened movement, excess fatigability, and incoordination, which are part of the schedular rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra. For these reasons, the Board finds that the schedular rating criteria are adequate to rate the Veteran's service-connected lumbar spine osteoarthritis, and no referral for an extraschedular rating is required. Regarding the right hip and thigh disability, turning to the first step of the extraschedular analysis, the Veteran's right hip disability has manifested in limitation of motion, including due to pain. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically provides ratings based on limitation of motion (DC 5251, 5252, 5253), including motion limited to orthopedic factors such as pain, weakness, and guarding (38 C.F.R. §§ 4.40 , 4.45, DeLuca, supra). In this case, comparing the Veteran's disability level and symptomatology of his right hip and thigh to the rating schedule, the degree of disability of each throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. In the absence of exceptional factors associated with the lumbar spine and right hip, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Veteran has indicated that he has been employed throughout the appellate period and during his most recent February 2012 VA examination. Consequently, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER An initial rating of 20 percent, but no more, for lumbar spine osteoarthritis prior to February 1, 2012, is granted; an initial rating in excess of 20 percent for any period is denied. An initial rating for limitation of abduction of the right thigh in excess of 20 percent is denied. An initial rating of 10 percent, but no more, for status post fracture of the right femur, prior to February 1, 2012, is granted; an initial rating in excess of 10 percent for any period is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs