Citation Nr: 1311033 Decision Date: 04/03/13 Archive Date: 04/19/13 DOCKET NO. 07-13 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to increases in the "staged" ratings assigned for the Veteran's service connected left knee disability, currently assigned 10 percent rating prior to November 27, 2007 and a combined 20 percent from that date. 2. Entitlement to a rating in excess of 10 percent for a left hip disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Tabitha G. Macko, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1999 to March 2004. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Los Angeles, California Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for right knee, left knee, and left hip disabilities, rated 10 percent, each, all effective March 30, 2004. [The rating decision separately awarded service connection for left patella surgical scars rated 10 percent. The veteran did not disagree with that determination, and that disability is not at issue herein.] A December 2007 San Diego RO Decision Review Officer decision granted the Veteran a separate 10 percent rating for left knee instability, effective November 27, 2007. [The issue has been characterized to reflect that staged ratings are assigned, and that both "stages" are on appeal.] In February 2011 the Board denied an increased rating for the right knee disability and remanded for further development the issues pertaining to the left knee and left hip disabilities. In January 2013, the Veteran informed VA that he has relocated to the State of Washington. His claims file has not yet been transferred to the jurisdiction of the Seattle, Washington RO. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service-connected postoperative left knee disability has been manifested by limitation of flexion (but to no less than 95 degrees) and by slight instability; limitation of extension and/or more than slight instability are not shown; the knee is not ankylosed. 2. At no time during the appeal period is the Veteran's service-connected left hip disability shown to have been manifested by flexion limited to 30 degrees or less, or abduction limited to motion lost beyond 10 degrees. CONCLUSIONS OF LAW 1. A 20 percent combined rating for left knee disability (based on a formulation of 10 percent under Code 5260 (for limitation of flexion) and 10 percent under Code 5257 (for instability)) is warranted throughout (i.e., to include the evaluation period prior to November 27, 2007); a combined rating in excess of 20 percent is not warranted. - 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes (Codes) 5257, 5260, 5261 (2012). 2. A rating in excess of 10 percent is not warranted for the Veteran's left hip disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5252, 5253 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and 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) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (April 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Mayfield v. Nicholson, 444 F 3d. 1328 (Fed. Cir. 2006). This appeal is from initial ratings assigned with a grant of service connection. The statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, statutory notice has served its purpose, and its application is no longer required because the claim has been substantiated. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). A May 2008 letter provided the specific criteria for rating disabilities of the knee and thigh (hip). A March 2007 statement of the case (SOC), and December 2007, June 2008, and January 2012 supplemental SOCs (SSOCs) provided notice on the "downstream" issue of an increased initial rating, and readjudicated the matters after the Veteran had opportunity to respond. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). He has not alleged any prejudice from a notice defect. See Goodwin v. Peake, 22. Vet. App. 128 (2008). The Veteran's pertinent treatment records have been secured, and the Veteran submitted additional private records. The Board finds that there has been substantial compliance with the Remand directives. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall v. West, 11 Vet. App. 268 (1998), violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). The Veteran was afforded VA examinations in March 2005, November 2007 (though found to be inadequate in the Board's February 2011 remand regarding the left hip disability) and March 2011. The March 2011 report contains sufficient clinical findings, and discussion to be adequate for rating purposes, there has been substantial compliance with the February 2011 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). VA's duty to assist the Veteran in the development of facts pertinent to his claims is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Disability ratings are determined by application of a schedule of ratings, based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for such rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue (including the degree of disability) shall be given to the claimant. 38 C.F.R. §§ 3.102, 4.3. As this is an appeal from the initial rating assigned with the grant of service connection, the possibility of staged ratings must be considered. Fenderson v. West, 12 Vet. App. 119 (1999). Left Knee Disability 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. 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. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). 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. Flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension of a leg limited to 5 degrees or less warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71a, Plate II. In addition, the rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability of a knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Code 5257. The Veteran's statements describing his symptoms and his disorder are competent evidence to the extent that he can describe what he experiences. It is well established that a lay claimant is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. The General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Code 5260 (limitation of flexion of the leg) and under Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September, 2004). As well, the VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997). However, throughout the entire appeal period, no assessment of arthritis has been made. The Veteran sought treatment for his left knee during service, in August and September 2000. He denied any trauma, but reported it was swollen and hurt when he ran. The service clinician assessed RPPS (retropatellar pain syndrome). In August 2003 the Veteran participated in a parachute jump as part of his Ranger duties and his left leg became entangled in the rigging. By late August he was referred to an MRI study after a service clinician observed a grossly unstable left knee. The August 2003 MRI study revealed an ACL (anterior cruciate ligament) rupture with grade II MCL (medial collateral ligament) and a tear of the lateral meniscus, in addition to bone contusions and a large joint effusion. In late September 2003 the Veteran underwent surgery, a diagnostic arthroscopy and an arthroscopic ACL and PCL (posterior cruciate ligament) reconstruction. The service surgeon noted in the surgery report that the Veteran had experienced left knee instability since the early August injury. As a Ranger and being active in sports, the Veteran sought stabilization for his knee with the surgery. A January 2004 follow-up evaluation noted there were no complaints and that the Veteran was receiving therapy. Left knee range of motion was from 0 to 115 degrees, there was a trace posterior Drawer sign, but negative Lachmans; there was no varus/valgus instability, and no effusion. An X-ray found excellent tunnel and hardware position. He was doing well. On March 2004 physical examination for separation it was noted that the Veteran had had the ACL/PCL reconstruction and still required a knee brace for physical activity and reported residual edema after exercise. In a March 2004 Report of Medical History, prepared for separation, the Veteran also reported he needed a knee brace when doing physical activity. In July 2004 the Veteran sought VA treatment for his left knee. He reported chronic pain and that at the end of the day, the knee was swollen. The left knee felt weaker and he was unable to run since the surgery. The pain radiated down to the shin. The clinician observed that the Veteran walked without difficulty, there was no erythema or swelling; and there was full range of motion with no crepitus. On August 2004 orthopedic clinic evaluation the Veteran reported left knee pain. Range of motion was 0 to 120 degrees and the left knee was varus/valgus stable at 0 and 30 degrees. The Lachman, drawer test and McMurray tests were negative. The joint line was not tender to palpation. Quadriceps was positive for atrophy. The clinician assessed a left knee status post ACL/PCL reconstruction that was still painful but not unstable. The Veteran declined more surgery and was discharged from the clinic. On fee-basis examination on behalf of VA in March 2005 the Veteran reported to the examiner that he had had ACL and PCL reconstruction surgery on the left knee. He reported constant pain and stiffness in the left knee. He had difficulty climbing stairs and using a stick shift. Motrin would help the symptoms. He denied losing time at work because of his left knee and denied any periods of incapacitation. He was able to accomplish the activities of daily living. He was working at UPS. The examiner observed that the Veteran's posture was normal; he walked with a normal gait that was not unsteady and did not use an assistive device. The examiner observed the two scars on the anterior patella, eight centimeters and seven centimeters, and that there was no edema. There was limited and painful motion of the left knee. While there was mild crepitus, there was no heat, redness, swelling, effusion, drainage, or instability or weakness. The drawer sign and the McMurray test were negative. Range of motion testing demonstrated: 0 to 95 degrees flexion, with pain at 95 degrees. Though limited by pain, range of motion was not limited by fatigue, weakness, lack of endurance or incoordination. Sensation and muscle strength were intact and within normal limits. An X-ray revealed the previous ligament repair and minimal joint effusion with no other significant findings. In April 2005, the Veteran sought VA treatment following an injury at work. He was loading and unloading packages when he reported he experienced a sharp pain in his knee and had swelling. He rested and evaluated the knee, but there was no relief from the pain. He reported a lump on the knee and that the pain was worsened by activity and weightbearing, though he denied weakness. The clinician observed increased warmth and swelling with slight effusion. Though the left knee was not tender to palpation, there was a palpable mass, about the size of a dime. Muscle strength was 4/5. There was no lateral instability, and sensation to light touch was decreased over the lateral aspect of the knee (which the Veteran reported was unchanged). He was referred for an MRI which found post-operative changes status post ACL and PCL reconstruction without evidence of recurrent injury. There was no evidence of a tear of the ligaments, though there was small to moderate joint effusion. The patella cartilage appeared intact. In September 2005 the Veteran was privately evaluated for the left knee work injury. He reported his left knee had been aggravated while loading and unloading packages and that the pain would fluctuate to a 7/10 without a brace and increase when the knee locked. He also reported the knee swelled most of the time, that the original surgery was in September 2003 and the work-place injury was in April 2005. He was allowed to return to work, though sedentary only. On September 2005 initial private orthopedic evaluation, in connection with a worker's compensation claim, the Veteran reported experiencing a sharp pain in the left knee while unloading a trailer. He reported the left knee injury and surgery in service and complained of pain and numbness in the left knee with stiffness, weakness, swelling, locking and giving way. The private evaluator observed effusion in the left knee and that he wore a body glove neoprene sleeve. Range of motion was decreased minimally at the extreme of flexion, recorded as 0 to 95 degrees, with 110 degrees considered to be normal by this private clinician. An x-ray study revealed the reconstruction hardware. A later October 2005 private evaluation noted the Veteran had a new brace, though there was no description as to what it was, and he had no pain and was doing better. An October 2005 private evaluation noted the VA April 2005 MRI revealed some irregularity at the meniscal edges, without clear evidence of tears to the meniscus. The private clinician assessed left knee persistent pain and mechanical signs and symptoms, status post old ACL and PCL reconstructions. In February 2006 the Veteran underwent another private left knee evaluation. He described the April 2005 workplace injury now as a gradual onset of pain and that his left knee had locked up. He reported he quit that employment some weeks later as his employer required him to return to off-loading parcels and he had not returned to work since. The left knee pain was generally sharp, though taking naproxen alleviated most of the pain and swelling. He remained unable to run, jump, or over-exert the knee because that caused pain and swelling. He experienced frequent catching of the knee with excessive weightbearing activity. The private clinician observed full range of motion, measured at 0 to 140 degrees and noted there was no gross joint effusion. There was no abnormal tenderness and the quadriceps tone was normal and there was no atrophy. Ligament stability testing was negative. There was mild crepitus at the patellofemoral joint. An x-ray study showed the ACL reconstruction. On August 2007 VA evaluation the Veteran reported his left knee would lock-up, and remain so for 15 to 20 hours, after overuse. Occasionally there was swelling. He wore a "Don-Joy" brace with flares. Upon examination the clinical noted there was no edema, the pulses were symmetrical, and there was no effusion or crepitus, or joint line tenderness. The range of motion was described only as "good." In October 2007 the Veteran was evaluated for physical therapy for the left knee, though he did not continue it beyond a few sessions. He was a full time student. Again he reported constant knee pain and that the knee would lock. He was unable to run secondary to the pain and the left knee would swell with occasional use. (While he reported to the clinician that an orthopedic surgeon told him in a worker's compensation evaluation that he had a meniscus tear, the Board observes that the Veteran submitted the workers' compensation claim medical records following the April 2005 workplace injury and no evaluation included that assessment.) The VA clinician observed a slight left quad atrophy, but found muscle strength and sensation intact. Varus and valgus testing was negative. On November 2007 VA joints examination, the Veteran (who was then attending school to complete a Master's degree and participating in work-study as part of a VA program) reported the parachute injury in-service, that was followed by instability and surgery. Following the surgery, he had used a brace and underwent therapy. He reported that currently the knee was unstable, especially when he was fatigued after prolonged walking or standing. He used a hinged brace with any physical activity, and did not participate in competitive sports. He was unable to do any type of running. He did not use the brace (while sitting) in his work-study program. Repetitive or continuous activity such as prolonged standing, walking, or sitting increased the symptoms and corresponding functional impairment. Upon objective examination, the examiner did not observe any physical deformity. There was no swelling, effusion, or temperature increase. He could squat to approximately 60 percent and there was no crepitation in the left knee, though there was crepitation in the sitting position. The left knee extended to 0 degrees; flexion was to 120 degrees (with pain at full extension). The examiner found at least 1+ positive Lachman sign which suggested posterior instability. Upon repetition, the examiner did not observe increased symptomatology or evidence of additional functional impairment. Measurement of thigh circumference at a level 10 centimeters proximal to the patella found the left thigh one centimeter smaller than the right. X-rays showed the previous reconstruction surgery and no significant arthritic changes. The assessment was residual instability and painful limitation of motion in addition to the status post ACL/PCL reconstruction. The examiner also noted a suggestion of very minimal early chondromalacia. (Softening of the articular cartilage, most frequently in the patella of the knee. Dorland's Illustrated Medical Dictionary 352 (32d ed.2012)). On March 2008 the Veteran sought VA treatment and referral for a left knee MRI. (It was noted that he had failed to present for a scheduled MRI and needed referral for another.) He reported he was a VA work-study student. The clinician observed slight left knee effusion, though no joint line tenderness. There was no valgus/varus instability, and McMurrays', and anterior and posterior drawer signs were negative. The assessment for the left knee was continual pain with a locking sensation such that there was a concern for a meniscal tear. The Board notes there was no evidence of record this left knee MRI study was actually obtained. Subsequent treatment records are scattered and contained no mention of such a study. In March 2011 VA joints examination, the Veteran reported left knee symptoms remained consistent as seen throughout the record, namely intermittent pain, stiffness, weakness, popping and catching. He denied giving way, locking, a history of dislocation, or symptoms of subluxation. Activities of daily living were slowed by the left knee though he estimated he lost no time at his occupation due to the left knee. The left knee symptoms would wax and wane and increase with stairs, squatting, or kneeling. He used acupuncture to alleviate symptoms; he denied current use of any assistive device. Objectively, the Veteran walked with a gait that did not favor either knee. He could squat to 120 degrees. There was no knee tenderness and no swelling. Circumferential measurements of the thighs above the patella gave no evidence of atrophy. Knee strength was 5/5 and sensation was normal, except for the 1/2 mediolateral to distal knee scar in the infrapatellar area. Range of motion was measured as 0 to 125 degrees. Active and passive ranges of motion were similar. Lachman's test, anterior, posterior, varus and valgus stresses suggested no instability. The examiner found no crepitus and no impingement by McMurray's test. There was mild objective evidence of pain in the left knee, but no spasms or weakness. Repetitive testing found no added objective loss of joint function due to pain, weakness, fatigue or incoordination. An x-ray study found evidence of the reconstruction surgery. The examiner assessed no instability and noted the related scars were absent. The Veteran has submitted statements reporting that because of his left knee disability he has had to change professions and can no longer participate physically challenging activities such as jujitsu. Regarding the rating under Code 5257 (for laxity), granted effective November 27, 2007 ( the date of a VA examination), the Board notes that there is conflicting evidence regarding instability prior to that date. The Veteran has repeatedly reported instability and the wearing of a brace, which are variously described in the record. However, every objective examination prior to November 2007 found no instability on valgus/varus testing. His subjective reports cannot be discounted, as the Board finds him to be a credible witness of his left knee being intermittently weak, stiff, and swollen. Significantly, while physical examination did not show subluxation/instability, the Veteran repeatedly reported prior to November 2007 that he wore a knee brace (even in March 2004 while in service and after the January 2004 in-service evaluation to the left knee surgery that found no instability). Such evidence reasonably supports a finding of slight (but no greater) instability, warranting the assignment of a 10 percent rating under Code 5257 for the entire period on appeal, to include that from separation to November 27, 2007. Left knee flexion was found to be limited on multiple, though not all, examinations during the appeal period,. In service, in January 2004, three-months after surgery, flexion was to 115 degrees, and post-service, flexion was to 120 degrees in August 2004 and dipped to its lowest (95 degrees) on March 2005 VA general medical examination, and again on September 2005 workers' compensation evaluation. [The Board notes that the RO has not excluded any knee pathology/symptoms from consideration as due solely to the intercurrent postservice injury, and likewise finds that the record provides no basis for doing so. On February 2006 private evaluation flexion was found to be full, to 140 degrees, though it was somewhat less on November 2007 VA examination, when flexion was to 120 degrees and on March 2011 examination when flexion was to 125 degrees. The Veteran's reported pain was noted and considered by the examiners and by the Board, nonetheless, nearly full flexion was found on multiple examinations throughout the appeal period. These finding warrant no more than the current 10 percent rating; no examination found left knee flexion found to be limited to less than 60 degrees. The Board has considered whether any other diagnostic codes apply, and would afford the Veteran an increased rating for this disability (either as alternate ratings or in combination with that currently assigned). Notably, no examination has found a compensable level of extension limitation. The Board notes the representative's December 2010 argument that the Veteran is entitled to a 40 percent rating under Code 5262; however no examination has found malunion or nonunion of the tibia/fibula. As there is no evidence of pathology such as ankylosis, dislocated or removed semilunar cartilage, or tibia and fibula involvement, ratings under Codes 5256, 5258, 5259, and 5262 are not warranted. Based on the foregoing, a 20 percent (but no higher) combined rating is warranted, for the Veteran's left knee joint disability throughout the appeal period, to include from March 30, 2004, to November 27, 2007, based on a formulation of 10 percent for slight instability under Code 5257 and 10 percent for flexion limitation (due to pain) under Code 5260. 38 C.F.R. § 4.25. Left Hip Disability The Veteran's left hip disability is rated under Codes 5299-5253. Limitation of hip motion is rated under Codes 5251, 5252, and 5253 (and 5250 if there is ankylosis; here, there is none). Notably, of these, only Codes 5252 and 5253 provide for ratings in excess of 10 percent. Under Code 5252 (for limitation of flexion), a 20 percent rating is warranted where the limitation is to 30 degrees, a 30 percent rating is warranted where the limitation is to 20 degrees; and a 40 percent rating is warranted where the limitation is to 10 degrees. Under Code 5253, a 20 percent evaluation is warranted where there is limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71. Normal range of motion of the hip is from 0 to 125 degrees of flexion and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. The Veteran reported in a March 2004 Report of Medical History for separation from service, that he had a "rupture" on his left hip in service. A review of the service treatment records found no report of medical treatment for the left hip itself. On March 2005 fee-basis general medical examination on behalf of VA, the veteran denied a history of left hip trauma, but reported that he was experiencing hip pain, intermittently throughout the day, every day. He denied any incapacitation or functional impairment and reported he had not lost any time from work due to the left hip disorder. On objective examination the examiner noted evidence of limited and painful motion in flexion only. There was no evidence of heat, redness, swelling, effusion, drainage, abnormal movement, instability or weakness. Range of motion was: 90 degrees active flexion, with pain to 90 degrees; 30 degrees active extension, without pain; 25 degrees active adduction, without pain; 45 degrees active abduction, without pain; 60 degrees active external rotation, without pain; and 40 degrees active internal rotation, also without pain. The examiner noted that motion was limited by pain, but not limited by fatigue, weakness, lack of endurance, or incoordination. Motor strength in the lower extremities and the examiner observed there was no atrophy. There were no significant findings in the x-ray study of the left hip. The examiner did not provide an assessment of a left hip disorder. An April 2005 rating decision granted service connection for left hip pain. In early October 2007 the Veteran underwent a physical therapy evaluation for a program regarding his service-connected left knee. The clinician noted his posture was normal and that there was slight left quad atrophy. On November 2007 VA joints examination the Veteran reported there had been no specific acute injury to the left hip in service, other than the continuous trauma of his duties, which included parachute jumps. He reported that he was participating in a VA work-study program and attending a local university in pursuit of a master's degree. He had become aware of a painful swelling or a lump on the anterior of the left hip; an MRI study (which is not of record as the source has never been identified) suggested the possibility of soft tissue damage without evidence of a hip joint pathology. The Veteran also reported stiffness in the hip following periods of inactivity and following periods of increased physical activity such as prolonged walking. Discomfort flared virtually daily in association with normal physical activities. His gait was normal. Objective examination of the left hip found limitation of motion. Range of motion testing was incomplete (as noted in the Board's February 2011 remand) as the examiner did not note range of left hip abduction; therefore, this examination was inadequate. The Board notes that that the examination is inadequate does not void the Veteran's statements to the examiner, and so, the Board has considered them. On March 2011 VA joints examination (per the Board's February 2011 remand) it was noted that the Veteran was employed by a transcription service. Regarding the left hip, he reported intermittent pain and stiffness. Current symptoms included popping, though he denied catching, giving way, locking, a history of dislocation, and symptoms of subluxation. Though he reported having lost no time at work due to his left hip, he did report his activities of daily living were slowed by the left hip. He denied flare-ups of additional limitations, as the left hip symptoms waxed and waned. Extreme activity would increase the symptoms. He reported he did nothing to alleviate the symptoms and used no assistive devices. On objective examination, the Veteran walked with a gait that favored neither lower extremity. Limb lengths were equal, and there was no hip asymmetry, hip tenderness to light palpation, or swelling. Circumferential measurements were symmetrical, suggesting there was no atrophy. Hip strength was 5/5 throughout, as was left hip sensation (2/2). Ranges of motion were: 0 to 125 degrees flexion, 0 to 30 degrees extension, 0 to 60 degrees external rotation, 0 to 40 degrees internal rotation, 0 to 25 degrees adduction, and 0 to 45 degrees abduction. Active and passive ranges of motion were similar; no instability was found, though there was mild crepitus in the left greater trochanter and no impingement. There was no objective evidence of pain, spasm, or weakness. Repetitive testing provided no added objective loss of joint function. An x-ray study demonstrated no significant pathology. The examiner assessed left hip sprain. On March 2005 examination the Veteran's left hip flexion was to 90 degrees and abduction was to 45 degrees (which is full abduction). On March 2011 VA examination left hip flexion was to 125 degrees and abduction was measured to 45 degrees, which was not lost beyond 10 degrees, but remained at full abduction. At no time during the appeal period has the Veteran's left hip disability been manifested by limitation of flexion to 30 degrees, or limitation of abduction of motion lost beyond 10 degrees, even with DeLuca factors considered. There is no evidence of ankylosis of the left hip, of a fail joint, or of an impairment of the femur; therefore, Codes 5250, 5254, and 5255 are not applicable. Accordingly, a higher rating under Codes 5252 or 5253 is not warranted. The Board also has considered whether these claims warrant referral for consideration of an extraschedular rating. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that schedular criteria are inadequate, i.e., whether there are manifestations of impairment that are not encompassed by the schedular criteria. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. Comparing the manifestations and associated impairment of the Veteran's left knee and hip disabilities to the rating schedule, the Board finds that the degree of disability shown throughout the entire period under consideration is wholly encompassed by the schedular criteria for rating such disabilities, and that those criteria are not inadequate. Therefore, referral for consideration of an extraschedular rating in not necessary. Finally, as the record shows that the Veteran is self-employed (see November 2011 report) and during the appeal period did not report that he was unemployable because of his left knee or left hip disability, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A 20 percent combined rating for left knee disability, excluding scars (based on 10 percent under Code 5260 and 10 percent under Code 5257) is granted for the period prior to November 27, 2007, subject to the regulations governing payment of monetary awards; a combined rating in excess of 20 percent is denied. A rating in excess of 10 percent for a left hip disability is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs