Citation Nr: 1312574 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 08-27 996 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a bilateral hip disability, including arthritis of the hips, secondary to service-connected bilateral femoral neck stress fractures. 2. Entitlement to service connection for a psychiatric disorder secondary to service-connected bilateral femoral neck stress fractures. 3. Entitlement to an evaluation in excess of 20 percent for right femoral neck stress fracture residuals. 4. Entitlement to an evaluation in excess of 20 percent for left femoral neck stress fracture residuals. 5. Entitlement to an evaluation in excess of 10 percent for gastritis, from the initial grant of service connection. 6. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran had active service from January 7, to June 29, 1982. This matter comes before the Board of Veteran's Appeals (Board) on appeal from April 2006 and September 2007 decisions by the RO. In April 2006, the RO denied service connection for arthritis and a psychiatric disorder secondary to the service-connected residuals of right and left femoral neck stress fractures and denied increased ratings for the service-connected bilateral lower extremity disabilities. In September 2007, the RO, in part, granted service connection for gastritis, denied service connection for a bilateral hip disability a low back disability, and denied entitlement to TDIU. The case was remanded by the Board in September 2010 for further development of the evidence, including additional VA compensation examinations. In an April 2012 rating decision, the RO granted service connection for a lumbosacral spine disability, as secondary to service-connected residuals of femoral neck stress fractures. The Veteran did not disagree with the rating or effective date. The Board notes that during the development of this appeal, separate issues relating to service connection for bilateral hip disability and arthritis were addressed. After review of the Veteran's contentions, which relate his claim of service connection for arthritis to a VA bone scan study showing arthritis of the lumbosacral spine, the Board finds that the April 2012 grant of service connection for a lumbosacral spine disability partially addresses this issue. As the record shows that the only other joints affected by arthritis are currently those of the hips, in the interest of clarity, the Board has included the issue of service connection for arthritis with that of service connection for bilateral hip disability. As such, the matter of service connection for arthritis is considered to be part and parcel of the claim relating to service connection for bilateral hip disability and it will be addressed in the discussion of that issue. The issues of service connection for a psychiatric disability secondary to service-connected disabilities and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A bilateral hip disability, including arthritis, is caused by, or increased in severity beyond the natural progress of the disease by a service-connected disability. 2. Throughout the appeal, the Veteran's right femoral stress fracture has been manifested by no more than moderate impairment, with flexion to, at minimum 55 degrees, without ankylosis. 3. Throughout the appeal, the Veteran's left femoral stress fracture has been manifested by no more than moderate impairment, with flexion to, at minimum 75 degrees, without ankylosis. 4. Throughout the appeal, the Veteran's gastritis has been manifested by pain and constipation, without additional gastrointestinal (GI) symptoms, erosion, or ulceration. CONCLUSIONS OF LAW 1. Service connection for a left hip disability, including arthritis, is warranted. 38 C.F.R. § 3.310(a) (2012). 2. The criteria for an increased rating in excess of 20 percent for right femoral fracture residuals have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5255 (2012). 3. The criteria for an increased rating in excess of 20 percent for left femoral fracture residuals have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Code 5255 (2012). 4. The criteria for an initial rating in excess of 10 percent for gastritis have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Code 7307 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, 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, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, and general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. January 2006, July 2006, September 2006, June 2007, and August 2007 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. Most of these letters also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. Regarding the matter of an initial rating for gastritis, as the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. At 490. The September 2008 statement of the case (SOC) provided notice on the "downstream" element of initial rating; while a March 2010 supplemental SOC (SSOC) readjudicated the matter after the Veteran responded and further development was completed. 38 U.S.C.A. § 7105 (West 2002); see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded a VA medical examination, most recently in April and April 2011. The Board finds that the opinions obtained are adequate. The opinions were provided by a qualified medical professional and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinion rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has not challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2011). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is considered competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. 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). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus more specifically on what the evidence shows, or fails to show, as to the claim. 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 shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection for Bilateral Hip Disability Including Arthritis The Veteran contends that service connection is warranted for bilateral hip disability that he asserts is related to the bilateral femoral neck stress fractures that he sustained while on active duty. After review of the record, the Board finds that a bilateral hip disability, including arthritis, is caused by, or increased in severity beyond the natural progress of the disease by, a service-connected disability, specifically bilateral femoral neck stress fractures. Review of the record shows that service connection is currently in effect for bilateral femoral neck stress fractures, each rated 20 percent disabling. On April 2011 VA examination, it was noted that the Veteran had been service connected for bilateral hip stress fractures that had progressively worsened. X-ray studies showed enthesopatic changes in both the femoral heads and the iliac bones. The diagnoses were bilateral hip stress fractures and bilateral hip enthesopatic changes. The examiner opined that the enthesopatic changes in both hip joints were degenerative joint disease and were as likely as not a consequence of the Veteran's service-connected stress fractures at the bilateral femoral head areas. It was further elaborated that the Veteran had likely developed posttraumatic osteoarthritis in his hip joints in the areas where he had sustained the stress fractures. The only medical opinion of record that directly addresses the question of whether arthritis of the hips is related to the service-connected bilateral femoral stress fractures is the above noted VA medical opinion. The Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). As the only pertinent medical evidence in the record supports the Veteran's claim, service connection for degenerative joint disease of each hip as secondary to bilateral stress fractures is warranted. The Board notes that the Veteran's claims included a generic claim of service connection for arthritis, which could be considered a claim of service connection for every joint. As noted previously, the Veteran has only demonstrated degenerative joint disease in the hips and the low back, for which service connection was awarded in an April 2012 rating decision. As demonstrated on VA orthopedic examination in October 2009, the Veteran has not manifested arthritis in any joint other than the hips and lumbosacral spine. As such, to this extent, arthritis is found to be denied in additional joints. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). (In the absence of proof of a current disability there is no valid claim of service-connection.) Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating 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 (2012). 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 shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. 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) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Femoral Stress Fracture Residuals, With Arthritis Service connection for residuals of bilateral stress fractures was awarded by rating decision of the RO dated in October 1982. A 100 percent pre-stabilization rating was initially assigned. By rating decision in October 1983, the rating was reduced to 10 percent each for stress fractures of the right and left femoral heads under Diagnostic Code 5255. The rating was increased to 20 percent in a September 2006 rating decision, effective the date of the Veteran's current claim in December 2005. Under Diagnostic Code 5255, malunion of the femur with slight knee or hip disability warrants a 10 percent evaluation. Malunion of the femur with moderate knee or hip disability warrants a 20 percent evaluation. Malunion of the femur with marked knee or hip disability warrants a 30 percent evaluation. Fracture of surgical neck of the femur, with false joint or fracture of the shaft or anatomical neck of the femur with nonunion, without loose motion, weight bearing preserved with aid of brace warrants a 60 percent evaluation. Fracture of the shaft or anatomical neck of the femur with nonunion, with loose motion (spiral or oblique fracture) warrants an 80 percent evaluation. 38 C.F.R. § 4.71a, Code 5255. Normal ranges of motion of the hip are from 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. Diagnostic Code 5250 provides for rating the hip on the basis of ankylosis. Favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction is to be rated 60 percent disabling; intermediate ankylosis of the hip is to be rated 70 percent disabling; and extremely unfavourable ankylosis, with the foot not reaching ground, crutches necessitated, is to be rated 90 percent disabling, and is entitled to special monthly compensation. 38 C.F.R. § 4.71a. Diagnostic Code 5251 provides a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. 38 C.F.R. § 4.71a. On August 2006 orthopedic examination, the Veteran complained of constant pain while standing, sitting or lying down. He stated that he stumbled or fell due to bilateral hip pain and weakness. He stated that his right hip was more painful than the left, with a deep, aching and throbbing pain. He used liniment rubs to both hips, with poor relief. He could not use oral medications because of gastrointestinal difficulties. He used a one-point cane, as needed. He had not had surgeries on his hips and reported no episodes of dislocation or subluxation. Range of motion in each hip was 115 degrees flexion, 30 degrees abduction, 25 degrees internal rotation, and 20 degrees external rotation. Manual muscle testing was 5/5 in all planes of motion. Pain was noted at 115 degrees flexion, 20 degrees external rotation, 25 degrees internal rotation, and 30 degrees abduction. There was additional limitation due to pain, but not due to fatigue, weakness, lack of endurance, or incoordination of either hip. The additional limitation was described as being functional deficits of 115 to 125 degrees flexion, 30 to 45 degrees abduction, 15 to 40 degrees internal rotation, and 20 to 60 degrees external rotation. There was tenderness to palpation on greater trochanters and the anterior coxo-femoral joints, but no instability. The Veteran walked with an antalgic gait on both the right and left side. There was no ankylosis of either joint, no inflammatory arthritis. X-ray studies showed no radiographic evidence of a recent fracture. The diagnosis was bilateral femoral neck fracture residuals. On October 2009 VA orthopedic examination, the Veteran stated that he had pain with an intensity of 6/10 and some stiffness and limited ambulation tolerance. This flared to 9/10 weekly, on prolonged standing or with cloudy, rainy days. Repeated flexion of both hips caused pain at the trochanteric areas, but no weakness or fatigue. There was no effusion or edema. Gait was antalgic, with a limp from the right hip. There were no callosities. There was no ankylosis and no leg length discrepancies. Range of motion of the right hip included flexion from 0 to 90 degrees, with pain in the last 30 degrees and functional loss in the last 35 degrees. Extension was from 0 to 30 degrees, with pain in the last 10 degrees and functional loss of 0 degrees due to pain. Adduction was from 0 to 20 degrees, with pain in the last 10 degrees and functional loss of 5 degrees. Abduction was from 0 to 25 degrees, with pain in the last 10 degrees and functional loss of 20 degrees. External rotation was from 0 to 30 degrees, with pain in the last 10 degrees and functional loss of 30 degrees due to pain. Internal rotation was from 0 to 40 degrees with pain in the last 10 degrees and functional loss of 0 degrees. Range of motion of the left hip was flexion from 0 to 100 degrees, with pain in the last 10 degrees and functional loss in the last 25 degrees. Extension was from 0 to 30 degrees, with pain in the last 10 degrees and functional loss of 0 degrees due to pain. Adduction was from 0 to 25 degrees, with pain in the last 10 degrees and functional loss of 0 degrees. Abduction was from 0 to 45 degrees, with pain in the last 10 degrees and functional loss of 0 degrees. External rotation was from 0 to 50 degrees, with pain in the last 10 degrees and functional loss of 10 degrees due to pain. Internal rotation was from 0 to 40 degrees with pain in the last 10 degrees and functional loss of 0 degrees. Magnetic resonance imaging (MRI) of the hips showed a single punctuate lesion in the left inferomedial iliac bone. Range of motion of the knees was from -10 degrees extension to a normal 140 degrees flexion. The pertinent diagnoses were left hip stress fracture and right hip stress fracture. On April 2011 VA examination, the Veteran reported symptoms of giving way, pain, stiffness and weakness. He had decreased speed of joint motion, but no episodes of dislocation or subluxation. He had episodes of locking and tenderness. Cloudy or rainy days exacerbated the symptoms and pain mediation alleviated the pain. On examination, the Veteran walked with an antalgic gait with tenderness, pain and rest and guarding at movement noted. Range of motion on the right was flexion from 0 to 90 degrees, extension from 0 to 20 degrees, abduction from 0 to 15 degrees. On the left, flexion was from 0 to 90 degrees, extension was from 0 to 20 degrees, and abduction was from 0 to 15 degrees. The Veteran could not cross either leg over the other. There was evidence of pain with active motion on the right side. There was objective evidence of pain following repetitive motion, but no additional limitations after repetitive range of motions. There was no joint ankylosis. It is initially noted that, while the Veteran has been service connected for arthritis of the hips, the record does not show additional disability as a result of arthritis that is separate from the other residuals of the bilateral femoral fractures. Where there is separate and distinct symptomatology of a single condition it should be separately rated. Where the symptomatology of a condition is duplicative or overlapping with symptomatology of another condition, it may not receive a separate evaluation. 38 C.F.R. §§ 4.14, 4.25; Esteban v. Brown, 6 Vet. App. 259 (1994). For a rating in excess of the currently assigned 20 percent for each femur fracture residual, the record must show either marked knee or hip disability, flexion of the thigh that is limited to 20 degrees, or ankylosis of the hip joint. The record does not demonstrate a disability of either knee or ankylosis of either hip joint. The flexion of the hips is shown to be limited to, at most 55 degrees on the right and 75 degrees on the left, when all functional impairment is taken into consideration. Although the Veteran has significant pain and limitations of his hips, the severity does not reach that of marked impairment for either hip. As such, there is no basis for a rating in excess of 20 percent for either hip disability. There is also no additional uncompensated limitation of motion that could provide a basis for a higher rating due to pain on functional use under Deluca v. Brown, 8 Vet. App. 202 (1995). See also 38 C.F.R. §§ 4.40, 4.45, and 4.59 (2012). For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for increased rating for residuals of femoral fractures of each hip, and the claims must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Rating Gastritis Service connection for gastritis was granted by the RO in a September 2007 rating decision. The 10 percent initial disability rating was awarded under the provisions of Code 7317 from the date of claim in June 2006. Although the RO used the Code 7317, which is for injury of the gallbladder; the Board finds Code 7307, for gastritis is more appropriate. Diagnostic Code 7307 provides ratings for hypertrophic gastritis. Chronic hypertrophic gastritis, with small nodular lesions, and symptoms is rated 10 percent disabling. Chronic hypertrophic gastritis, with multiple small eroded or ulcerated areas, and symptoms, is rated 30 percent disabling. Chronic hypertrophic gastritis, with severe hemorrhages, or large ulcerated or eroded areas, is rated 60 percent disabling. Atrophic gastritis, which is a complication of a number of diseases, including pernicious anemia, is to be rated on the underlying condition. 38 C.F.R. § 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. On VA gastrointestinal examination in November 2006, the Veteran complained of gastric acidity, reflux of acid content and heartburn three to four times per week. These were partially relieved by medication. Examination of the abdomen showed normal peristalsis. The abdomen was soft and depressible. There was no history of ulcer disease, weight changes, or signs of anemia. The Veteran had no pain or tenderness. On VA gastrointestinal examination in July 2007, the Veteran reported no periods of incapacitation due to stomach or duodenal disease. He did complaint of burning pain weakly, one to several hours after eating. Examination showed positive bowel sounds, no guarding, no rebound and no tenderness. Laboratory testing was within normal limits. The diagnosis was gastritis. On VA gastrointestinal examination in October 2009, the Veteran complained of intermittent heartburn, dyspepsia, reflux of acids, regurgitation, epigastric pain, sore throat, and constipation. He was treated with oral mediation on a daily basis. He reported incapacitation due to stomach disease four or more times per year. He had a burning pain on a weekly basis, at night. This was relieved by antacids. Examination showed no signs of weight loss, malnutrition or anemia. Bowel sounds were positive and there was no rebound or guarding. An upper gastrointestinal study showed adequate distendibility and mucosa of the distal esophagus, stomach and duodenum. There were no active ulcerations, intrinsic or extrinsic mass-effect. The impression from the study was normal. The diagnosis was gastritis. For the Veteran's gastritis to warrant a rating in excess of the currently assigned 10 percent multiple small eroded or ulcerated areas would have to be demonstrated. While the Veteran has exhibited gastric pain, the upper gastrointestinal study performed in October 2009 was normal and there is no evidence of erosion or ulcerated areas. While the Veteran's gastric symptoms could be rated under the provisions for ulcer disease, it is noted that no gastric, marginal, or duodenal ulcers have been demonstrated. As such a rating under those codes (Codes 7304, 7305, and 7306) is not warranted. As the examinations of record show no erosion or ulceration, the Board finds that a preponderance of the evidence is against the Veteran's appeal for a higher initial rating for gastritis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2009); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. 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 VA 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. Turning to the first step of the extraschedular analysis, the Veteran's right and left hip disabilities have manifested in arthritis, limitation of motion, including due to pain, weakness, and guarding of movement. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (DC 5003, 38 C.F.R. § 4.59), and contemplate 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). In this case, comparing the Veteran's disability level and symptomatology of each hip 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 20 percent ratings under Code 5255 are, therefore, adequate. Regarding the Veteran's gastritis, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's gastritis causes pain and periodic constipation, but no other GI symptoms are shown. Moreover, no erosion or ulceration is demonstrated in the record. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's gastritis, and no referral for an extraschedular rating is required. In the absence of exceptional factors associated with the arthritis of the hips, 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). Regarding the matter of TDIU, it is noted that this issue is held in abeyance pending the completion of the remand included herein. ORDER Service connection for a bilateral hip disability, including arthritis of the hips, secondary to service-connected bilateral femoral neck stress fractures, is granted. An evaluation in excess of 20 percent for right femoral neck stress fracture residuals is denied. An evaluation in excess of 20 percent for left femoral neck stress fracture residuals is denied. An evaluation in excess of 10 percent for gastritis, from the initial grant of service connection is denied. REMAND The Veteran is also claiming service connection for a psychiatric disorder secondary to his service-connected disabilities. It is noted that service connection is currently in effect for residuals of a right femoral neck stress fracture, rated 20 percent disabling; residuals of a left femoral neck stress fracture, rated 20 percent disabling; lumbosacral spine disability, associated with residuals of femoral stress fractures, rated 20 percent disabling; and chronic gastritis, associated with residuals of femoral stress fracture residuals, rated 10 percent disabling. While the Veteran was examined by VA to determine the validity of these contentions, the examination is inadequate, primarily because it does not address the question of whether the disabilities were aggravated, or increased in severity beyond the nature progress of the disease, by the service-connected disabilities. The matter of TDIU must remain in abeyance pending the completion of these orders. Accordingly, the issue of service connection for a psychiatric disability secondary to service-connected disabilities is REMANDED for the following actions: 1. The RO/AMC should arrange for the Veteran's claims folder to be reviewed by the VA examiner who completed the May 2011 VA examination for a supplemental opinion. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent of more) that diagnosed major depression is aggravated, i.e., increased in severity beyond the natural progress of the disease, by any of the Veteran's service-connected disabilities. If the VA examiner is not available, the Veteran should be scheduled for a new examination so that the requested opinion may be obtained. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 2. Thereafter, the RO/AMC should readjudicate the issue of entitlement to service connection for a psychiatric disability secondary to service-connected disabilities and TDIU. If either determination remains unfavorable to the Veteran, he should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claims for benefits, and the Veteran should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs