Citation Nr: 1323306 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 08-12 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for residuals of a right pubic ramus fracture, to include residual tendonitis of the adductor magnus tendon, to include on an extraschedular basis. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from April 2001 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The December 2005 rating decision granted entitlement to service connection for "status post right pubic ramus fracture with degenerative changes at the symphysis pubis" and assigned a 10 percent rating, effective March 12, 2005. The Veteran filed a notice of disagreement with the assigned disability rating in December 2006. A statement of the case was issued in March 2008. The Veteran filed a VA Form 9 substantive appeal in April 2008. A January 2011 Decision Review Officer decision from the RO in Portland, Oregon, recharacterized the issue on appeal as "residual of tendonitis, status post right pubic ramus fracture with history of possible degenerative changes at the symphysis pubis," and continued the 10 percent rating. In June 2011, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A transcript of this hearing was prepared and associated with the claims file. In September 2011 and August 2012, the Board remanded this case for additional development, and the case has been returned for further appellate review. During the pendency of the appeal, the Veteran's claims file was transferred to the jurisdiction of the RO in Portland, Oregon, which certified the appeal to the Board. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. This evidence has been considered in the following decision. Finally, the Veteran contends that the disability at issue makes sexual intercourse painful for her and that her inability to have an intimate relationship with her husband due to her disability resulted in the dissolution of her marriage. She also contends that, following her most recent pregnancy, she has decided to avoid any future pregnancies because of the extent of the limitations she experiences when pregnant. These concerns raise the issue of entitlement to special monthly compensation based on loss of use of a creative organ under 38 C.F.R. § 3.350 (2012). The issue of entitlement to special monthly compensation based on loss of use of a creative organ under 38 C.F.R. § 3.350 had been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The residuals of the Veteran's right pubis ramus fracture, to include residual tendonitis of the adductor magnus tendon, is manifested by flexion limited to no more than 75 degrees with pain, but not by ankylosis, limitation of abduction of the thigh with motion lost beyond 10 degrees, limitation of adduction-cannot cross lets, limitation of rotation of-cannot toe-out more than 15 degrees, hip flail joint, limitation of extension or impairment of the femur. 2. The residuals of the Veteran's right pubis ramus fracture, to include residual tendonitis of the adductor magnus tendon, have not caused marked interference with her employment or frequent hospitalizations. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for residuals of a right pubis ramus fracture, to include residual tendonitis of the adductor magnus tendon, and to include on an extraschedular basis, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5250-5255 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. However, for initial rating claims, where, as here, entitlement to disability benefits has been granted and an initial rating has been assigned, the original claim has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for entitlement to benefits has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess, 19 Vet. App. at 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes an evidentiary development letter dated in July 2005 in which the RO advised the appellant of the evidence needed to substantiate her claim of entitlement to service connection for residuals of a fractured pelvis. This letter advised the Veteran of her and VA's responsibilities under VCAA, to include what evidence should be provided by her and what evidence should be provided by VA. A November 2008 letter further advised the Veteran as to the type of evidence needed to substantiate a disability rating for her claim, which satisfies that particular element of the Court's holding in Dingess, supra. The Board notes that the November 2008 letter was not issued prior to the initial adjudication of the Veteran's claim in December 2005. Her claim, however, was subsequently readjudicated, most recently in a February 2013 supplemental statement of the case. In any event, because an increased rating is being denied for the claim at issue, the Board finds that any deficiencies in the timeliness of this notice letter would not be prejudicial. Despite the inadequate notice provided to the appellant on the effective date element of her claim, the Board finds no prejudice to the appellant in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the appellant has been prejudiced thereby). Because the Board concludes below that the preponderance of the evidence is against the appellant's claim for compensation, any questions as to the appropriate effective date to be assigned are rendered moot. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issue on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's service treatment records and VA medical records. One purpose of the prior remands was to attempt to obtain obstetrician records from the Veteran's second pregnancy that had not been associated with the claims file. The Veteran's VA medical records reflect that she was seeing an obstetrician at Oregon Health and Science University at the time of her second pregnancy. In September 2002, the Veteran was sent a letter requesting that she submit records from such treatment, or to complete and return an authorization to permit VA to obtain these records. She did not respond. VA's duty to assist a veteran in developing the facts and evidence pertinent to a veteran's claim is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of veterans to cooperate with VA. See Olson v. Principi, 3 Vet. App. 480, 483 (1992). In the case at hand, the Board finds that VA satisfied its duty to assist the Veteran in attempting to obtain any outstanding pertinent private medical evidence and that no further actions on VA's part were necessary. The RO arranged for the Veteran to undergo VA examinations in connection with the claim at issue in November 2005, February 2008, February 2010, and October 2011. The Board finds that the resulting examination reports are adequate for the purpose of determining entitlement to an increased rating. The examiners elicited from the Veteran her history of complaints and symptoms, and the examination reports provide pertinent clinical findings detailing the results of the examinations to allow for effective evaluation of the Veteran's disability. For these reasons, the Board concludes that the examination reports in this case provide an adequate basis for a decision. The Veteran was also provided an opportunity to set forth her contentions during the June 2011 Board hearing. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 23 Vet. App. 488 (2010). In regard to the first duty, during the hearing, the Veterans Law Judge enumerated the issue on appeal. In regard to the second duty, the Veterans Law Judge elicited the Veteran's own competent descriptions of the limitations that are caused by the residuals of her right pubic ramus fracture. This testimony includes the Veteran's descriptions of how this disability affects her ability to care for her children and her ability to complete her cosmetology training. Following this hearing, this case has been remanded twice for the purpose of obtaining relevant medical records that had previously been overlooked and for the purpose of scheduling the Veteran for an examination that would address aspects of her claim that may have been overlooked. The obligations under 38 C.F.R. 3.103(c)(2) were thus met and, even if not met, there is no prejudice to the Veteran as VA has made attempts to assist the Veteran in getting the type of evidence necessary to support her claim. II. Higher Initial Rating The Veteran has claimed entitlement to an initial rating in excess of 10 percent for her service-connected residuals of a right pubic ramus fracture. This disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010. Disability evaluations are 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson, the Court also discussed the concept of the 'staging' of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127. The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2012) and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45 (2012). See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). Another intent of the 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 (2012). However, merely having pain throughout the entire range of motion of a joint does not warrant a maximum rating. Rather, any such painful motion must be shown to produce actual functional limitation. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Mitchell held that pain on motion is not, itself, functional loss, but "may result in functional loss ... only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance.'" Id. at 38 (quoting 38 C.F.R. § 4.40). Under 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012), arthritis due to trauma that is substantiated by x-ray findings is rated under the rating criteria for degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A 20 percent rating is available under Diagnostic Code 5003 when, in the absence of limitation of motion, there is x-ray evidence of involvement of two or more major joints or two or more minor joints, with occasional incapacitating exacerbations. Because the case at hand does not contemplate two or more major joints or two or more minor joint groups, a 20 percent rating is not available for the residuals of the Veteran's right pubic ramus fracture. The Board will next consider whether a rating in excess of 10 percent is available for the Veteran based on limitation of motion. Limitation of motion of the hip and the thigh are evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5250 through 5253. Diagnostic Code 5250 applies to ankylosis of the hip, assigning ratings ranging from 60 percent to 90 percent based on the angle of ankylosis. Diagnostic Code 5251, which rates limitation of extension of the thigh, assigns a maximum 10 percent rating and thus need not be further considered. In relevant part, Diagnostic Code 5252, which rates limitation of flexion of the thigh, assigns a 20 percent rating for flexion limited to 30 degrees; a 30 percent rating for flexion limited to 20 degrees; and a 40 percent rating for flexion limited to 10 degrees. In relevant part, Diagnostic Code 5253 assigns a 20 percent rating for limitation of abduction of the thigh, with motion lost beyond 10 degrees. Turning to the evidence of record, a November 2005 VA joints examination report notes that the Veteran experienced increased pain during her pregnancy that has worsened since that time. She reported right hip stiffness in the morning and increased pelvic pain with repetitive movement. Range of motion in the right hip diminished intermittently. She was not awakened during the night with pain. Activities of daily living were affected, as she avoided picking things up, horseback riding, dancing, and exercise. Flare-ups occurred with activity when she stands for long periods of time, resulting in a limp on the right. She treated it with rest and it was noted to be better with a half an hour to an hour. On physical examination, there was tenderness in the right groin area. There was no lateral hip pain. Range of motion was 0 to 100 degrees flexion, 30 degrees internal rotation, and 30 degrees external rotation, with pain at those end points, actively and passively. There was 35 degrees of abduction with pain at that end point. The examiner diagnosed pelvic ramus fracture, stress type, with chronic pain and degenerative changes at the symphysis pubis. The examiner expected moderate alteration in the Veteran's gait manifested by a limp on the right during flare-ups of pain, but did not expect additional motion loss or weakness. The examiner noted that the Veteran was not employed and had not been employed since the military and opined that the Veteran would be best served in a sedentary line of work where she would be able to sit or stand at will, and would not tolerate heavy labor. A February 2008 VA bones examination report notes that the Veteran had pain in the pubic area, mainly in the groin region, that limited her walking to 10 to 15 minutes at a time. She treated it with over-the-counter medications which helped some. It awakened her at times. Long periods of time resulted in a limp on the right side when she walked. She denied right hip morning stiffness. There was some crepitation at times. She did not feel as though her range of motion was affected in the right hip unless she spent longs periods of standing. Activities of daily living in terms of personal hygiene and dressing were not affected. She continued to avoid lifting heavy objects, riding horses, dancing, general conditioning, and physical exercises. During flare-ups, there was no additional motion loss, fatigue, or incoordination. On physical examination, there was mild tenderness over the anterior right hip. There was no compression tenderness at the pubis. There was mild pain on movement and increased pain on repetitive movement of the right hip without additional motion loss. Active and passive range of motion was 0 to 95 degrees flexion, 30 degrees internal and external rotation, and 35 degrees abduction. There was no sacroiliac tenderness. The examiner did not expect additional motion loss, fatigue, or incoordination during flare-ups of pain. A July 2008 VA medical center record noted that the Veteran requested a wheelchair because "it's excruciating for her to walk for any period of time. She's expected to deliver in January, and she can't bear to think that she won't be able to leave the house from now until then." She was issued a wheelchair in August 2008. In November 2008, she was issued a front wheel walker "for stress relief of pelvis," and she underwent physical therapy as ordered by her obstetrician. The November 2008 record expressly noted that the Veteran was not on bed rest. The February 2010 VA joints examination report noted that the Veteran reported increased pelvic pain during both of her pregnancies. The Veteran reported that she was on bed rest for the last six months of her last pregnancy. She reported a baseline pain of 2 or 3 out of 10 which increases to 7 or 8 out of 10 with a lot of activity. Climbing stairs did not seem to impact her pain level. She reported that she had onset of more pelvic pain after 15 to 20 minutes of walking. She denied radiation of the pain. She denied groin pain. She reported that the pain was back between her vaginal area and the adductor tendon area of the right hip region. She did not have increased pain when sitting for short periods of time. It was uncertain what activities exacerbated her pain. The examiner noted that the Veteran had been seen by VA since 2005 but that there had been no Orthopedic Clinic visits. She did not have a good answer as to why she had not requested to be seen by the Orthopedic Clinic, stating that she seemed to feel that no one could really help her pain situation. After the birth of her last child, she had two days of bed rest, but she denied any recent episodes of bed rest. She was currently not working. On examination, the Veteran had the ability to stay seated on the examination table comfortably. She was not squirming around or changing positions. There were no assistive devices in the room. Lying down, the Veteran had a negative Patrick's test bilaterally, indicating no sacroiliac joint disease or problems. The abduction of the right hip was noted to be 25 degrees, 25 degrees, and 28 degrees on three repetitions. She seemed to have more discomfort with moving the right hemi pelvis area around. She seemed to think there was some discomfort with adduction as well. However, adduction was strong. Adduction power and abduction power were both 5/5. Hip flexion was 105 degrees, and was 104 degrees on both the second and third repetitions. Extension was 25 degrees, 24 degrees, and 24 degrees on three repetitions. There was no pain or discomfort on palpating over the anterior hip joint on the right side. There was no tenderness on palpating over the right symphysis pubis. Therefore, the examiner noted, the examination was basically completely normal and unremarkable except for some tenderness that was felt to be present with maximal contraction and exertion of the adductor tendons, coming off of the inferior pubic ramus. X-rays were taken and compared to x-rays from 2008. Both were totally and completely unremarkable. The assessment was subjective complaints of pain over the inferior pubic ramus and ischium with certain activities. There were no degenerative changes, and the examiner felt that the Veteran's condition was a smoldering adductor tendonitis. The examiner stated that the Veteran would probably benefit from being seen and treated at the Orthopedic Clinic, most likely with an injection. The examiner opined that the Veteran's disability was not at all functionally limiting for her, as she was able to carry off her normal activity level, her normal activities of daily living, and the normal caring for her 11-month-old child. The examiner opined that the Veteran could perform any and all work activities involving a female of the Veteran's age and condition. At her June 2011 Board hearing, the Veteran described the limitations that her disability has had on her daily activities, including on her efforts to raise two children as a single mother while going to school. She reported that she had noticed her cosmetology school work had been getting more difficult for her to perform because she had to sit (while doing nails, for example) or stand (while doing hair, for example) for hours at a time and could not sit down or stand up as she pleased. An August 2011 VA medical record reflects that the Veteran received an injection of the hip joint capsule, which she reported did not alleviate her pain. The Veteran underwent a VA examination in October 2011. The examiner diagnosed residual symptoms status post right pubic ramus fracture, to include tendonitis. She reported daily pain in the right groin at a severity of 3 or 4 out of 10 that could flare up to 8 to 9 out of 10 a few times per month based on activities. Pain increased with walking, prolonged standing, and intimate relations. She also reported popping and snapping. She denied stiffness but reported increased pain with motion. During a flare-up, she could not walk for more than 15 minutes. She was in cosmetology school, which she could tolerate because it allowed her to sit as needed. She reported increased pain if she stood more than two hours. Intimate relations were painful and thus limited. She reported that she had decided not to have more children because it would likely be too painful and would put her in a wheelchair or on bed rest and prevent her from caring for her other two children. She took over-the-counter medications. An injection into the right groin muscle did not give any significant relief. She did not use a cane or a crutch for walking. She used a wheelchair for about four to five months when pregnant with her second child. She was on home bed rest when pregnant with her first child. On examination, flexion was to 90 degrees, with pain beginning at 90 degrees. Extension was to 0 degrees without objective evidence of painful motion. Abduction was not lost beyond 10 degrees. Adduction was not limited such that the Veteran could not cross her logs. Rotation was not limited such that the Veteran could not toe-out more than 15 degrees. On repetitive motion, the Veteran's right hip flexion ended at 75 degrees. Post-test extension was to 0 degrees. Post-test abduction was not lost beyond 10 degrees. Post-test adduction was not limited such that the Veteran could not cross her legs. Post-test rotation was not limited such that the Veteran could toe-out more than 15 degrees. On repetitive motion, there was less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and/or weightbearing. There was pain on palpation. Muscle strength was normal to flexion, extension, and abduction. There was no ankylosis. There was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. Internal rotation was 40 degrees with pain at 30 degrees. On repetition, range of motion decreased to 30 degrees. Abduction is limited to 30 degrees with pain at 30 degrees but no change with three repetitions. Adduction was 10 degrees without pain. There was no change with three repetitions. External rotation was limited to 25 degrees with pain at 25 degrees but no further limitation with three repetitions. She had tenderness in the medial group of the right hip. She had pain in the same area with resisted muscle testing of the adductor muscles and hip flexor muscles. She had slow but normal gait. She could walk on her toes. She did not attempt single leg jump on the right because of pain. A magnetic resonance arthrogram of the right hip was within normal limits. It was noted that the Veteran was in school for cosmetology and could tolerate this schooling because it allowed her to sit as needed. If she stood for more than two hours, she had increased pain. She could not tolerate manual type labor work or work that did not allow her to sit and stand as tolerated. The examiner opined that the pelvic pain during the Veteran's pregnancy in 2008-2009 was a result of the Veteran's service-connected tendonitis. He noted that the pain in pregnancy was in the same area in the right groin as symptoms before pregnancy. The symptoms were consistent with an increase in the pre-pregnancy symptoms. The examiner noted that this was not a typical pregnancy pain and therefore found it most likely that the pelvic pain suffered during pregnancy was a result of her residual tendonitis. Based on this evidence, the Board finds that a disability rating in excess of 10 percent is not warranted for the residuals of the Veteran's right pubic ramus fracture. The Board notes, in particular, that the greatest limitation of flexion of record was to 75 degrees on repetitive motion. This measurement was taken during the October 2011 VA examination, which expressly notes consideration of the DeLuca factors. As noted above, the examiner found that additional limitation of motion and functional impairment was due to less movement than normal, weakened movement, pain on movement, and interference with sitting, standing, and/or weightbearing. A range of flexion to 75 degrees with functional impairment does not approach the 30 degree flexion limit that is required for a 20 percent rating under Diagnostic Code 5252. Therefore, a rating in excess of 10 percent is not available under Diagnostic Code 5252. In the absence of ankylosis, a rating in excess of 10 percent is not warranted under Diagnostic Code 5250. Additionally, the preponderance of the evidence does not show limitation of extension to 5 degrees, limitation of adduction which prevents the Veteran from being able to cross her legs, limitation of rotation which results in the Veteran not being able to toe out more than 15 degrees, or limitation of abduction of the thigh, with motion lost beyond 10 degrees. As such a rating in excess of 10 percent is not warranted under Diagnostic Codes 5251 or 5253. The Board has also considered whether a higher rating is warranted under another diagnostic code that is applicable to disabilities of the hip and the thigh. However, in the express absence of hip flail joint and femur impairment, an increased rating under Diagnostic Codes 5254 (hip flail joint) or 5255 (impairment of the femur) is not warranted. In short, after considering the totality of the evidence of record, the Board finds that the criteria for an evaluation in excess of 10 percent have not been met. The Board has considered whether the Veteran is entitled to a staged rating. See Hart, supra. However, at no time during the pendency of this appeal have the Veteran's service-connected residuals of a right pubic ramus fracture, to include residual tendonitis of the adductor magnus tendon, been more than 10 percent disabling. As such, a staged rating is not warranted. The Board notes the Veteran's assertion of increased pain during pregnancy; however, there is no evidence showing that she met the criteria for a higher rating under the applicable diagnostic codes. The Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to a rating in excess of 10 percent for residuals of a right pubic ramus fracture, to include residual tendonitis of the adductor magnus tendon, must be denied. In reaching this conclusion, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disability at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, 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. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. 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 first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. Second, if the schedular evaluations do not contemplate the Veteran's level of disability and symptomatology and are found inadequate, the Board must determine whether the Veteran'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, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Based on the above, the Board finds that the first Thun criteria is satisfied in this case for the period of the Veteran's second pregnancy, as the Board finds that this period of the claim presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Specifically, the Board notes that the applicable rating criteria of 38 C.F.R. § 4.71a, Diagnostic Codes 5010 (arthritis due to trauma) and 5250 through 5255 (disabilities of the hip and thigh) do not adequately compensate the impairment caused by the Veteran being issued a wheelchair during her most recent pregnancy. The Board finds, however, that the second Thun step is not satisfied, as the Veteran's disability picture does not exhibit other related factors such as those provided by the regulation as "governing norms." "Governing norms" include "marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). Even though the evidence does not demonstrate that the Veteran was on bed rest during her second pregnancy, it does reflect that she was given a wheelchair and a front wheel walker at that time. However, there is neither allegation nor evidence of record suggesting that the Veteran's use of a wheelchair and a front wheel walker during her second pregnancy caused marked interference with employment. In fact, the Veteran was not employed during her first pregnancy, and she testified at her June 2011 Board hearing that she did not start cosmetology school until February 2011, which is well after her second pregnancy. In addition, the record does not reflect frequent periods of hospitalization during the Veteran's second pregnancy. The record does not reflect any hospitalizations during that period. The Veteran did report during her February 2010 VA examination that she was confined to bed rest for the last six months of her second pregnancy. While such confinement may be determined to result in a level of impairment that is similar to that of hospitalization, the Board notes that the remaining evidence of record, including multiple VA treatment records, statements made at other VA examinations, and the Veteran's own personal testimony, reflect that she was on bed rest during her first pregnancy (outside of the appeal period), not her second pregnancy (inside of the appeal period). The Board thus finds that any assertion on the Veteran's part that she was confined to bed rest during her second pregnancy are noncredible. In short, the Veteran has not alleged, and the record does not demonstrate, that the Veteran's service-connected residuals of a right pubic ramus fracture have caused marked interference with her employment and/or frequent hospitalizations. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim. ORDER Entitlement to an initial evaluation in excess of 10 percent for residuals of a right pubic ramus fracture, to include residual tendonitis of the adductor magnus tendon, to include on an extraschedular basis, is denied. ____________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs