Citation Nr: 1330102 Decision Date: 09/19/13 Archive Date: 09/25/13 DOCKET NO. 09-16 878 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for lumbago with residuals. 2. Entitlement to an initial rating in excess of 10 percent for residuals of a right hip fracture. 3. Entitlement to an initial rating in excess of 10 percent for fracture of the left inferior pubic rami. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from September 2004 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In October 2009, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge. The issue of entitlement to service connection for right and left foot disabilities was previously before the Board and was remanded for additional development in March 2012. Subsequently, service connection for pes cavus of the right and left foot was granted in a July 2013 rating decision. Accordingly, the issues of service connection for right and left foot disabilities are no longer before the Board, as the grant of service connection was a full grant of the benefit sought. See AB v. Brown, 6 Vet. App. 35 (1993). The Board previously remanded this appeal in March 2012. The development directed by the remand included obtaining outstanding VA treatment records and affording the Veteran a VA examination. The Board is satisfied that there was substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Prior to March 20, 2012, lumbago with residuals did not manifest forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour and was not manifested by incapacitating episodes of intervertebral disc syndrome. 2. From March 20, 2012, lumbago with residuals more nearly approximated forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees and was not manifested by favorable ankylosis of the entire thoracolumbar spine or by incapacitating episodes of intervertebral disc syndrome have a total duration of at least 4 weeks but less than 6 weeks during a 12-month period. 3. Throughout the appeal period, residuals of a right hip fracture has been manifested by flexion of the right hip greater than 30 degrees, without limitation of abduction of the right thigh, with motion lost beyond 10 degrees and without ankylosis of the right hip. 4. Throughout the appeal period, fracture of the left inferior pubic rami has been manifested by flexion of the left hip greater than 30 degrees, without limitation of abduction of the left thigh, with motion lost beyond 10 degrees and without ankylosis of the left hip. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 10 percent for lumbago have not been met for the period prior to March 20, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 2. From March 20, 2012, the criteria for a 20 percent rating for lumbago, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 3. The criteria for an initial disability rating in excess of 10 percent for residuals of a right hip fracture have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253 (2012). 4. The criteria for an initial disability rating in excess of 10 percent for fracture of the left inferior pubic rami have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 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, 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 notice from VA 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ, in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, a February 2008 letter advised the Veteran of the evidence required to substantiate a service connection claim. The February 2008 letter informed the Veteran of what evidence was required to substantiate his claims and of the Veteran's and VA's respective duties for obtaining evidence. This letter also informed the Veteran of how disability ratings and effective dates are determined. The Veteran's appeal for a higher initial rating for sciatica stems from his disagreement with the initial rating assigned in the June 2008 rating decision which granted service connection for lumbago, residuals of a right hip fracture and fracture of the left inferior pubic rami. Because the appeal stems from the Veteran's disagreement with the initial rating following the grant of service connection for the disabilities at issue, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the record indicates that the RO obtained all information relevant to the Veteran's claim. The record includes service treatment records and post-service private and VA treatment records. The Veteran has not identified any outstanding evidence that is pertinent to these claims. Moreover, the Veteran underwent adequate and probative VA medical examinations. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran had a VA examinations in February 2008 and May 2013. The Board finds that the VA opinions and findings obtained in regard to his increased rating claims are adequate. The examiners reviewed the Veteran's medical history and recorded pertinent examination findings. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Next, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge in October 2009. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to 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. Here, during the October 2009 hearing, the undersigned Veterans Law Judge stated the issues on appeal. The Veterans Law Judge elicited information from the Veteran with regard to the severity of the symptoms of his disabilities and as to whether the Veteran would be willing to attend another VA examination to evaluate his disabilities. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the appellant's claim. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained relevant records, and has provided adequate examinations to the Veteran. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis of Claims Disability Ratings - Law and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Veteran has challenged the initial disability ratings assigned to service-connected lumbago, right hip disability and left inferior pubic rami disability by seeking appellate review. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999) (noting distinction between claims stemming from an original rating versus increased rating). Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as a "staged" rating. Id. at 126. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular 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. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The Board has reviewed all of the evidence in the 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) (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 will focus specifically on what the evidence shows, or fails to show, as to the claims. Initial Rating for Lumbago A June 2008 rating decision granted service connection for lumbago and assigned a 10 percent rating from June 2008. The Veteran asserts that the initial rating assigned does not accurately reflect the severity of his disability. At the Board hearing in February 2008, the Veteran testified that he has sharp pain the lower back. The Veteran stated that he has trouble bending down and has spasms in his back. Lumbago is rated according to the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes following the General Rating Formula criteria, which provide the following: First, associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. 38 C.F.R. § 4.71a. The Formula for Rating Intervertebral Disc Syndrome based upon Incapacitating Episodes provides that a 10 percent rating is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assignable with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is assignable with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). In February 2008, the Veteran had a VA examination. The VA examiner indicated that the claims file was reviewed. The Veteran reported that he started having back pain with gradual onset in 2004, which became worse after a trauma in October 2006. The Veteran reported that the location of the back pain was above the belt line, non-radiating. He reported that the duration was every other day. The Veteran characterized the pain as a sharp pain with intensity level of 8-9. The Veteran reported that he had no periods of acute incapacitation. The Veteran reported that he did not wear a back brace and had not had back surgery. Upon physical examination, the Veteran had forward flexion of the thoracolumbar spine to 80 degrees, with mild discomfort. He had lateral flexion to 30 degrees bilaterally without discomfort and lateral rotation to 30 degrees bilaterally without discomfort. The VA examiner noted that the Veteran had objective evidence of painful motion without spasm, weakness or tenderness. The VA examiner indicated that there was no additional limitation of motion with three repetitions of movement during the physical examination that was related to pain, fatigue, incoordination, weakness or lack of endurance. Neurological examination of the lower extremities revealed motor, sensory and deep tendon reflexes to be intact. The VA examiner diagnosed lumbago, with residuals. The Veteran had a VA examination in March 2012. The VA examiner indicated that the claims file was reviewed. The Veteran again reported a history of back pain since 2004. The Veteran reported that he had to wear a back brace 4 days a week due to back pain since the last VA examination. The Veteran reported flare-ups that impacted the function of the spine. He reported that flare-ups occurred about once a week. The Veteran stated that his back completely locked up once in a couple of months and that he would go to the emergency room. He reported that the pain level was 10/10. The Veteran reported that he could barely walk for about one day when he had flare-ups. On physical examination, the Veteran had forward flexion to 70 degrees, with painful motion beginning at 60 degrees. He had right lateral flexion to 25 degrees, with painful motion beginning at 20 degrees. The Veteran had left lateral flexion to 25 degrees, with pain beginning at 20 degrees. The Veteran had right lateral rotation to 25 degrees,with pain beginning at 20 degrees. He had left lateral rotation to 25 degrees, with pain beginning at 20 degrees. With repetition of range of motion testing, the Veteran had forward flexion to 70 degrees. He had extension to 25 degrees, right lateral and left lateral flexion of 25 degrees each and right and left lateral rotation of 25 degrees each. The VA examiner indicated that the Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive use testing. The VA examiner indicated that the Veteran did have functional impairment and functional loss of the thoracolumbar spine. The VA examiner indicated that the functional loss included less movement than normal, pain on movement and interference with sitting, standing and/or weight-bearing. The VA examiner noted that there was localized tenderness or pain to palpation of the joints. The VA examiner indicated that there was guarding or muscle spasm present, but it did not result in abnormal gait or spinal contour. The VA examiner indicated that signs and symptoms of radiculopathy were not present. The VA examiner noted that the Veteran did not have any other neurologic abnormalities or findings related to his thoracolumbar spine condition. After a review of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for lumbago for the period prior to March 20, 2012. During that period, the Veteran had flexion of the thoracolumbar spine no worse than 80 degrees. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 202. There was no additional limitation of motion with three repetitions of movement during the physical examination that was related to pain, fatigue, incoordination, weakness or lack of endurance. Thus, the range of motion findings during this period do not more nearly approximate the criteria for a rating in excess of 10 percent, even when painful motion is considered. In addition, as the evidence during this period does not show incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during a 12-month period, a higher rating is not assignable based upon incapacitating episodes of intervertebral disc syndrome. The evidence establishes that, upon VA examination in March 2012, the Veteran had forward flexion of 70 degrees with pain from 60 to 70 degrees. Based upon the examination finding of painful motion at 60 degrees, the Board finds that the Veteran's lumbago disability more nearly approximates forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204 Accordingly, the Board finds that a 20 percent rating is warranted from March 20, 2012. The Board notes that the criteria for a rating in excess of 20 percent are not met for any period, as the evidence does not show forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Nor does the evidence establish incapacitating episodes which would warrant a rating in excess of 20 percent under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board has considered whether a separate rating is warranted for neurological impairment associated with the Veteran's lumbar spine disability. The VA examiners have indicated that the Veteran does not have neurological abnormalities associated with his back condition. Accordingly, there is no basis for a separate rating for neurological abnormalities. For the reasons set forth above, the Board finds that a rating in excess of 10 percent is not warranted for the period prior to March 20, 2012. The Board finds that a 20 percent rating, but no higher, is warranted for lumbago from March 20, 2012. Initial Rating for Residuals of Right Hip Fracture A June 2008 rating decision granted service connection for a residuals of a right hip fracture. An initial 10 percent rating was assigned from June 2008. The Veteran asserts that the rating assigned does not accurately reflect the severity of his right hip disability. At a hearing before the Board in October 2009, the Veteran testified that he has pain in his hip that wraps around and goes into the right buttock. Residuals of right hip fracture is rated according to Diagnostic Code 5251, which provides that a 10 percent rating is warranted for extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Diagnostic Code 5252 pertains to limitation of flexion of the hip. A 10 percent rating is assignable for flexion limited to 45 degrees. A 20 percent rating is assignable for flexion limited to 30 degrees. A 30 percent rating is assignable for flexion limited to 20 degrees, and a 40 percent rating is assignable for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5253 pertains to impairment of the thigh. A 20 percent rating is assignable for limitation of abduction of the thigh, with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The Board notes that normal flexion of the hip is to 125 degrees. Normal abduction of the hip is to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Veteran had a VA examination in February 2008. The VA examiner indicated that the claims file was reviewed. The Veteran reported that he was involved in an explosion of a guard tower wall in October 2006, collapsing the wall and trapping him within the rubble. The Veteran reported that he sustained a fracture of the right hip. The Veteran reported that the hip had healed well, and he was treated with immobilization without operative procedure. The Veteran reported pain with prolonged standing more than 15 minutes or walking more than 1 block. The Veteran reported that he was currently taking one Motrin tablet per day with mild relief and without significant side effects. The Veteran noted aching and stiffness with the cold, damp weather. Upon physical examination, the Veteran had full range of motion of the right hip, with flexion to 125 degrees, extension of 30, adduction to 25 degrees, abduction of 45 degrees, external rotation to 60 degrees and internal rotation to 40 degrees. The VA examiner diagnosed right hip fracture, with residuals. The Veteran had a VA examination in May 2013. The VA examiner indicated that the claims file was reviewed. The Veteran reported continuous right hip pain. The VA examiner noted that the Veteran ambulated with a cane because of his right hip disability. Upon physical examination, there was anterior tenderness of the right hip which extended at times posteriorly. There was no swelling and no erythema or warmth. On range of motion testing, the Veteran had forward flexion of the right hip to 110 degrees. He had extension to 35 degrees and abduction to 40 degrees. The Veteran had adduction to 25 degrees and internal and external rotation of 0 to 40 degrees with pain at the end of range of internal rotation and adduction and no with any other range of motion. The VA examiner indicated that there was no edema, instability or deformity and no ankylosis. The VA examiner diagnosed right hip strain. In this case, the Board concludes that the criteria for a rating in excess of 10 percent have not been met at any point during the appeal period. Under the applicable rating criteria, a rating in excess of 10 percent is warranted for impairment of the thigh with limitation of abduction and motion lost beyond 10 degrees or for limitation of flexion of the thigh to 30 degrees. In this case, the 2008 and 2012 VA examinations show abduction of 45 degrees and 40 degrees, respectively. The examinations show flexion of 125 degrees and 110 degrees. There is no change in the ranges of motion of the right hip with repetition. Accordingly, even with consideration of sections 4.40 and 4.45 and DeLuca, there is no basis for the assignment of a rating greater than 10 percent based on limitation of motion. The Board has considered the applicability of other diagnostic codes, but as there is no evidence of ankylosis of the hip (Diagnostic Code 5250), that the Veteran suffers from a flail joint (Diagnostic Code 5254), or that he has impairment of the femur (Diagnostic Code 5255), no other criteria pertaining to impairment of the hip and thigh is applicable to the Veteran's disability. For the reasons stated, the Board finds that a preponderance of the evidence is against the appeal for an increased rating higher than 10 percent for an initial rating in excess of 10 percent for residuals of a right hip fracture. As there is a preponderance of the evidence against the claim for a higher initial rating for a right hip fracture in excess of 10 percent, the claim must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Fracture of the Left Inferior Pubic Rami A June 2008 rating decision granted service connection for a fracture of the left inferior pubic rami. An initial 10 percent rating is assigned for fracture of the left inferior pubic rami, pursuant to Diagnostic Code 5252. The Veteran asserts that a higher initial rating is warranted. At the Board hearing, the Veteran testified that the left inferior pubic rami injury results in pinching pain. Diagnostic Code 5252 pertains to limitation of flexion of the thigh. A 10 percent rating is assignable for flexion limited to 45 degrees. A 20 percent rating is assignable for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A 40 percent rating is warranted for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252 (2012). The Veteran had a VA examination in February 2008. The VA examiner indicated that the claims file was reviewed. The Veteran reported a fracture of the left inferior pubic rami, which occurred when he was injured in an explosion of a guard tower wall in October 2006. Physical examination of the left hip showed full range of motion to 125 degrees, extension of 30 degrees, adduction to 25 degrees, abduction to 45 degrees, external rotation to 60 degrees and internal rotation to 40 degrees. The VA examiner noted that there was no additional limitation with three repetitions of movement during the physical examination that was related to pain, fatigue, incoordination, weakness or lack of endurance. The VA examiner diagnosed fractured left inferior public rami. The Veteran had a VA examination in May 2013. The VA examiner indicated that the claims file was reviewed. The VA examiner noted that, for left pubic symphysis, the range of motion was not applicable. The VA examiner noted a leg length discrepancy of the left leg. The left leg was longer by about a half centimeter. The VA examiner indicated that this was not clinically significant and was an incidental finding not related to the claim. The Board finds that a rating in excess of 10 percent is not warranted for a left inferior pubic rami disability, including residuals of a fracture. The evidence does not show that flexion of the left thigh is limited to 30 degrees or that there is limitation of abduction, with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5252, 5253. The record does not show that a higher rating is warranted based upon additional functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. The Board has considered the applicability of other diagnostic codes, but as there is no evidence of ankylosis of the hip (Diagnostic Code 5250), that the Veteran suffers from a flail joint (Diagnostic Code 5254), or that he has impairment of the femur (Diagnostic Code 5255), no other criteria pertaining to impairment of the hip and thigh is applicable. For the reasons stated, the Board finds that a preponderance of the evidence is against the appeal for an initial rating higher than 10 percent for a left inferior pubic rami disability. As there is a preponderance of the evidence against the claim for an increased rating for a higher initial rating, the claim must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111(2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the schedular rating criteria contemplate the Veteran's lumbar spine, right hip and left inferior pubic rami disabilities. The rating criteria pertaining to the back disability include both forward flexion and combined ranges of motion, whether there is ankylosis, and whether there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria also consider whether there are incapacitating episodes due to intervertebral disc syndrome. The rating criteria for the right hip and left inferior pubic rami consider limitation of flexion of the hips and whether there is impairment of the thigh with limitation of abduction. The rating criteria also consider limitation of motion due to pain and other orthopedic factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. Because the schedular rating criteria are adequate to rate the Veteran's disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. Accordingly, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER Prior to March 20, 2012, a rating in excess of 10 percent for lumbago is denied. From March 20, 2012, a 20 percent rating is granted for lumbago, subject to regulations governing the payment of monetary benefits. An initial rating in excess of 10 percent for residuals of a right hip fracture is denied. An initial rating in excess of 10 percent for fracture of the left inferior pubic rami is denied. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs