Citation Nr: 1337361 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 04-22 265 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a chronic nerve disorder of the lower extremities. 2. Entitlement to a rating in excess of 20 percent for bilateral pubic rami stress fractures. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant and K.B., M.D. ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1991 to October 1992. This case comes to the Board of Veterans' Appeals (Board) on appeal from a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico, which continued a previously assigned 20 percent rating for bilateral pubic rami stress fractures and denied entitlement to service connection for a chronic nerve disorder of the lower extremities. In August 2004 the Veteran testified at a hearing before RO personnel. A transcript of the hearing is of record. Thereafter, the Veteran's claims file was transferred to the jurisdiction of Waco, Texas. In July 2010 the Veteran and K. B., M.D., testified at a Travel Board hearing before the undersigned Veterans Law Judge. The transcript of that hearing is of record. The Board previously remanded the matters on appeal for additional development in October 2011 and January 2013. As a final preliminary matter, the Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the appellant's claims. A review of the documents in such file reveals that contain additional evidence and procedural documents that are relevant to the issues on appeal. The Board notes that any future adjudication should also take into account this paperless, electronic claims file. The issue of entitlement to service connection for a nerve disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action is required on her part. FINDING OF FACT The Veteran's service-connected residuals of a pubic rami stress fracture are manifested by no more than pain on motion, fatigability, and tenderness. CONCLUSION OF LAW The criteria for an evaluation in excess of 20 percent for residuals of a pubic rami stress fracture have not been met. 38 C.F.R. §§ 4.20, 4.71a, Diagnostic Code 5299-5255 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2013). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in letters dated in August 2004, October 2004, and May 2008, the appellant was provided notice regarding what information and evidence is needed to substantiate her claim for an increased rating as well as what information and evidence must be submitted by the appellant and what information and evidence will be obtained by VA. Those letters also advised the appellant of how disability evaluations are assigned and the type of evidence which impacts those determinations. As her increased rating claim herein is denied, the Board finds that the Veteran is not prejudiced by any lack of notice concerning how effective dates are assigned. The claim was last adjudicated in April 2013. In any event, neither the Veteran nor her representative has alleged or demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Indeed, as a service officer for a veterans service organization, the Veteran is clearly aware of the information and evidence necessary to substantiate her claim. The record also reflects that VA has made reasonable efforts to obtain relevant records. In this regard, the RO obtained service treatment records, relevant post service treatment records to include outstanding VA treatment records requested in the Board's October 2011 remand, and VA examination and opinion reports. Also of record and considered in connection with the claim are various written statements provided by the Veteran as well as a transcript of the Veteran's hearing testimony provided in July 2010. The Veteran has not identified any other evidence relevant to this claim. The Board notes that it previously remanded the matter on appeal in January 2013 for development, to include a VA examination and opinion. That examination and opinion was obtained in April 2013. Additionally, pursuant to the October 2011 Board remand, the RO requested the Veteran identify and complete authorizations for records from any provider who has treated her for her disability on appeal during the appeal period. However, the Veteran did not respond to the RO's request. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which she presented oral argument in support of her claims on appeal. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fully explain the issues and suggest the submission of evidence that may have been overlooked. Here, the Veteran's representative asked specific questions directed at identifying whether the Veteran had symptoms meeting the criteria for service connection. Moreover, the Veteran volunteered her treatment and symptoms and further, had a physician testify on her behalf. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claim for an increased rating. Accordingly, the Veteran is not shown to be prejudiced on this basis. Additionally, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the VLJ hearing. The hearing focused on the elements necessary to substantiate the claim. As such, the Board finds that there is no prejudice to the Veteran in deciding this case. As discussed above, the VCAA provisions have been considered and complied with. The appellant was notified and aware of the evidence needed to substantiate her claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the appellant and VA in obtaining such evidence. Indeed, as a service officer for a veterans service organization, the Veteran is clearly aware of the information and evidence necessary to substantiate her claim. Therefore, she was provided with a meaningful opportunity to participate in the claims process and has done so. Thus, consideration of this matter on the merits at this time is appropriate. II. Analysis The Board has reviewed all the evidence in the Veteran's claims file and the electronic, paperless Virtual VA file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims herein decided and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that the residuals of her bilateral pubic rami fractures are more severe than currently evaluated and result in significant pain and limitation of functioning. Preliminarily, the Board notes that neurological, muscle, back, and knee symptoms claimed by the Veteran to be related to her pubic rami stress fracture residuals have been separated out from the increased rating claim being decided herein. Specifically, in an August 2012 rating decision, the Veteran was granted service connection for a low back strain, bilateral pelvic muscle strain, and a bilateral knee disorder secondary to her pubic rami fractures. The Veteran did not appeal the initial disability ratings assigned by that decision. Additionally, the issue of service connection for a nerve disorder of the lower extremities secondary to the pubic rami stress fracture requires further development and is being remanded as discussed further below. As such, this decision will focus on the orthopedic manifestations of the Veteran's pubic rami stress fracture residuals, and consideration of impairment from her pelvic muscle, knee, and low back strain cannot be considered. 38 C.F.R. § 4.14 (the evaluation of the same manifestation or disability under different diagnoses is to be avoided). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2013); see also 38 C.F.R. §§ 4.45, 4.59 (2013). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The Veteran's residuals of bilateral pubic rami fractures have been rated as 20 percent disabling under Diagnostic Code 5299-5255 by analogy to impairment of the femur. 38 C.F.R. § 4.71a (2013). This 20 percent evaluation was assigned by a 1999 rating decision for bilateral pain in the ischial area about the junction of the pubic and ischial bones. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Diagnostic Code 5255 contemplates impairment of the femur. Malunion of the femur warrants a 10 percent rating with slight knee or hip disability, a 20 percent rating with moderate knee or hip disability, and a 30 percent rating with marked knee or hip disability. 38 C.F.R. § 4.71a, Diagnostic Code 5255 (2013). The words slight, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2013). Use of descriptive terminology such as mild by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. The Board notes that there are other potentially relevant diagnostic codes. The pubic rami are parts of the collection of bones making up the pelvic girdle, including the hip joints. Accordingly, diagnostic codes applicable to evaluation of limitation of motion of the hips have been considered. Other potentially relevant diagnostic codes include degenerative arthritis shown on x-ray (Code 5003); ankylosis of a hip (Code 5250); limitation of extension of the thigh (5251); limitation of flexion of the thigh (Code 5252); loss of abduction beyond 10 degrees, limitation of adduction (cannot cross legs), and limitation of rotation (affected leg cannot toe-out more than 15 degrees) (Code 5253); and flail joint of the hip (Code 5254). However, there is no allegation of, clinical finding showing, or competent medical or lay opinion supporting any finding of ankylosis or flail joint. Further, no x-rays show evidence of degenerative changes associated with the past stress fractures; radiographic evidence is required for increased evaluation under Code 5003. Therefore, only Diagnostic Codes 5251, 5252, and 5253 need be discussed. Diagnostic Code 5251 pertains to limitation of extension of the thigh. 38 C.F.R. § 4.71a. Under Diagnostic Code 5251, a maximum 10 percent rating is assigned 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 thigh. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252, a 10 percent rating is assigned for flexion of the thigh limited to 45 degrees. A 20 percent rating is assigned for flexion of the thigh limited to 30 degrees. A 30 percent rating is assigned for flexion of the thigh limited to 20 degrees. A 40 percent rating is assigned for flexion of the thigh limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5253 provides a 10 percent rating for limitation of rotation such that the affected leg cannot toe-out more than 15 degrees, or limitation of adduction such that legs cannot be crossed. A 20 percent rating is assigned for limitation of abduction with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Normal hip joint motion is from 0 degrees to 125 degrees of flexion and abduction is from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II (2013). Private treatment records dated from November 2001 to February 2002 show physical therapy treatment for hip and pelvic pain diagnosed as pubic pain and right hip capsular tightness. The Veteran was initially fitted for axillary crutches, but by February 2002, was performing her activities of daily living and exercising daily without pain. She also had full and pain free motion of the bilateral lower extremities. The Veteran was afforded a VA examination in February 2003 to evaluate her bilateral pubic rami fracture residuals. She reported constant pain rated as 7/10, fatigue, and occasional swelling. She reported further reported flare-ups three times per month during which pain was rated 10/10 and lasted from 6 to 24 hours. Precipitating factors included lifting, walking up and downs stairs, and walking a quarter of a mile on a flat surface, and alleviating factors included Tylenol, rest, and heat. Regarding functional impairment, the Veteran reported that she cannot exercise, sit for long periods of time, perform housework, or lift her small children, as it is very painful for her to bend over. However, she denied the use of assistive devices. Physical examination was positive for weakness and pain. There was no ankylosis, but a leg length discrepancy was noted. A right hip/pelvis x-ray revealed no arthritic change or previous fracture deformity. The examiner diagnosed residual significant pelvic pain post fracture, unclear etiology per plain film. Private treatment records dated in May 2003 and June 2003 show continued complaints of hip and pelvic pain and a diagnosis of pelvic dysfunction and pain. In June 2003, the Veteran underwent an additional VA examination. At that time, she reported severe pain with an intensity of 10/10, and weakness secondary to pain. She reported flare-ups two to three times daily, lasting 30 minutes each time. During flare-ups, the Veteran has to lie in bed and rest, and cannot bear weight or perform basic activities of daily living. The Veteran reported use of a back brace, walking stick, and cane. Functionally, she reported that she cannot lift her children, exercise, carry books up the stairs, and has difficulty studying in school because of pain. Physical examination revealed no malunion or ankylosis, but was positive for tenderness of the pelvis with ambulation and weight-bearing. Right hip flexion was to 90 degrees actively, and 100 degrees passively. Left hip flexion was to 90 degrees actively and 110 degrees passively. Right hip abduction was to 20 degrees, and left hip abduction was to 25 degrees. Pelvic x-ray was normal with no evidence of a stress fracture. The examiner diagnosed persistent radiating pelvic pain of unclear etiology, noting that it may be secondary to the now-healed documented pelvic stress fracture. However, there was no evidence of former stress fractures or new stress fractures by plain film or bone scan. The examiner noted that the pain severely affects the Veteran's quality of life, but could not give an opinion as to whether that pain is service connected. During August 2003 private treatment, the Veteran complained of intermittent pubic pain and could not perform squats secondary to weakness. She was advised to begin exercising and to lose weight. In September 2004, private records show normal range of hip motion. Subsequent VA treatment records dated through April 2005 show continued complaints of chronic pelvic pain. The Veteran was afforded another VA examination in July 2005. She described her pelvic pain as a constant, agonizing pain, the worst possible pain of her life with daily flare-ups of this pain lasting five to six hours that are more than the worst possible pain of her life. She reported that the pain radiates to both her legs and feet and to her lower back. She stated that she is not able to care for her home, and her sister and her sister's husband help her. She added that she cannot lift or play with her kids, but she is able to cook and do some chores. She stated that it does not affect her job as a veterans service representative because it is mostly a desk job, but she takes frequent stretching breaks to relieve pelvic pain. On examination, she appeared alert, talkative, and not in apparent distress. She came to the physical examination walking with no signs of pain or limping with ambulation. The examiner repeated that there was no sign of the "constant worst possible pain of her life in this patient." He remarked that she was an obese individual. There was some tenderness to deep palpation at the level of the pubis and pain to deep percussion of both hips, even in the anterior and posterior aspects of her hips. There were objective signs of bursitis of both sides of both hips. On examination of the lower extremities, there were decreased sensory deficits in the right leg and left leg. The examiner indicated that during the physical examination, the Veteran showed obvious positive Waddell testing for nonorganic signs of pain that were manifested basically by positive simulation test. On examination of the lower back, there was some tenderness to deep palpation of the lumbosacral area, but no muscle spasm. There were no gait abnormalities. Radiologic examination was performed on the lumbosacral spine, bilateral hip series, and bilateral pelvic series. Results from all studies were reported as no significant abnormalities. A lumbar spine MRI (magnetic resonance imaging) study was reported as normal. A whole body bone scan study was reported as unremarkable with the exception of minimal changes present in the ankles. The diagnosis was residuals of pelvic rami stress fractures resolved. The examiner opined that the Veteran's present symptoms of lower extremity and pelvic pain were less likely than not secondary to her residuals of pelvic rami stress fractures. He explained that according to the medical literature, the pelvic rami stress fractures usually resolve spontaneously with time with no residuals because usually these stress fractures are very tiny and small fractures of the bone that, as soon as the patient stops the activity causing the stress fractures, they heal with no abnormalities. He added that all the x-rays and MRI reports were within normal limits with no evidence of stress fractures. He concluded that the Veteran's complaints were most likely related to her lower extremities and probably secondary to her hip condition that was manifested by bursitis of the bilateral hips and to another systematic condition that needs to be evaluated by her primary care physician. During subsequent October 2005 VA treatment, the Veteran complained of chronic pelvic pain and was noted to have very stiff muscles in the hips, right worse than left. However, her gait was within normal limits and internal and external hip rotation also appeared normal. The Veteran submitted opinions from Dr. K.B., who was asked by the Veteran's representative/employer to provide a consultation on the Veteran's case. In a December 2005 report, Dr. K. B. indicated that after an "extensive interview and physical examination of this Veteran, and after thorough review of her medical records," she believed that multiple medical conditions were related to the Veteran's bilateral inferior pubic rami fractures, including back, hip, and bilateral knee pain, and pain at the site of the fractures, groin, and pelvic floor. Dr. K. B. stated that early in basic training the Veteran began to experience groin, back, and hip pain that was found to be secondary to bilateral inferior pubic rami stress fractures. She explained that: [u]ncomplicated single fractures are known as closed ring fractures and generally heal well with bed rest and rehabilitation. Double/bilateral fractures, such as this Veteran's, are known as open ring fractures and usually are deferred to an orthopedist for traction, lengthy immobilization followed by specialty care and long term rehabilitation. This treatment was not accomplished. Dr. K. B. opined that the leg length discrepancy, for which she did not include a measurement, was associated with the pubic ramus stress fractures and was "probably secondary to chronic muscle tension, chronic bursitis and tendonitis, and muscle spasm." She added that the leg length discrepancy "also may explain her intermittent radiculopathy" and it "certainly explains the asymmetrical wear and tear on her back, legs and knees causing pain currently, and promising future osteoarthritis." Although Dr. K. B. indicated in her 2005 report that she conducted an "extensive interview and physical examination of this Veteran," reported objective findings on examination were sparse. Additionally, although five post-service x-ray reports and two bone scan reports were of record at the time of Dr. K. B.'s evaluation of the Veteran, Dr. K. B. did not address the lack of objective evidence of ongoing pubic rami disability. The Veteran underwent a VA bones examination in July 2007 during which she reported pain in her pubic area that is usually aggravated by prolonged standing and sitting. She reported that she can only walk one-quarter of a mile and then she starts having pain. She reported taking Motrin for pain with occasional relief, and also uses a cane when the pain is severe. She further reported that she puts more weight on her right side when she walks and has a history of frequent falls. Regarding occupational functioning, the Veteran had not lost any days from incapacitation during the last 12 months. She reported the effects of her disability on her job as complaining of pain. Physical examination revealed the Veteran to walk with a nonantalgic gait at regular pace and without the use of assistive devices. Range of motion testing of the right hip revealed abduction to 45 degrees, flexion from 0 to 125 degrees, internal rotation to 60 degrees, and external rotation to 60 degrees, all without evidence of pain, fatigue, weakness, or lack of endurance during repetitive use. Range of motion testing of the left hip revealed flexion from 0 to 125 degrees with pain at the pudendal area and inguinal area. Left hip abduction was to 45 degrees without evidence of pain, fatigue, weakness, or lack of endurance. Internal and external rotation were each to 60 degrees with pain on the pudendal area and inguinal area of the left side. However, there was no loss of motion during repetitive use due to pain, fatigue, weakness, or lack of endurance. Bilateral hip and pelvis x-rays revealed no abnormalities. The examiner diagnosed pubic bone arthralgia without evidence of arthritis and fractures of the pubic rami, bilaterally, resolved. Thereafter, the record reveals that the Veteran was involved in a motor vehicle accident in July 2008, during which she sustained injury to her neck, back, and right knee. She subsequently underwent private chiropractic treatment through at least December 2011. Notably, on her initial September 2008 intake form, she reported that her pelvic stress fracture was aggravated by the accident, and records dated in June 2010 note complaints of pelvic pain. In July 2010 Dr. K. B. testified that the Veteran had pain in her legs and knees due to a leg length discrepancy and was "probably gonna end up with arthritis" in the knees and other areas. When asked whether the Veteran currently had arthritis in her knees or hips, Dr. K. B. replied that the Veteran "feels mechanically like she does," but x-rays had not been done, and as a consultant she does not order x-rays. Dr. K. B. testified about the Veteran's claimed muscle, nerve, and low back disorders in relation to her service-connected bilateral pubic rami stress fractures, which she characterized as "a double bilateral fracture...known as open-ring fractures." She described the location of the in-service fractures, stating "it seems like we're talking about, um, the birth canal." Later, she stated that residuals from the fractures included faulty posture, limited adduction and abduction, massive calluses where the fractures healed that were putting pressure and strain on the muscles, and damage to the pelvic floor musculature. She testified that the Veteran had a leg length discrepancy and that "it seems to be worse today than it was then." She stated that the Veteran had painful motion of the lumbar spine that was dependent on how much muscle spasm was present and that muscle spasm was a characteristic of the pelvic bone fracture. She added that the Veteran had intermittent neuropathy from her spine down her leg and peripheral nerve pain depending on the degree of muscle spasm on a particular day. She also acknowledged that the Veteran had not been diagnosed with any neuropathy in her leg. She stated that the limitation of hip motion was obvious because the Veteran could not sit for any length of time, sexual activity was painful, and pushing on the site of the fractures caused "clear, unadulterated, uncomfortable pain." She further testified that the Veteran's alleged in-service rape was an emotional cause for her chronic pelvic pain. Private treatment records dated November 2011 to February 2012 show physical therapy for right knee complaints. Significantly, those records show reports of functional limitations on sitting, walking, standing, squatting, kneeling, and performing activities such as cleaning the floor, due to the right knee. The Veteran underwent another VA examination in June 2012 during which she reported pelvic pain and pain in the low back radiating to the hips and knees. She denied flare-ups that impact the function of her hip and/or thigh, and the examiner noted that no assistive devices were used for locomotion. Physical examination revealed, bilaterally, pain to palpation, normal muscle strength in hip abduction and extension, and active movement against some resistance in hip flexion. There was no ankylosis, nor was there evidence of malunion or nonunion of the femur or flail hip joint. The examiner also noted pain and tenderness over both trochanteric bursae and over the lateral aspect of both thighs to the lateral aspect of both knees along the course of fascia lata. Range of motion testing revealed right and left hip flexion to 65 degrees, with evidence of painful motion beginning at 60 degrees. Bilateral hip extension was to 5 degrees with no objective evidence of painful motion or abduction lost beyond 10 degrees. Additionally, bilateral adduction was not limited such that the Veteran could not cross her legs, and bilateral rotation was not so limited that the Veteran could not toe-out more than 15 degrees. The Veteran was able to perform repetitive-use testing without any additional limitation of bilateral hip motion. The examiner noted that diagnostic studies of the hip had been performed and did not reveal degenerative or traumatic arthritis. The examiner diagnosed chronic strain/sprain of both hips with limited motion and bilateral trochanteric bursitis. Regarding functional loss, the examiner noted less movement than normal, weakened movement, incoordination, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. The examiner further noted that the Veteran's profession was that of a postal worker, but that she was unable to be on her feet for extended periods of time. Nor could she bend or lift as required for the position due to increased hip and pelvic pain. Significantly, however, the Board notes that the Veteran has not worked as a postal worker, but instead as a veterans service representative since 2003. Subsequent VA treatment notes dated from June 2012 to August 2012 show continuing complaints of hip pain, rated 4/10 and 5/10. Those records also show that the Veteran gardened, walked frequently, went to the gym with her peers, and was going on a shopping trip with peers. Moreover, while the Veteran reported in July 2012 that she usually uses a cane, a VA nurse noted that, upon admission to a VA Women's Trauma Recovery Program, the Veteran did not have the cane with her. The Board also observes that those VA treatment notes document the Veteran's report that she falls due to her knees and ankles giving out. In April 2013, the Veteran was examined again to evaluate the severity of her hip and thigh condition. The Veteran reported that her condition had worsened and she experienced more pelvic pain since her last VA examination. She described the pain as continuous. She also stated that the left side was worse than the right. She treated her pain with ibuprofen and gabapentin. The examiner noted that the Veteran constantly used a cane to ambulate. It was also noted that available imaging of the hips did not show degenerative or traumatic arthritis. Physical examination revealed pain to palpation of both the right and left hip. There was no ankylosis, malunion or nonunion of the femur, or flail hip joint. Muscle testing revealed normal strength in bilateral hip flexion, abduction, and extension. Range of motion testing revealed bilateral hip flexion to 90 degrees with painful motion beginning at 90 degrees. Bilateral hip extension was to greater than five degrees with no objective evidence of painful motion. There was no abduction lost beyond 10 degrees, bilaterally, nor was adduction so limited that the Veteran could not cross her legs, nor rotation limited such that the Veteran could not toe-out more than 15 degrees. There was no additional limitation of hip motion following repetitive-use testing. Regarding functional loss, the examiner noted less movement than normal and pain on movement, bilaterally. Based on the foregoing, the examiner diagnosed healed pubic rami stress fractures. The examiner noted that the stress fractures appeared to have healed long ago, as the Veteran had normal MRI and bone scan in 2005, and pelvic films in 2012 were unremarkable. Regarding the impact of the Veteran's disability on her ability to work, the Veteran reported that her pelvis hurts if she sits for a long period of time. However, the examiner noted that the pubic rami stress fractures, per se, are not having a current impact on the Veteran's ability to work. In this regard, the examiner noted that years of repeated radiologic studies have shown no evidence of significant abnormalities in the areas in question. Additionally, the Veteran was working full time at the time of the examination, despite telling her primary care physician in December 2012 that she has severe pain all over her body. The examiner also noted that the Veteran's complaint of pain all over her body was not consistent with old pubic rami stress fractures. In light of the foregoing evidence, the Board finds that a rating in excess of 20 percent is not warranted for residuals of pubic rami stress fractures at any time during the period on appeal. Pursuant to Diagnostic Code 5251, separate maximum schedular 10 percent ratings could be assigned for each lower extremity based on the June 2012 and April 2013 VA examination findings of bilateral thigh extension limited to five degrees or greater. However, even considering bilateral factor and taking into account functional loss, as 10 percent is the maximum schedular rating assignable for each extremity, the combined rating for the pubic rami stress fracture residuals would still be only 20 percent. Thus, Diagnostic Code 5251 cannot serve as the basis for a rating in excess of 20 percent. Next, pursuant to Diagnostic Code 5252, neither right nor left thigh flexion has been limited to less than 30 degrees to warrant a higher 30 percent rating. In fact, neither right nor left thigh flexion has been limited to even 45 degrees during the period on appeal to warrant a compensable rating for either leg. Thus, assigning separate noncompensable or even 10 percent ratings for limitation of thigh flexion for each lower extremity, taking into account the bilateral factor and functional loss, Diagnostic Code 5252 would not provide for a combined evaluation in excess of the currently-assigned 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Similarly, Diagnostic Code 5253 does not provide for a higher rating at any time during the appeal period. Initially, the Board notes that Diagnostic Code 5253 provides for a maximum 20 percent rating where the evidence shows limitation of thigh abduction with motion lost beyond 10 degrees. Here, however, the record is negative for evidence of limitation of rotation, adduction, or abduction to warrant even a compensable rating for either lower extremity under Diagnostic Code 5253. Accordingly, even when considering the bilateral factor and functional loss, Diagnostic Code 5253 cannot service as the basis for a rating in excess of 20 percent for pubic rami stress fracture residuals. Thus, the only Diagnostic Code that could provide a basis for a rating in excess of 20 percent is the currently-assigned Diagnostic Code 5255. However, the Board finds that such an evaluation is not warranted here. The Veteran is not shown by evidence of record to have malunion of either femur, and her current 20 percent rating was rated based on bilateral pain in the pelvic bones analogously under Diagnostic Code 5255. The range of motion testing of the right and left hips throughout the period on appeal revealed flexion limited to no more than 65 degrees, at worst, and most recently 90 degrees. Abduction has been limited to, at worst, no more than 20 degrees in the right hip and 25 degrees in the left hip. The Board notes that the Veteran has also demonstrated full ranges of motion at times during the period on appeal. The Board concludes that such findings, showing limitation of motion to a noncompensable degree throughout the entire period on appeal, are tantamount to no more than slight hip disability for each hip. Thus, taking into account the Veteran's complaints of pain and weakness, the Board finds that the Veteran's overall residuals of pubic rami stress fractures would warrant no more than a 20 percent combined rating analogous to hip disability. Therefore, the Board finds that a rating in excess of 20 percent is not warranted under Diagnostic Code 5255. 38 C.F.R. § 4.71a, Diagnostic Code 5255 (2013). The Board notes that functional loss due to pain and weakness has already been considered in assigning the Veteran's 20 percent rating under Diagnostic Code 5255. 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, supra. Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Veteran reports some weakness and fatigability in addition to pain, and the Board has considered her subjective reports throughout the appeal, as well as the commentary from Dr. K.B. However, despite the Veteran's functional complaints and claimed limitations, the record during the appeal period shows that she was able to perform housework, garden, walk, use exercise machines, and even go shopping. To the extent that the Veteran has suggested that her residuals of pubic rami stress fractures have caused her to fall, the Board notes that during VA treatment the Veteran has also reported that it is giving way in her knees and ankles and weakness in her back that causes her to fall. Additionally, while the Veteran has claimed during the period on appeal that she requires a cane due to her pubic rami stress fracture residuals, the Board notes that the Veteran presented for inpatient treatment without her cane and therefore, is capable of ambulating without the cane. Moreover, VA examiners have questioned the accuracy of the severity of symptomatology being reported to them, especially in light of the completely negative radiographic findings. For example, the 2003 examiner noted her reported level of pain was not consistent with her presentation. Similarly, the 2005 examiner noted she reported constant, agonizing pelvic pain, yet she presented with no gait disturbance and there was no sign of her reported "constant worse possible pain of her life." Additionally, Dr. K.B. has stated that the Veteran's residuals from the fractures included "massive calluses where the fractures healed that were putting pressure and strain on the muscles, and damage to the pelvic floor musculature." However, all of the post radiographic studies during the course of the claim have revealed no residuals of the fractures. The inconsistent self-report by the Veteran of constant agonizing pain, when compared with the actual physical findings and observations of the examiners at the time of examinations, raise a significant question as to the reliability of the symptomatology being reported. Her demeanor at her hearing also raised some suspicion as to possible exaggeration of symptomatology. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). As such, the Board accords greater probative weight to the objective findings on VA examinations than to the Veteran's assertions as to the severity of her disability. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Likewise, as Dr. K.B. has indicated that the Veteran's residual disability of the pelvic fractures includes "massive calluses where the fractures healed", a fact that is completely discounted by the numerous negative radiographic findings, the reliability and credibility of the information and opinions she has provided are suspect. Thus, her conclusions are afforded little, if any, probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that "an opinion based upon an inaccurate factual premise has no probative value"). The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of her pubic stress fracture residuals. The symptomatology noted in the competent and credible evidence has been adequately addressed by the 20 percent evaluation assigned and does not more nearly approximate the criteria for a higher evaluation at any time during the relevant period on appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5255 (2013); see also Hart, supra. The Board further points out that the Veteran has been granted separate ratings for pelvic muscle strains affecting the left and right lower extremities pursuant to Diagnostic Code 5313, which specifically contemplates extension and flexion of the hip. 38 C.F.R. § 4.73, Diagnostic Code 5313. Thus, the Veteran's separate evaluations appear to violate the rule against pyramiding. The evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. While the Board will not disturb the additional muscle group rating at this time, as the issue is not on appeal, an additional or higher rating for hip disability manifested by limitation of motion would amount to further pyramiding, and will not be granted. The Board will leave it to the RO's discretion as to whether corrective action is necessary. The Board has also considered whether the Veteran's residuals of pubic rami stress fractures present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. Her 20 percent rating contemplates her subjective complaints and functional impairment. Thus, her disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Finally, the Board recognizes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court found that entitlement to a TDIU is properly considered as part of the claim for increased rating when the record shows evidence of unemployability. However, here, the record shows the Veteran to be working full time as a veterans service officer. Thus, the Board finds that TDIU has not been raised by the record or by the Veteran, and Rice is not for application. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER A disability rating in excess of 20 percent for residuals of pubic rami stress fractures is denied. REMAND The Board finds that remand is necessary once again regarding the claim for service connection for a chronic nerve disorder of the lower extremities. Pursuant to the Board's prior remand instructions, the Veteran was afforded a VA examination in April 2013 to determine the nature and etiology of any nerve disorder affecting the lower extremities. The April 2013 VA examiner diagnosed meralgia paresthetica, consistent with the prior June 2012 VA examiner's diagnosis. However, the examiner did not address evidence of record showing that the Veteran may suffer from radiculopathy secondary to her service-connected low back disorder. In this regard, the June 2012 VA examiner noted on the examination report that the Veteran had signs or symptoms of radiculopathy, though in describing the symptoms, noted that the signs "did not suggest radiculopathy." Even so in May 2003, during the period on appeal, the Veteran was noted to have low back pain with radiculopathy. Additionally, VA treatment notes dated May 2009, March 2012, and April 2012 show assessments of radiculopathy. As such, a remand is necessary to address whether the Veteran has a nerve disorder, to include radiculopathy, that is related to her service-connected pubic rami stress fracture residuals or low back disability. Given that neither the June 2012 nor the April 2013 VA examiner conducted diagnostic neurologic testing in conjunction with the respective examinations, the Board finds that additional VA examination with medical opinion is necessary. Ongoing VA medical records should also be obtained. See 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Obtain relevant treatment records from the New Mexico VA Health Care System dating since June 2012. 2. Schedule the Veteran for a VA peripheral nerves examination to determine whether the Veteran currently suffers from a neurologic disorder of the lower extremities and to obtain a medical opinion as to whether any diagnosed neurologic disorder is related to service or a service-connected disability. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. Objective neurological testing, along with any other tests or studies deemed necessary, should be conducted, and the results should be reported in detail. The medical rationale for all opinions expressed should be provided. Following a review of the claims file and examination of the Veteran, the physician should respond to the following: a. Does the Veteran have any diagnosed neurological disorder, to include radiculopathy, of the lower extremities? b. If so, was the disorder caused by or did the disability first manifest in service? c. If the disorder was not caused by service, is it caused by or permanently worsened beyond normal progression (aggravated) by the Veteran's service-connected bilateral pubic rami fractures. If aggravation is found, the examiner should attempt to quantify the extent of aggravation. d. If the disorder was not caused by service, is it caused by or permanently worsened beyond normal progression (aggravated) by the Veteran's service-connected low back disability. If aggravation is found, the examiner should attempt to quantify the extent of aggravation. A medical rationale for the conclusions reached should be provided. If a neurological disorder is diagnosed, objective testing to confirm the diagnosis should be obtained unless contraindicated. 3. Then, the record should again be reviewed. If the benefit sought on appeal remains denied, then the Veteran and her representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. 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). 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). ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs