Citation Nr: 1626202 Decision Date: 06/29/16 Archive Date: 07/11/16 DOCKET NO. 94-36 011A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for bilateral exotropia, to include the issue of whether there was clear and unmistakable error (CUE) in a September 1988 rating decision that denied entitlement to service connection for bilateral exotropia. 2. Entitlement to an initial disability rating in excess of 10 percent from May 21, 1990 to June 21, 2001; in excess of 20 percent from June 22, 2001 to September 11, 2005; and in excess of 30 percent from November 1, 2006 for osteoarthritis with avascular necrosis, status post arthroplasty, of the right hip (right hip disability). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Ralph, J. Bratch, Attorney-at-Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had creditable active military service from February 1971 to February 1973 and November 1976 to November 1977. The Board notes that he also had noncreditable active military service from August 1973 to May 1975. (See Administrative Decision dated June 10, 2008.) However, the claims presently on appeal are not related to that period of noncreditable service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 1990 and May 2010 rating decisions issued in October 1990 and September 2010, respectively, by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In the August 1990 rating decision, the RO determined that new and material evidence had not been received to reopen claims for service connection for bilateral exotropia and a hip injury, which were previously denied on the merits in a final September 1988 rating decision. In the May 2010 rating decision, the RO granted service connection for the right hip disability and assigned ratings of 100 percent for right total hip arthroplasty effective April 3, 2006 (based upon correspondence from the Veteran's representative that the RO took as a claim for service connection) and 30 percent effective November 1, 2006. The Veteran appealed the effective date of service connection as well as the assigned ratings. Subsequently, in an August 2011 rating decision, the RO granted an earlier effective date of May 21, 1990 for the grant of service connection for the right hip disability, and assigned ratings of 10 percent effective May 21, 1990, 20 percent effective June 22, 2001, 100 percent effective September 12, 2005, and 30 percent effective November 1, 2006. The Veteran continued his appeal. The Veteran appeared and testified at a Board videoconference hearing held before the undersigned Veterans Law Judge in August 2014. A copy of the transcript of this hearing has been associated with the claims file. The Veteran's appeal was initially before the Board in January 2015 at which time it determined that the issues on appeal included a claim for an earlier effective date for the grant of service connection and a claim for entitlement to a TDIU. The Board also clarified that additional issues had been favorably adjudicated or withdrawn, including that the character of discharge issue, which included a claim of service connection for a laceration of the right forearm, was withdrawn by the Veteran through his representative in statements received in March 2010 and June 2013 and, therefore, such claim was not on appeal. In January 2015, the Board issued a decision denying an effective date earlier than May 21, 1990 for the grant of service connection for the right hip disability and remanded the claims for increased disability ratings and a TDIU for further development. With regard to the January 2015 remand, the Board finds that substantial compliance with the prior remand has been accomplished. Substantial compliance with a remand order, not strict compliance, is required. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). Therefore, the Board may proceed forward with adjudicating the Veteran's claim without prejudice to him. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In addition, in the January 2015 decision, the Board stated that issues for service connection for a left hip disability and for a bilateral eye disability (other than bilateral exotropia) had been raised by the Veteran during his August 2014 hearing. The Veteran's representative also emphasized in an August 2014 statement that, in May 1990, the Veteran filed a claim for service connection for a bilateral eye disability that was separate and distinct from the bilateral exotropia that was considered by the RO in the September 1988 rating decision (i.e., an eye condition caused by the in-service surgery rather than the eye condition for which the surgery was conducted). The Board referred these issues to the RO for appropriate action. To date it does not appear that any action has been taken on these claims. Therefore, the Board again refers them to the Agency of Original Jurisdiction (AOJ) for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issue of whether new and material evidence has been received to reopen a claim for service connection for bilateral exotropia, to include consideration of CUE in the September 1988 rating decision, is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Prior to March 21, 2001, the Veteran's service-connected right hip disability was not productive of ankylosis, flexion limited to 30 degrees or less, limitation of abduction with motion lost beyond 10 degrees, limitation of adduction with inability to cross the legs, limitation of external rotation (toe-out) of more than 15 degrees, flail joint, fracture of the femur shaft or neck with nonunion, malunion of the femur with moderate knee or hip disability, or functional limitation consistent with a higher degree of disability. 2. From March 21, 2001 through August 9, 2001, the Veteran's service-connected right hip disability was productive of flexion limited to 30 degrees, but not ankylosis, flexion limited to 20 degrees or less, limitation of extension to 5 degrees or less, limitation of abduction with motion lost beyond 10 degrees, limitation of adduction with inability to cross the legs, limitation of external rotation (toe-out) of more than 15 degrees, flail joint, fracture of the femur shaft or neck with nonunion, malunion of the femur with moderate knee or hip disability, or functional limitation consistent with a higher degree of disability. 3. From August 10, 2001 to September 11, 2005, the Veteran's service-connected right disability was manifested by moderate osteoarthritis with avascular necrosis shown by X-ray with severe pain, severe limitation of motion in all ranges and functional limitations in sitting, walking and standing requiring frequent position changes productive of a disability picture analogous to a fracture of the femoral shaft with false joint. 4. On September 12, 2005, the Veteran underwent a right total hip arthroplasty for degenerative arthritis of the right hip. 5. Since November 1, 2006, the Veteran's service-connected right his disability has been status post right total hip arthroplasty and has not been productive of post-prosthetic placement with moderately severe residual weakness, pain or limitation of motion, ankylosis, flexion limited to 10 degrees, or fracture of the femur shaft or neck with nonunion. 6. Prior to March 21, 2001, the evidence fails to demonstrate the Veteran had avascular necrosis of the right hip. As of March 21, 2001, the Veteran's avascular necrosis of the right hip was more analogous to osteoarthritis and, thus, his symptoms have already been contemplated in the disability ratings assigned. 7. The Veteran's right hip disability does not represent an exceptional disability picture such that the VA rating schedule is inadequate to evaluate it. 8. From August 10, 2001, through September 11, 2005, the Veteran was unable to follow or sustain a substantially gainful occupation due to his service-connected right hip disability; however, prior to August 10, 2001 and as of November 1, 2006, the Veteran's right hip disability has not precluded him from all employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for service-connected right hip disability are not met prior to March 21, 2001. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5050 through 5255 (2015). 2. The criteria for a disability rating of 20 percent, but no higher, for service-connected right hip disability are met from March 21, 2001 to August 9, 2001. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5252 (2015). 3. The criteria for a disability rating of 60 percent, but no higher, for service-connected right hip disability are met from August 10, 2001 to September 11, 2005. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5255 (2015). 4. The criteria for a disability rating in excess of 30 percent for service-connected right hip disability are not met as of November 1, 2006. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5054, 5050 through 5255 (2015). 5. A separate disability rating for avascular necrosis of the right hip is not warranted. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14 and 4.71a, Diagnostic Codes 5000, 5003, 5010, 5252-5255 (2015). 6. The criteria for a TDIU rating have been met from August 10, 2001 to September 11, 2005, but not before or after. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Requirements The Board finds that, with respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's appeal has a long history and he has received multiple letters over that time relating to his and VA's responsibilities in obtaining evidence. His representative has also pointed out the lack of evidence in the record regarding the Veteran's right hip disability, especially during the 1990s indicating the Veteran's actual knowledge of the need to have evidence to establish the severity of his right hip disability. Despite that knowledge, the Veteran has not actually directly submitted or identified medical evidence in support of his claim since 2006 except for at his Board hearing in August 2014, where he only identified VA and VA fee-basis private treatment. See August 2014 Board hearing transcript, pp. 12-17. With regard to the concern raised by the Veteran's representative as to the lack of records, the Board notes that the claims file contains VA treatment records from May 1981 through May 1990. At the time the Veteran's representative raised his concern, there were no further treatment records until March 2001 in the claims file. However, in October 2015, the RO obtained treatment records from multiple VA medical facilities from 1998 to the present. The Board recognizes that there is still an eight year time gap in the medical records. However, the RO sought to obtain the Veteran's treatment records as far back as possible and the February 1998 records were the earliest ones it could obtain from the Palo Alto VA Medical Center where the Veteran testified he had been treated in the 1990s. Consequently, it would appear that any further efforts to obtain earlier treatment records would be futile. In addition, the Veteran has not identified any other source of treatment records that could assist in filling this gap. Rather, he has requested that a retrospective medical opinion be obtained. The Board finds, however, that the duty to assist does not require a medical opinion in this case as there is not an outstanding medical question for an opinion provider to address. Rather, there is a void in the medical records. See Chotta v. Peake, 22 Vet. App. 80, 84-85 (2008). The Board finds that the evidence of record is sufficient to evaluate the Veteran's service-connected right hip disability. Therefore, the Board may proceed to adjudicate the Veteran's claim without prejudice to him in not obtaining a retrospective medical opinion. Furthermore, the Board notes that, although the Veteran testified at the August 2014 Board hearing that he has only had treatment at VA or by VA fee-basis private physicians for his right hip disability, the VA treatment records obtained in October 2015 indicate that, over the years, he has received treatment by other private physicians whom he has not identified to the RO. For example, an October 2009 Palo Alto Primary Care note indicates the Veteran had been treated by a private physician in the community for the past four and a half years before returning to reestablish care. Given the Veteran's knowledge (whether actual or inferred through his attorney) of the need to provide VA with information relating to all his medical treatment of his right hip disability and his failure to do so despite being directly asked about it at the August 2014 hearing, the Board finds that no further efforts are necessary to obtain any private treatment records relating to his right hip disability, and the Board may proceed to adjudicate the Veteran's claims without prejudice to him. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). II. Analysis In the present case, the Veteran seeks higher initial disability ratings for his service-connected right hip disability, to include a TDIU. As previously discussed, service connection for the Veteran's right hip disability was awarded effective May 21, 1990 and was evaluated as 10 percent disabling from that date; 20 percent disabling from June 22, 2001; 100 percent disabling from September 12, 2005; and 30 percent disabling from November 1, 2006. The Veteran disagrees with these disability ratings assigned appealing that they should be higher. He also contends that a separate disability rating should be assigned for his avascular necrosis under Diagnostic Code 5000. He seeks a separate 20 percent disability rating for his avascular necrosis under Diagnostic Code 5000 from May 21, 1990 in addition to the 10 percent already assigned. In addition, he contends that his right hip disability should be rated as 60 percent disabling under Diagnostic Code 5000 for avascular necrosis as of August 10, 2001, the evaluation assigned for this condition by a November 2002 rating decision that granted nonservice-connected pension and permanent and total status, arguing that the avascular necrosis had to be severe to warrant a total hip replacement. Although the Diagnostic Code that the Veteran's right hip disability is evaluated under changes to Diagnostic Code 5054 after September 12, 2005 because of his uncemented right hip total arthroplasty, that Veteran claims that, effective November 1, 2006, his rating should be 70 percent based on the November 2002 disability rating as this condition was continuously evaluated as 60 percent disabling or more since August 2001 and there was no discussion of any evidence to warrant a lesser evaluation. With regard to TDIU, the Veteran relies upon the RO's finding in the November 2002 rating decision finding that he was unable to obtain and sustain a substantially gainful occupation and, therefore, was permanently and totally disabled for nonservice-connected pension in arguing that a TDIU is warranted. LAWS AND REGULATIONS Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor, 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran is service-connected for osteoarthritis with avascular necrosis of the right hip. Under Diagnostic Code 5003, osteoarthritis established by X-ray findings is rated on the basis of limitation of motion of the affected joints. When, however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, or as 20 percent disabling when show by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Disabilities of the hip are evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5250 through 5255. Standard motion of the hip is from 0 to 125 degrees of flexion, and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5250, ankylosis of the hip warrants a 60 percent evaluation for favorable ankylosis in flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction; a 70 percent evaluation for intermediate ankylosis of the hip; and a 90 percent evaluation for unfavorable or extremely unfavorable ankylosis with the foot not reaching the ground and crutches necessitated. 38 C.F.R. § 4.71a. Diagnostic Codes 5251 through 5253 evaluate limitation of motion of the hip and thigh. Diagnostic Code 5251 provides a 10 percent rating when extension of the thigh is limited to 5 degrees. Id. Diagnostic 5252 provides a 10 percent rating when flexion of the thigh is limited to 45 degrees; a 20 percent rating when flexion is limited to 30 degrees; a 30 percent rating when flexion is limited to 20 degrees; and a maximum 40 percent rating when flexion is limited to 10 degrees. Id. Diagnostic Code 5253 evaluates impairment of the thigh and provides a 10 percent rating when rotation of the thigh is limited in that the affected leg cannot toe-out more than 15 degrees. Id. A 10 percent disability rating is also provided when there is limitation of adduction in that the legs cannot be crossed. Id. A 20 percent rating is warranted when there is limitation of abduction lost beyond 10 degrees. Id. Diagnostic Code 5254 provides for a single maximum evaluation of 80 percent for flail joint of the hip. Id. Diagnostic Code 5255 evaluates impairment of the femur and provides an 80 percent rating for fracture of shaft or anatomical neck with nonunion and loose motion (spiral or oblique fracture); a 60 percent rating for fracture of shaft or anatomical neck with nonunion without loose motion where weight bearing is preserved with the aid of a brace or for fracture of the surgical neck of the femur with false joint; a 30 percent rating for malunion of the femur with marked knee or hip disability; a 20 percent rating for malunion of the be assigned for malunion of the femur with slight knee or hip disability. Id. Diagnostic Code 5054 provides a 100 percent rating for hip replacement (prosthesis) with prosthetic replacement of the head of the femur or of the acetabulum for one year following implantation of prosthesis. Thereafter, a 90 percent rating may be assigned following implantation of prosthesis, with painful motion or weakness such as to require the use of crutches. A 70 percent rating is assignable for markedly severe residual weakness, pain or limitation of motion following implantation of prosthesis. With moderately severe residuals of weakness, pain, or limitation of motion, a 50 percent rating may be assigned. The minimum rating assignable is 30 percent. Id. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Pain may be taken into consideration when rating "functional loss." However, 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.'" Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Finally, it is the intention of the VA rating schedule 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. 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. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). With regard to the Veteran's contention that his avascular necrosis should be rated separately, the Board notes that there is not a diagnostic code specifically for avascular necrosis. When an unlisted condition is encountered, it is permissible to rate the condition 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. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. 38 C.F.R. § 4.27. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran proposes that his avascular necrosis of the right hip be evaluated as analogous to osteomyelitis, which is rated under Diagnostic Code 5000. Under Diagnostic Code 5000, for osteomyelitis, acute, subacute, or chronic, a 10 percent evaluation is assigned for inactive osteomyelitis following repeated episodes without evidence of active infection in the past 5 years. 38 C.F.R. § 4.71a. A 20 percent evaluation is assigned for osteomyelitis with discharging sinus or other evidence of active infection within the past 5 years. Id. A 30 percent evaluation is assigned for osteomyelitis with definite involucrum or sequestrum, with or without discharging sinus. Id. A 60 percent evaluation is assigned for frequent episodes of osteomyelitis with constitutional symptoms. Id. A 100 percent evaluation is assigned for osteomyelitis of the pelvis, vertebrae, or extending into major joints, or with multiple localization or with long history of intractability and debility, anemia, amyloid liver changes or other continuous constitutional symptoms. Id. FACTUAL BACKGROUND The Board notes that the Veteran's attorney has raised concerns that no one has sufficiently discussed the evidence to support the ratings set forth. Consequently, the Board will set forth the evidence it finds relevant to the Veteran's claims. Service treatment records available contain a single clinical note from May 1977 showing the Veteran complained of "pain to hip" for two to three months. His separation examination reports from November 1977 are silent for any complaints or findings relating to any disorder of the right hip. The first relevant post-service evidence is from May 1981 from the VA Medical Center in Palo Alto, California. The Veteran was seen for complaints of chronic intermittent bilateral hip pain, right greater than left, since injury in 1972. His pain was worse after running or other stressful activities. He was referred for consultation with Rehabilitation Medicine at which he denied previous X-rays or examination. He reported having pain in the morning, worse on the right, and pain with activity, worse on the left. His pain was worse with damp weather and improved with rest, but not heat or aspirin. His pain occasionally radiated to the right groin. On examination, range of motion of the right hip was 120 degrees of flexion, 10 degrees of extension, 60 degrees of abduction, 15 degrees of adduction, 20 degrees of external rotation and 45 degrees of internal rotation. X-rays showed the right femoral head was tilted vertically. The assessment was questionable old slipped (unreadable) right femoral head. He was given pain medication and range of motion exercises. Subsequent Palo Alto VA Medical Center treatment records from 1982 to 1990 do not show any additional treatment of the right hip. Rather these records show treatment for the left hip, left shoulder, hemorrhoids, eye complaints, poison oak, a syncopal episode and substance abuse. The next treatment seen for the right hip was in March 1999 when the Veteran came into the Palo Alto VA Medical Center complaining of worsening right hip pain. He was noted to have slightly decreased mobility of the hip during flexion and abduction but no local tenderness. An April 1999 follow-up note indicates X-rays showed mild degenerative joint disease but, although the Veteran reported his pain had been getting worse lately, examination of the right hip was essentially normal. The Veteran reported his pain worsened when standing for too long, but at other times, his hip is not in much pain. He was told to avoid activities that make the pain worse. The assessment was mild degenerative joint disease to be controlled with exercise and as needed pain medication. In August 1999, he came into the VA clinic on an urgent basis for right hip pain. He reported that most of the time his pain gets better with pain medication (aspirin, ibuprofen or Tylenol) and he is able to walk without problem, but if he has nothing for pain, then he limps at times. That day, he walked with a slight limp and kept his legs straight when sitting. His hip movements were slightly restricted on external rotation and abduction. In May 2000, he underwent consultation with Orthopedic Surgery. It was noted that he was taking junior college courses and he would be able to work as a cook in the near future. On examination, his gait was unremarkable. Hip flexion was to 120 degrees bilaterally, extension to about 5 to 10 degrees bilaterally, abduction to about 45 to 50 degrees bilaterally, adduction to about 20 degrees bilaterally, external rotation on the left to 45 degrees and on the right to 20 degrees, and internal rotation on the left to about 15 degrees and on the right to -5 degrees. X-rays of the right hip were noted to show no definite abnormality. The assessment was right hip joint pain and limitation of motion of unclear etiology. On March 21, 2001, the Veteran was seen in Ambulatory Care on referral from the Urgi-Center, where he had been seen a couple of days earlier for right hip pain and given Motrin and Vicodin. The Veteran reported he had injured his hip in service in 1972 but that it did not bother him again until 1992. After that, the pain became increasingly worse over time and he became unable to work. He reported that he took a warehouse job in November 2000 hoping he could tolerate the pain, but instead it exacerbated his hip pain until it became so severe he quit on March 12th. He was told at the Urgi-Center that he could return to work with restricted activity, but he stated he had already quit and could not go back. He further disagreed that a month restricted duty would help to diminish his pain as was constant and had been for years. Instead he desired a different recommendation from VA that he could show his social worker. It was noted that he was homeless. Physical examination of the right hip demonstrated range of motion limited to 30 degrees of flexion, 20 degrees of abduction, 10 degrees of adduction, and 20 degrees of extension. There was no tenderness to palpation around the hip joint. X-rays of the right hip showed moderate narrowing of the articular cartilage of the hip and marginal osteophyte formation. The impression was that these findings were most consistent with moderate osteoarthritis. There was also an overall increase in density involving the adjacent acetabulum and femoral head without subchondral lucency to suggest avascular necrosis although a magnetic resonance imaging (MRI) study was recommended for further evaluation. The assessment was osteoarthritis of the right hip - chronic pain not controlled. A March 28th follow-up note shows the assessment of the Veteran's right hip disability was osteoarthritis of the right hip - chronic pain not controlled; and rule out avascular necrosis - MRI ordered. In April 2001, the Veteran underwent orthopedic examination related to his application for Social Security disability benefits. He reported using a cane on occasion and taking Tylenol with codeine, Ibuprofen and Celecoxib. The examiner noted that he had significant difficulty while moving about the examination table, he had a right-sided antalgic gait, and significant loss of range of motion of the right hip. The diagnosis was chronic right hip pain, probable arthritis of the right hip. On June 14, 2001, the Veteran underwent VA Orthopedic consultation. X-rays of the right hip were noted to show degenerative osteoarthritis. The Veteran reported having about one-half mile walking tolerance, although it was noted he was able to walk up and down the hall without an apparent limp. On examination, he had some limitation of internal and external rotation, but good flexion and no problems with extension. No thigh atrophy was present. The assessment was osteoarthritis of the right hip. On June 22, 2001, the Veteran was seen as a new patient in the Primary Care Clinic with complaints of right groin and hip pain made worse with walking. Examination showed limited abduction, adduction and internal rotation. The assessment was avascular necrosis and osteoarthritis of the right hip. Notably, there is no mention that the MRI ordered in April had been completed or that it confirmed the diagnosis of avascular necrosis. In December 2001, the Veteran was seen in Urgent Care at the San Diego VA Medical Center and noted to have limited flexion and rotation of the right hip. The assessment was documented post-traumatic osteoarthritis with possible diagnosis of avascular necrosis. In January 2002, the Veteran was seen in the San Diego VA Medical Center's Emergency Department for complaints of having more hip pain while doing chores at his homeless shelter (i.e., lifting tables, etc.) but having good pain relief with Sulindac. He ambulated without much difficulty with the assistance of a cane. Examination of the right hip showed a slight decrease in range of motion with internal and external rotation of the right hip secondary to pain and decreased right hip strength, but no tenderness to palpation over the hip. The assessment was chronic pain from right hip osteoarthritis. In July 2002 at the VA Medical Center in Portland, Oregon, the Veteran was seen for an initial appointment with Primary Care. Examination of the right hip showed limited adduction, abduction and internal and external rotation, as well as flexion of 60 degrees. There was also decreased strength of the quadriceps muscles in the right leg. In October 2002, the Veteran underwent VA examination for nonservice-connected pension purposes. The examiner noted that the Veteran was on Social Security disability for a hip injury. Veteran provided the history of falling in service and injuring his hip, and that he started having problems in 1988 related to this fall. He related that, in 2000, he was diagnosed to have avascular necrosis as well as osteoarthritis of the right hip. The Veteran reported that he can sit for one to two hours; walk up to a quarter mile before stopping to rest; stand for 45 to 60 minutes before having to change positions. He stated that, if sitting to long, his hip will get stiff and feel like it is starting to "disconnect," and, if walking for too long, his hip will get sore. H reported that he last worked in March 2001 for a produce company and he quit because of hip pain. The physical examination did not provide any specific findings relating to the right hip except to note that he ambulates with a cane and his gait is steady, although he favors the right hip. The examiner's assessment was: "Veteran with osteoarthritis of his right hip, avascular necrosis is documented in his medical records, from patient's report. The Veteran's hip would preclude him from many occupations, however, the Veteran is interested in retraining because he is interested in working, but he does not want to start out at the bottom of the rung at age 51. The Veteran would need a job that would provide him with frequent position changes from sitting, walking, and standing, since he can do none of those for more than an hour due to pain." From May 2003 to July 2003, the Veteran was hospitalized at the White City VA Medical Center for inpatient substance abuse treatment. A May 14th Nursing Admission Evaluation Note shows he reported having stiffness in the right hip with occasional pain when he walks or sits for too long. The assessment was avascular necrosis despite the Veteran's report of being diagnosed with both avascular necrosis and osteoarthritis in the hip. In contrast, the May 19th History and Physical note states that a "diagnosis of avascular necrosis has been considered," but under the list of the Veteran's medical problems only identifies "chronic right hip pain - X-rays done 7/9/02 in Portland showed osteoarthritic changes in both hips, worse on right." The assessment was merely right hip pain, but he was noted to have good range of motion and pain-free ambulation that day. During this hospitalization, it was noted the Veteran complained of pain on only one occasions - on May 22nd he complained to the nurse of right hip pain and rated it a 6 out of 10. Otherwise his right hip pain was noted to remain at baseline, which was some morning stiffness that loosened up but "not too much pain." See June 16, 2003, Physician's Note. He was next seen in November 2003 for hip pain in the Emergency Department at the Portland VA Medical Center and diagnosed with degenerative joint disease of the right hip and given Vicodin for pain. A December 2003 Kinesiotherapy Note indicates the Veteran was provided forearm crutches to improve his gait given the amount of limping he was exhibiting. However, in March 2004, he reported to his primary care physician that he rarely uses them as he was having a "bad day" when he was evaluated in December. He was noted to need arthroplasty but he wanted to wait. A month later in April 2004, the Veteran was seen again at the San Diego VA Medical Center at a new patient appointment with Primary Care and noted to have pain with rotation and decreased range of motion of the right hip. The assessment was avascular necrosis. In August 2004, the Veteran reestablished primary care within the Palo Alto VA Healthcare System. The assessment was osteoarthritis of the right hip. Subsequent treatment records show the Veteran was to be scheduled for an MRI of his right hip but he could not be reached. An April 2005 primary care physician's note does not show any specific complaints related to the right hip disability. In May 2005, the Veteran was seen by a private orthopedist for evaluation of his right hip disability. Examination of his right hip revealed flexion to about 90 degrees, internal rotation to 0 degrees, and external rotation to 20 degrees with pain on motion. X-rays of his right hip demonstrated he had severe arthritis in the hip joint. The orthopedist felt he was a candidate for total hip replacement. On examination in June 2005, he was noted to have good motion of the right hip (flexion to 110 degrees) but pain with internal and external rotation. X-rays were noted to show near bone on bone changes of the right hip. After discussion with the Veteran, it was decided to try an injection first to see if that would help before proceeding with a total hip replacement. On follow-up in August, the Veteran reported only having good relief from the injection for about two weeks before his pain returned. The physician noted that the Veteran was really limited in his ability to get around and he did not think that another injection would be helpful. After discussing the risks and options, the Veteran decided to proceed with a total hip replacement. On September 14, 2005, the Veteran underwent an uncemented right total hip arthroplasty. The post-surgical diagnosis was degenerative arthritis to the right hip. The Veteran did well after surgery. On September 25, 2006, at his one-year follow-up after his total hip arthroplasty, the Veteran reported doing very well, and he had no complaints. On examination, he had good motion of the right hip. There was no pain with weight bearing and normal appearing gait pattern. X-rays showed no excessive loosening. He was discharged with instructions to return if he had any further problems. In October 2006, the Veteran saw a physician to discuss a "military evaluation" he had coming up and what he could and could not do. The physician stated that the Veteran could walk, but not march. He could not lift greater the 20 pounds, bend over 90 degrees, cross his legs, crawl or get into tight areas. In essence, the Veteran needed to avoid any activity that would either dislocate or loosen the prosthetic hip quicker than normal. The next relevant medical evidence is a VA examination from July 2008, which was conducted to evaluate the Veteran's right hip for service connection. The Veteran's representative has argued that, therefore, this examination is not adequate for rating for the Veteran's right hip disability. The Board notes that the report of this examination reflects that the examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate physical examination, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that this examination is adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The The examiner noted the Veteran's history of injury in service in 1972 with diagnosis of contusion; continued intermittent pain and seen in 1977 for hip pain and using Ben-Gay at that time; deterioration of his hip problems in due course with subsequent X-rays showing a significant amount of traumatic degenerative arthritis; diagnosed with avascular necrosis in his hip at a rating decision in the Portland RO in 2001; severe pain increasing over time; his right hip condition considered enough to preclude him from many types of employment since he would need to change positions frequently from sitting to walking, and he was unable to secure and follow a substantially gainful occupation due to disability; and his uncemented right total hip replacement in 2005. With regard to the current state of the Veteran's right hip disability, the examiner noted that he had done quite well following his right total hip replacement in 2005 although he experienced pain in the hip, which is worse at times, and pain is also in the thigh. On physical examination, he had a mild limp favoring his right lower extremity without his cane, but with the cane his gait improved. He was able to stand on just his right leg, stand on his toes and heels, and squat to 90 degrees hip flexion quite easily. He got on and off the examination table without much difficulty. The range of motion of his right hip was flexion to 95 degrees, extension to 15 degrees, adduction to 25 degrees, abduction to 40 degrees, internal rotation to 25 degrees and external rotation to 30 degrees. There was no significant discomfort with these movements. The hip was stable. After three repetitions of movement, there was no decrease in the range of motion due to pain, fatigue, weakness, or lack of endurance. X-rays of his right hip showed that he has a right total hip replacement, uncemented, in good alignment. The impression was status post total hip replacement for avascular necrosis and traumatic arthritis, right hip. In May 2009, the Veteran was seen at the VA Medical Center in Amarillo, Texas. He had no real complaints relating to his right hip disability except to report that he still takes pain medication two to four times a day as needed for it. The assessment was osteoarthritis of the right hip. On October 2009, the Veteran returned to the Palo Alto VA Medical Center to reestablish primary care after seeing a private physician in the community since 2005. He reported continued pain in the right hip for which he took prescribed narcotic pain medication and smoked marijuana. Subsequent treatment records show his continued reports of right hip pain with having trouble walking far and using a cane off and on, but he had no other complaints. He was advised to lose weight and exercise regularly. In December 2011, it was noted he was having trouble with left hip pain and he was seeing a private orthopedist to consider replacing that hip too. A July 2012 note indicates he was to have left hip replacement surgery on September 4th by his private orthopedist. A December 2012 note shows he had left hip replacement and was doing a lot better with his pain level. In December 2013, he reported having continued pain in both hips and having trouble walking; he reported his medication was not working as before. In June 2014, he continued to report having pain in both hips for which he takes narcotic pain medication daily and smokes marijuana occasionally. There are no further complaints related to the right hip disability seen in the remaining treatment records obtained through October 2015. In April 2015, the Veteran underwent VA examination. The Board notes that, at this examination, the Veteran appears to have mixed up his hip disabilities. Thus, the left hip history he gave is actually, when compared to the remainder of the record, the history for the right hip, and vice versa for the right hip history, which is actually the left hip's history. For example, the examination report states that the Veteran's right hip surgery was in 2012 and his left hip surgery was in 2005. Clearly the evidence discussed above shows the right hip surgery was in 2005 and the left hip surgery was in 2012. The Board finds that this does not affect the adequacy of the examination itself, however, because the current symptoms were reported on a bilateral basis - meaning there is no distinction made between symptoms related to the right hip versus those related to the left hip. Furthermore, the actual physical examination clearly accurately reports the physical findings related to each hip. The Board, therefore, concludes that this examination is adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr, 21 Vet. App. at 312. With regard to his current symptoms and functioning, the Veteran reported he is able to drive but cannot go long ways. He often drives members of his complex around to appointments or errands. He can go upstairs without much pain and, in fact, walks six floors at his apartment complex two times for exercise. He reported that his hips are still bothersome, but not every day. His main complaints are that he cannot cross his legs so it is difficult for him to tie his shoes so he usually uses slip-ons. He also needs to stretch them so they will not get stiff and does so at least once or twice an hour. He reported his daily pain is a 4 out of 10, but is less on some days. He takes medication and uses marijuana for pain. He has flare-ups of pain at least once a month. During a flare-up, his pain is a 10 out of 10. He takes his medications and stays in bed until it goes away, which is about eight hours. On examination, adduction was limited such that the Veteran could not cross his legs. External rotation was limited to 30 degrees. Internal rotation was limited to 20 degrees. The examiner did not note that the Veteran's right hip was limited in flexion, extension or abduction. However, pain was exhibited on abduction, adduction, external rotation and internal rotation. Also, pain was noted to cause functional loss in that the Veteran could not cross his legs so that he cannot tie his shoes. There was no objective evidence of localized tenderness to palpation of the right hip joint or associated soft tissue. The Veteran was able to perform repetitive use testing but there was no additional loss of function or range of motion after three repetitions. With regard to repeated use over time and flare-ups, the examiner stated that he could not comment about additional loss of range of motion, fatigue, pain, weakness or incoordination during flare ups without resorting to mere speculation, as the Veteran denied flare-up while being examined. The examiner identified "interference with sitting" as an additional contributing factor of disability. Further examination did not demonstrate any muscle weakness or ankylosis or the right hip. The examiner identified residuals of pain and range of motion deficits, but no weakness, from the Veteran's right total hip replacement. With regard to the functional impact the Veteran's right hip disability has on his ability to perform any type of occupational tasks, the examiner stated that he would need a position that he did not have to pick up items off of the floor and time out for stretching as his hip gets stiff. Thus, a position that is sedentary or semi-sedentary would be the most appropriate. In a separate report, the VA examiner responded to a request for a medical opinion as to whether the Veteran's right hip disability in and of itself, precludes "substantially gainful" employment, and if so, from what time period he may be deemed unemployable. The examiner reviewed the Veteran's educational history, military job and post-service job history, noting jobs in construction, a car wash, security work, and as a nursing assistant, as well as his current activities. The examiner stated that the Veteran would not have been physically able to perform that type of labor due to his pain and being "hobbled" per his report. However, since his hip surgeries, the Veteran has improved greatly and, although he would need special accommodation if he were to work, a more sedentary job would be suitable. With regard to his functional and industrial impairment, the examiner stated that the Veteran does very well with his hip prostheses and his functional ability has greatly improved with the new hips as evidenced by his reports seen in the medical records. As for the residuals of the right hip arthroplasty, the examiner characterized them as moderate rather than severe in that he uses only a cane when he walks for extended periods of time, does not use crutches, has pain but it is not present all the time, has no weakness, and has some range of motion limitations (most notably the inability to pick something up off the floor and tying his shoes). With regards to whether the Veteran's right hip disability results in unemployability, the examiner stated that he can no longer work in a physical labor job as he had in the past. However, if he had accommodations in a position to stretch out when needed, he would be able to train in a more suitable position than physical labor. Prior to his surgeries, he would not have been employable as his pain and symptoms were too incapacitating. As to the onset of unemployability, the examiner stated that, using the note from an orthopedic consult in 2001, the disability for employment purposes began in the year or two before his first hip surgery in 2005. The disability continued until his last hip surgery in 2012. In July 2015, the RO requested an addendum from the VA examiner determining that her April 2015 responses to the questions asked did not fully and completely address the Board's remand instructions. The RO sought clarification and more complete answers. In a July 2015 addendum, the VA examiner responded. In response to a question relating to the notation that the Veteran drives people to appointments and whether this indicates employment or an occasional personal favor, the examiner stated that the Veteran driving people is an occasional personal favor. The examiner further clarified her opinion as to whether the Veteran's right hip disability in and of itself, precludes "substantially gainful" employment. The examiner stated that he cannot perform the physical labor jobs as he once used to prior to his hip condition. He could work sedentary or semi-sedentary jobs only. He has improved enough to work after 2012, the date of his second hip surgery. The examiner set forth the Veteran has the current limitations: cannot climb ladders, cannot bend down to pick up something off the floor, cannot sit in the same spot for more than 45 minutes without need to stretch his legs, and cannot perform moderate to heavy physical labor (lifting heavy weight, running and jumping). She set forth that he is able to do the following: drive short to moderate distances, ambulate short and moderate distances, lift from a waist height up to 20 pounds, answer phones and perform light office work including carrying items 15 to 20 pounds, and walk up to 2 blocks without pain. The assessment was that the conditions of the bilateral hips would not affect or impose work restriction in fields of labor including semi-sedentary or sedentary jobs and would not affect the Veteran's reliability, productivity, ability to concentrate, follow instruction and ability to interact with co-workers and supervisors. Thus, the examiner opined that the Veteran is employable since his last hip surgery in 2012. With regard to the functional and industrial impairment caused by the service-connected right hip disability, the examiner further commented that the right hip impairment is pain if he over extends himself. The examiner continued to characterize the residuals of his right hip surgery as moderate. As to the onset of disability, the examiner opined that the onset, per Social Security Administration, began in 2001. FINDINGS After considering all the evidence, the Board finds that a 10 percent disability rating, but no higher, is warranted for the period of May 21, 1990 to March 20, 2001; a disability rating of 20 percent, but no higher, is warranted from March 21, 2001 to August 9, 2001; a disability rating of 60 percent, but no higher, is warranted from August 10, 2001 to September 11, 2005; and a disability rating of 30 percent, but no higher, is warranted. In addition, the Board finds that the Veteran is entitled to a TDIU from August 10, 2001 to September 11, 2005. 10 Percent Disability Rating Initially, the Veteran's former attorney argued that the 10 percent disability rating was improperly assigned under Diagnostic Code 5054 as that Diagnostic Code applies to status post hip replacement and the Veteran had not yet undergone hip replacement during the period when his hip was rated 10 percent. The Board acknowledges that the August 2011 rating codesheet appears to indicate that is the case. However, most likely the listing on the codesheet of all the rating periods under Diagnostic Code 5054 was simply a mistake as the prior codesheet was probably just updated to reflect the earlier effective date and new ratings instead of being updated by actually breaking out the pre-hip replacement period from the post hip replacement period to better reflect the characterization of the disability and the Diagnostic Code or Codes used to evaluate the right hip disability. Regardless, the Board finds that an initial staged rating in excess of 10 percent is not warranted. The rating decision itself does not specifically set forth the rating criteria used to assign the 10 percent disability rating but it does set forth the evidence. The RO relied on outpatient treatment records showing the Veteran received treatment for ongoing complaints of right hip pain as well as he was prescribed Flexeril and Celebrex for that condition. Based on this, the Board concludes that the 10 percent disability rating was likely assigned under Diagnostic Code 5003 or 5251 or 38 C.F.R. § 4.59 for a painful arthritic joint. For a higher rating to be warranted, the evidence must establish that the Veteran's right hip disability was productive of flexion limited to 30 degrees or less, abduction limited to 10 degrees or less, malunion of the femur with moderate knee or hip disability, fracture of the femur with false joint or nonunion or ankylosis, or the Veteran must show there is a combination of compensable limitation of motion of flexion, extension, abduction, adduction and external rotation such that separate disability ratings that can be combined are warranted. The Board finds that a disability rating higher than 10 percent is not warranted for the period prior to March 21, 2001 because the evidence demonstrates that the Veteran had mild osteoarthritis of the right hip manifested by only intermittent pain and generally noncompensable limitation of motion. A May 1981 examination only showed complaints of intermittent pain with some decrease in limitation of motion but it was not sufficient to be compensable under VA's rating schedule (flexion 120 degrees, extension 10 degrees, abduction 60 degrees, adduction 15 degrees and external rotation 20 degrees). In March 1999, when he sought treatment again at VA for right hip pain, he had only slight decreased mobility and X-ray evidence demonstrated only mild degenerative joint disease. The only treatment record showing a compensable limitation of motion is a May 2000 Orthopedic consultation note. Although examination did not demonstrate compensable limitation of motion for flexion, abduction, adduction or rotation, it noted the Veteran's hip extension was "5-10 degrees bilaterally." As this was a bilateral reading, it is unclear what exactly the right hip's limitation of motion was. However, resolving reasonable doubt in the Veteran's favor, the Board will find it was 5 degrees, which warrants a 10 percent disability rating under Diagnostic Code 5251. Such a rating, however, would be in lieu of, rather in combination with, the already assigned 10 percent disability rating as the same symptoms are used to evaluate the disability (i.e., limitation of motion and pain on motion). The Board has also considered whether a higher disability rating would be warranted due to functional loss but finds that the evidence fails to demonstrate the Veteran's functional loss would be consistent with a higher disability rating under any applicable Diagnostic Code. The evidence demonstrates the Veteran's hip disability was mostly manifested by pain which caused slight limitation of motion that occasionally limited his ability to walk without limping, mostly after he stood or walked for too long. "Pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. at 38 (citing 38 C.F.R. § 4.40 ). Also pain may be a cause or manifestation of functional loss, but limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Id.; 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). In the present case, the evidence indicates that the Veteran's pain slightly limited his right hip's range of motion, most significantly after exertion, such as standing or walking for long periods, which caused him to limp by his own report. There is no evidence to establish that the right hip motion was otherwise impeded. Thus, the Board finds that the 10 percent disability rating provided already contemplates the functional loss the Veteran's pain had on his right hip disability. Furthermore, the Board finds no indication in the evidence that there were any additional factors present such as more movement than normal, weakened movement, excess fatigability, or incoordination to warrant a higher disability rating. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that a disability rating higher than 10 percent was warranted prior to March 21, 2001, and the Veteran's appeal to that extent is denied. March 21, 2001, to August 9, 2001 On March 21, 2001, the Veteran was seen at the Palo Alto VA Medical Center with what appears to be an exacerbation of his right hip disability. He reported having recently quit a warehouse job because it had exacerbated his right hip pain to the point he could not tolerate it. Examination revealed flexion of his right hip was limited to 30 degrees, which is clearly consistent with a 20 percent disability rating under Diagnostic Code 5252. He also had significant limitation of motion throughout the remaining range of motions except extension. Furthermore, X-rays demonstrated advancement in the Veteran's osteoarthritis showing it was now of moderate severity, whereas previously it was no more than mild. Based on this clear objective evidence of a worsening in the Veteran's right hip disability, the Board finds that an increased disability rating to 20 percent, but no higher, is warranted. The Board acknowledges that the Veteran clearly had a worsening in his pain due to his right hip disability and this clearly resulted in an increase in the limitation of motion of the right hip. However, the evidence again did not show any condition that impeded motion of the hip other than by pain. For example, there was no tenderness to palpation around the hip joint, which would be suggestive of a ligamentous or muscle condition. In addition, although the March 21, 2001 treatment note indicates the Veteran had quit his warehouse job because it exacerbated his right hip pain, it also clearly indicates that the physicians felt the Veteran could return to his job with restrictions but he refused because he felt that a month of restricted duty would not help him. Rather he wanted VA to give him a different recommendation that he could show to his social worker. So, given the physicians thought he could return to the warehouse job with restrictions, it appears that he was still capable of performing his employment. Moreover, the subsequent treatment records over the next few months showed some improvement in his range of motion, although they continue to show his complaints of increased pain levels, abnormal gait and lowered tolerance level for walking. Consequently, these treatment records do not support that the Veteran's disability was either totally or permanently disabling. Furthermore, the Board acknowledges that the radiologist who reviewed the X-ray suggested that an MRI be obtained to exclude the possibility of avascular necrosis of the right hip. However, the records at this time do not show contain the report of this MRI nor do they show a definitive diagnosis of avascular necrosis. Regardless, the functional limitations due to the right hip disability are as described above. As previously discussed, the Veteran's right hip disability was manifested by pain with limitation of motion consistent with a 20 percent disability rating Diagnostic Code 5252 for limitation of flexion. There is no evidence to indicate the presence of other factors of function loss such as weakened movement, excess fatigability, or incoordination to warrant a higher disability rating. Consequently, the Board finds that the preponderance of the evidence is in favor of granting a 20 percent disability rating, but no higher, for the period of March 21, 2001 to August 9, 2001, and to that extent the Veteran's appeal is granted. August 10, 2001 to September 11, 2005 Effective August 10, 2001, the RO found that, for nonservice-connected pension purposes, the Veteran's right hip disability was consistent with a 60 percent disability rating and caused him to be permanently and totally disabled. Also in August 2001, the Social Security Administration determined that the Veteran was disabled for employment. VA treatment records after August 2001 show the Veteran continued to have limitation of motion in flexion, abduction, adduction and rotation secondary to pain in the right hip. He also began to show decreased strength in the right lower extremity. He eventually began to complain of stiffness in the right hip when sitting too long. Social Security Administration records note that, when the Veteran came in for an interview, he had difficulty walking as his limp was so pronounced that his whole body swung noticeably from side to side. On VA examination in October 2002, it was found that the Veteran's right hip disability was considered severe enough to preclude the Veteran from many occupations as he would need a job that would provide him with the ability to make frequent position changes from sitting, walking, and standing since he could not do any of these for more than an hour due to pain. In May 2005, the Veteran was evaluated by a private orthopedist and was noted to have severe, bone-on-bone osteoarthritis shown on X-rays, which caused him to be very limited in his ability to get around. On September 12, 2005, the Veteran underwent a right total hip arthroplasty. After considering all applicable Diagnostic Codes, the Board finds that the Veteran's right hip disability at this time is most consistent with the criteria for a 60 percent disability rating under Diagnostic Code 5255 for fracture of the femoral surgical neck with false joint. A false joint is defined as "a bony junction, usually occurring at the site of a poorly united fracture, that allows abnormal motion" also called pseudoarthrosis. The American Heritage(r) Stedman's Medical Dictionary, Houghton Mifflin Co., Copyright 2002. Pseudarthrosis is defined as "an abnormal union formed by fibrous tissue between parts of a bone that has fractured usually spontaneously due to congenital weakness." See http://www.merriam-webster.com/medical/pseudarthrosis. Dorland's Medical Dictionary defines pseudarthrosis as "a pathologic entity characterized by deossification [loss of mineral elements] of a weight-bearing long bone, followed by bending and pathologic fracture," with inability to form normal callus. See Betties v. Brown, 6 Vet. App. 333, 334 (1994). When considering the totality of the evidence from August 10, 2001 to September 11, 2005, the Board finds that the Veteran's right hip disability was productive of moderate to severe osteoarthritis with avascular necrosis and manifested by severe pain, limitation of motion, difficulty walking with significant limping, and significant limitations in prolonged sitting and standing, causing functional limitations such that his right hip disability seems more like a joint formed by a bony junction or fibrous tissue between the parts of the bone causing abnormal motion even though, in this case, such was not caused by a fracture. Thus, the Board finds that the Veteran's disability picture is more consistent with the criteria for an impairment of the femur caused by a femoral neck shaft fracture with false joint than any other applicable rating criteria. For that reason, the Board finds that a 60 percent disability rating under Diagnostic Code 5255 is warranted for the Veteran's right hip disability from August 10, 2001 to September 11, 2012. A higher disability rating is not warranted, however, because the evidence does not show nonunion of the femur with loose motion or ankylosis of the right hip or equivalent symptoms. Furthermore, the Board finds that the 60 disability rating should not be applied prior to August 10, 2001 because, unlike the prior 20 percent disability rating, this rating is not based upon any single treatment note or several notes close in time but, rather, is based upon the totality of the evidence within the applicable time period. Furthermore, the Board notes that the Veteran does not contend that the 60 percent disability rating should be taken back earlier than August 10, 2001, given credence to the Board's determination that this is the appropriate effective date for the increase to the 60 percent disability rating. For the foregoing reasons, the Board finds that the preponderance of the evidence is in favor of granting a 60 percent disability rating, but no higher, for the period of August 10, 2001 to September 11, 2005, and to that extent the appeal is granted. November 1, 2006 to the Present The Veteran had a right total hip arthroplasty done on September 14, 2005. Pursuant to Diagnostic Code 5054, a 100 percent disability rating was assigned for the 13-month period following the arthroplasty through October 2006. Effective November 1, 2006, the RO assigned a 30 percent disability rating, which is the minimum rating provided following hip replacement. In an August 2014 brief, the Veteran's representative argued that a 70 percent disability rating should be assigned based on the RO's November 2002 rating decision that determined that his hip condition rendered him permanently and totally disabled, the condition was continuously evaluated as 60 percent or more since August 2001, and there being no discussion of any evidence to warrant a lesser evaluation. In a January 2016 response to a Supplemental Statement of the Case, the Veteran's representative argued that the April 2015 VA examiner's characterization of the Veteran's right hip disability as moderate should be properly rated as 50 percent as moderately severe under Diagnostic Code 5054. Based on the evidence, the Board finds that it clearly demonstrates that the Veteran's residuals from the right total hip arthroplasty are not productive of the rating criteria for a disability rating higher than 30 percent under Diagnostic Code 5054. The medical evidence shows the Veteran's right hip disability healed well after his right total hip arthroplasty. He had no complaints at his one-year follow-up, and he had good range of motion. VA treatment records since November 2006 show the Veteran has merely continued to complain of right hip pain with trouble walking far. The July 2008 VA examiner stated he has done quite well following his right total hip replacement in 2005 although he experiences pain in the hip. Range of motion was limited in flexion, internal rotation and external rotation, but was not consistent with a compensable limitation of motion under either Diagnostic Code 5252 or 5253. Finally, on VA examination in April 2015, the Veteran again complained of pain in the right hip, but reported that it does not bother him every day. Flare-ups of severe pain occur about once a month and last for about eight hours causing him to stay in bed until the pain goes away. He described his main functional impairments as not being able to cross his legs so he cannot tie his shoes, needing to stretch his hips once or twice an hour so they do not stiffen up and not being able to walk for extended periods. Range of motion of the right hip was limited in only external and internal rotation with pain exhibited, although the examiner noted that pain was also exhibited on abduction and adduction. However, the examiner stated that there was no additional loss of function or range of motion after three repetitions. With regard to residuals from the Veteran's right total hip replacement, the examiner identified only residuals of pain and range of motion deficits. No weakness was noted. The examiner characterized these residuals as moderate in severity. A higher disability rating requires evidence showing at least moderately severe residuals with weakness, pain or limitation of motion. The Board acknowledges that the evidence shows limitation of motion and pain and the rating criteria does not require that the Veteran have pain, limitation of motion and weakness. However, the evidence does not indicate that the Veteran's residuals are consistent with moderately severe residuals. The Veteran's limitation of motion is not compensable under Diagnostic Codes 5251 through 5253. Thus, under any other applicable Diagnostic Codes, his right hip disability would be evaluated as 10 percent disabling, at most, for noncompensable painful limitation of motion under either 38 C.F.R. § 4.59 or Diagnostic Code 5003. As such, the right hip disability picture does not reflect a moderately severe limitation of motion consistent with a 50 percent disability rating under Diagnostic Code 5054. Rather, the 30 percent disability rating under Diagnostic Code 5054 is the more appropriate disability rating for the Veteran's right hip disability that is now status post total hip arthroplasty. Furthermore, the Board acknowledges the Veteran continues to complain of pain in the right hip. However, it does not appear that the Veteran's pain is excessive. The Board also notes that, since 2006, the Veteran has had increasing left hip pain and, in September 2012, underwent a left total hip replacement. He is not service-connected for this. It is difficult to differentiate how much of his complaints of pain seen in the treatment records relate to his service-connected right hip versus his nonservice-connected left hip. Rather the VA examinations are much more instructive on this point. They both show the Veteran has done well after his right total hip arthroplasty but that the residuals are no more than moderate in severity. The April 2015 VA examiner specifically marked "Other" when indicating the specific level of severity of the Veteran's residuals (marked severe, moderately severe or other) and, in her medical opinion, she stated they were "moderate." With regard to the arguments presented by the Veteran's prior attorney, it was argued that a 70 percent rating was warranted based on the pre-hip replacement surgery finding that the Veteran was totally disabled due to his hip. The argument set forth in the August 2014 brief fails to take into consideration that, due to the total hip arthroplasty, the Veteran's right hip disability has completely changed in character. Consequently, the evaluation of the right hip disability prior to the arthroplasty has no bearing on its evaluation afterward since the evaluation must now be done under completely different and very specific rating criteria for evaluating hip replacements. As to the argument set forth in the January 2016 correspondence, that a 50% rating is warranted because the 2015 VA examiner described the Veteran's condition as "moderate," the term "moderately severe" in Diagnostic Code 5054 must be read as a whole and, therefore, is a separate and distinct level of severity from "moderate." The VA rating schedule clearly makes a distinction between these two levels of severity. A good example of this is in the schedule for rating muscle injuries, which are rated as "slight," "moderate," "moderately severe" or "severe." See 38 C.F.R. § 4.73. There are many other Diagnostic Codes in the VA Rating Schedule that also make this distinction. Consequently, the VA examiner's statement that the Veteran's current right hip disability, status post right total hip arthroplasty, is characterized as "moderate" cannot be read to mean the same as "moderately severe" under Diagnostic Code 5054. This distinction is made even clearer by the fact that the VA examiner did not select the option for "Moderately severe residuals" on the examination report to describe the Veteran's residuals of the arthroplasty and instead checked "Other." The Board has also considered whether a higher disability rating would be warranted due to functional loss but finds that the evidence fails to demonstrate the Veteran's functional impairment would be consistent with a higher disability rating under any applicable Diagnostic Code. The VA treatment records demonstrate the Veteran's right hip disability was mostly manifested by pain which caused slight limitation of motion and occasionally limited his ability to walk without a limp, mostly after he stood or walked for too long. In addition, the April 2015 VA examination indicates that the Veteran's pain limited his right hip's range of motion, most significantly in that he could not cross his legs so he could tie his shoes. He also gets stiffness if he sits for too long so has to stretch once or twice an hour, and he continues to have difficulty walking for long periods so uses a cane occasionally for this. There is no evidence to establish that the right hip motion was otherwise impeded. The Board also acknowledges that the Veteran has flare-ups of pain that he describes as severe but these occur only about once a month. Thus, the Board finds that the 30 percent disability rating provided already contemplates the functional impairment caused by a right hip replaced by a prosthesis. Furthermore, the Board finds there is no indication in the evidence of any additional factors present such as more movement than normal, weakened movement, excess fatigability, or incoordination to warrant a higher disability rating. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that a disability rating higher than 30 percent has been warranted since November 1, 2006, and the Veteran's appeal to that extent is denied. Separate Rating for Avascular Necrosis The Veteran contends that a separate 20 percent disability rating should be granted for avascular necrosis under Diagnostic Code 5000, which evaluates osteomyelitis. The Board respectfully does not agree. Initially, the Board notes that, prior to March 21, 2001, the evidence fails to demonstrate the presence of avascular necrosis in the Veteran's right hip. A separate rating would not be appropriate until there is actually evidence that such a condition was present. Even in March 21, 2001, the X-ray report only suggested there may be avascular necrosis. The Veteran was supposed to have an MRI to confirm the presence of avascular necrosis. That report is not in the claims file, and it is unclear whether or when the diagnosis of avascular necrosis was confirmed. For this reason, at least until March 21, 2001, when the presence of avascular necrosis was first raised, a separate disability rating would clearly not be warranted. As for after March 21, 2001, the Board does not believe that Diagnostic Code 5000 is the appropriate rating criteria to evaluate the Veteran's avascular necrosis. "Osteomyelitis is defined as an infectious inflammatory disease of bone marked by local death and separation of tissue." McNeely v. Principi, 3 Vet. App. 357, 363 (1992); see also Seals v. Brown, 8 Vet. App. 291, 294 (1995) (Osteomyelitis is inflammation of a bone caused by a pus-producing organism.). The Board notes that, in 2003, VA proposed to add a new Diagnostic Code for asceptic necrosis of the femoral head (or avascular necrosis or osteonecrosis). See 68 Fed. Reg. 6998, 7017 (February 11, 2003) (Schedule for Rating Disability; the Musculoskeletal System). In this proposed rule, VA stated that asceptic necrosis (or avascular necrosis or osteonecrosis) of the hip is seen commonly if there has been interference of the blood supply to the head of the femur due to trauma, metabolic disease, vascular disease, etc., with resulting bone death of part or all of the femoral head; and, eventually, the affected bone collapses. Aseptic necrosis may be painless early but then cause progressive pain with weight bearing or even at rest. Eventually, a hip replacement may be needed because of bone destruction. Id. VA stated in this proposed rating that it is likely that asceptic necrosis would currently be rated analogous to fracture of the femur (Diagnostic Code 5255). Id. It also went on to state that, under the proposed rating for asceptic necrosis, evaluation would be based on whether ambulatory support is needed and whether the femoral head is collapsed, and evaluation of pain, when present, would be separate under § 4.59; or, in the alternative, it would be evaluated based on limitation of motion of the hip combined with an evaluation for pain when appropriate if that would result in a higher evaluation. Id. The Board notes that this proposed rule was withdrawn in April 2004 and, thus, is merely informative in this matter. However, it does give the Board a place to start from with when trying to determine what Diagnostic Code or Codes would be most analogous to evaluate the Veteran's avascular necrosis. The Veteran's symptoms of his right hip disability have essentially been the same before and after the possibility of avascular necrosis was first noted in March 2001 - pain and limitation of motion - for which he has been evaluated under Diagnostic Codes 5251 through 5255. The Board acknowledges that the note to Diagnostic Code 5000 permits ratings thereunder that are 30 percent or less to be combined with ratings for ankylosis, limited motion, nonunion or malunion, shortening, etc. subject to the amputation rule. 38 C.F.R. § 4.71a. The Board also acknowledges that both osteomyelitis and avascular necrosis may both result in bone loss. However, what causes that bone loss appears to be completely different and that difference is what is significant is choosing the Diagnostic Code to evaluate the Veteran's avascular necrosis. Diagnostic Code 5000 is evaluated based on the presence or recurrence of infection and whether that infection is local or has become systemic. However, with avascular necrosis, there is no infection. The loss of bone is due to loss of blood supply. See 68 Fed. Reg. 6998, 7017 (February 11, 2003) (Schedule for Rating Disability; the Musculoskeletal System). Thus, unlike osteomyelitis, avascular necrosis will not result in recurring infections, a discharging sinus or constitutional symptoms, all of which are rating criteria for evaluating osteomyelitis. As such, evaluation under Diagnostic Code 5000 does not seem appropriate. Rather avascular necrosis affects the bone itself causing pain and eventual bone collapse (or degeneration, to use a more all-purpose term). In that respect, it appears to be more like osteoarthritis or, as stated in the proposed rule above, a fracture of the femur if there is collapse of the femoral head because the pain and destruction of the femoral head would cause limitation of motion of the hip joint, such is present in this case. Consequently, the Board finds that the more appropriate Diagnostic Codes to evaluate the Veteran's avascular necrosis are those used to evaluate osteoarthritis (5003), traumatic arthritis (5010), limitation of motion of the hip joint (5250 through 5253) and impairment of the femur (5254 and 5255). Alternatively, a review of the VA treatment records makes it clear that the majority of the Veteran's treating physicians associated his symptoms with the osteoarthritis in the right hip rather than avascular necrosis. Avascular necrosis was only assessed a few times after March 2001, and it was unclear upon what basis such assessments were made as there was no reference to any radiographic evidence to support them. Furthermore, the private physician's medical records in 2005 relating to the right total hip arthroplasty show no finding of avascular necrosis. The post-surgical diagnosis was osteoarthritis of the right hip. Consequently, the Board finds that, even if the Veteran had avascular necrosis of the right hip, the medical evidence fails to establish that his symptoms of pain and limitation of motion were related thereto. Rather, the evidence establishes that his symptoms were associated with his osteoarthritis. Furthermore, as discussed above, the Board has already evaluated the Veteran's osteoarthritis with avascular necrosis as 60 percent disabling under Diagnostic Code 5255 effective August 10, 2001 based upon the right hip's total disability picture. Thus, the Board finds that it has already considered all manifestations of the Veteran's right hip disability in assigning that disability rating and to assign a separate disability rating would be impermissible pyramiding. See 38 C.F.R. § 4.14. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that a separate disability rating is warranted for the Veteran's avascular necrosis, and, to that extent, the Veteran's appeal is denied. Extraschedular Consideration It is generally provided that the rating schedule will represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from a service-connected disability. 38 C.F.R. § 3.321(a). Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). In the exceptional case, however, to accord justice, where the schedular evaluations are found to be inadequate, the Secretary is authorized to approve, on the basis of the criteria set forth in 38 C.F.R. § 3.321(b)(1), an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b). The governing norm in these exceptional cases is 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, as to render impractical the application of the regular schedular standards. Id. The claimant's entire history is reviewed when making disability evaluations. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). In Thun v. Peake, 22 Vet. App. 111, 115 (2008), the Court of Appeals for Veterans Claims (Court) clarified the method VA should take in determining whether referral for extraschedular consideration is warranted. The first question to answer is whether the evidence presents such an exceptional disability picture that the available schedular criteria for that disability are inadequate (i.e., is the disability picture adequately contemplated by the rating schedule). In considering this, the disability's level of severity and the symptoms should be compared with the established criteria provided in the rating schedule. If the first question is answered favorably, then it must be determined whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (i.e., marked interference with employment or frequent periods of hospitalization). Finally, if both the first and second questions are determined favorable to the Veteran, then the case must be referred to the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. The Board finds that the first Thun element is not satisfied here. The Veteran's service-connected right hip disability is manifested by signs and symptoms such as pain and limitation of motion, which essentially has impaired his mobility. This disability has increased in severity over time as evidenced by the staged ratings assigned. In the 1990s, it only caused intermittent pain with occasional difficulty with extended walking. By 2001, he began to have more problems with pain and limitation of motion and difficult sitting, standing and walking for prolonged periods. Eventually, in 2005, his right hip disability became so bad he was really limited in getting around, according to his private physician, and this led to his right total hip arthroplasty in September 2005. Since then, his right hip disability has again mostly been manifested by pain with noncompensable limitation of motion, but only in adduction, external rotation and internal rotation. These symptoms limit his functioning in that he cannot cross his legs and he has to take breaks once or twice an hour to stretch his hips so they do not become stiff. He also is limited in prolonged walking and uses a cane to assist in that. The Board notes, however, that these signs and symptoms have been used to provide staged disability ratings under multiple Diagnostic Codes related to disabilities of the hip. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The Diagnostic Codes in the rating schedule corresponding to disabilities of the hip provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a , Diagnostic Codes 5250 to 5253 (providing ratings on the basis of ankylosis and limitation of motion). The schedule also provides for disability ratings for impairments of the femur in Diagnostic Codes 5254 and 5255. Id. Finally, Diagnostic Code 5054 provides evaluation of the Veteran's right hip disability now that he is status post total hip replacement with a prosthesis. The Board acknowledges that the VA rating schedule does not provide a specific diagnostic code for evaluation of the Veteran's avascular necrosis. However, as discussed above, the Board finds that it is appropriate to rate it as analogous the musculoskeletal Diagnostic Codes for either osteoarthritis, traumatic arthritis, or those just mentioned in the previous paragraph. Even the Veteran did not argue that the VA rating schedule was not appropriate to evaluate the avascular necrosis and thus extraschedular consideration was warranted but rather contended that it be rated analogous to osteomyelitis (Diagnostic Code 5000). Furthermore, for all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture as it has evolved over time. In short, there is nothing exceptional or unusual about the Veteran's right hip disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. The Board finds, therefore, that the Veteran's service-connected right hip disability does not represent and unusual or exceptional disability picture that is not contemplated by the rating schedule or has not been considered by VA. 38 C.F.R. § 3.321(b)(1) . Thus, referral for consideration of an extraschedular disability rating would not be warranted. Conclusion For the foregoing reasons, the Board finds that the preponderance of the evidence is in favor of finding that the Veteran's right hip disability warrants the following disability ratings: (1) Prior to March 21, 2001, a disability rating of 10 percent, but no higher; (2) from March 21, 2001 to August 9, 2001, a disability rating of 20 percent, but no higher; (3) from August 10, 2001, to September 11, 2005, a disability rating of 60 percent, but no higher; and (4) from November, 1, 2006, a disability rating of 30 percent, but no higher. Furthermore, the Board finds that the preponderance of the evidence is against finding that a separate disability rating is warranted for avascular necrosis or that referral for extraschedular consideration is warranted. To the extent that the assigned disability ratings represent an increase in the previous assigned disability ratings, the Veteran's appeal is granted. TDIU Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). To establish a total disability rating based on individual unemployability, there must be an impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. In reaching such a determination, the central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation; provided that permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 4.15. The Veteran is service-connected for only one disability and that is his right hip disability. As set forth above, the Veteran's right hip disability is assigned a 10 percent disability rating prior to March 21, 2001; a 20 percent disability rating from March 21, 2001 to August 9, 2001; a 60 percent disability rating from August 10, 2001 to September 11, 2005; a 100 percent disability rating from September 12, 2001 to October 31, 2006; and a 30 percent disability rating from November 1, 2006 to the present. The Board notes that the period from September 12, 2001 to October 31, 2006 for which the Veteran is already rated a schedular 100 percent is disregarded as he cannot receive both a schedular 100 percent and a TDIU for the same disability as that would be impermissible pyramiding. See 38 C.F.R. § 4.14. With regard to the other periods of time, the now assigned 60 percent disability rating for August 10, 2001 through September 11, 2005, means that he meets the minimum schedular requirements for a TDIU under 38 C.F.R. § 4.16(a) for that period of time, but not for the other periods of time that are rated at 10, 20 or 30 percent. However, the evidence must still show that the Veteran is unable to pursue a substantially gainful occupation due to his service-connected disability. For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor, which takes this case outside the norm. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Factors to be considered are a veteran's education, employment history and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). After considering all the evidence, the Board finds that the preponderance of the evidence is in favor of finding that the Veteran was unable to pursue a substantially gainful occupation from August 10, 2001 through September 11, 2005 due to his right hip disability, which period coincides with the period that a 60 percent disability rating is assigned for his right hip disability. This finding is consistent with the November 2008 decision by the RO in granting nonservice-connected pension, which found that the Veteran was permanently and totally disabled due to his right hip disability because he was unable to obtain or sustain a substantially gainful occupation. Furthermore, it is consistent with the October 2002 VA examiner's finding that the Veteran's right hip disability would limit him in performing many jobs due to his need to change positions every hour. In order for a TDIU to be assigned prior to August 10, 2001 or as of November 1, 2006, however, the Board cannot in the first instance assign a TDIU because the Veteran's disability rating does not meet the schedular criteria. Rather his case must be referred for extraschedular consideration. In November 2015, the Veteran's claim was considered for an extraschedular TDIU and was denied. After reviewing that decision, the Board agrees. The evidence of record clearly indicates the Veteran had pain and limitation of motion of the right hip prior to August 2001 and that this caused him difficult in being able to walk for extended periods of time. However, in March 2001, although reporting he had to quit working at a warehouse job, the VA physicians thought he would be able to continue to work with restrictions. The Veteran disagreed stating that a month's rest was not going to make a difference in his symptoms. However, VA treatment records in the following months show that his range of motion improved although his reports of pain continued. This evidence clearly shows that the VA physician's thought the Veteran could work and that, despite the Veteran's beliefs to the contrary, rest did improve his symptoms. The Board acknowledges that the Veteran was granted Social Security disability benefits in August 2001 and that the disability date established was March 15, 2001. However that date was the date he filed his claim. The Board notes that his claim was initially denied in May 2001 based upon a vocation assessment that he was not disabled as he had the residual functional capacity for sedentary work. However, his application was granted upon a request for reconsideration and the Veteran's submission of additional evidence and a new vocational assessment that, although again finding he had a residual functional capacity for sedentary work, determined that he would not be able to perform other work as his skills were not transferable, which is not something VA considers when determining employability. Consequently, the Board finds that the sole fact that the Veteran was granted Social Security disability benefits is not sufficient enough reason to find that he was totally disabled due to his service-connected right hip disability prior to August 10, 2001 when these records show he maintained the residual function capacity for sedentary work. Furthermore, as pointed out in the extraschedular decision, the evidence fails to demonstrate the Veteran was prevented from all employment. Even the October 2002 VA examiner's opinion did not preclude him from all employment, only many occupations and specifically those in which he could not make frequent position changes. As for the April 2015 VA examiner's opinion, that opinion noted that before his hip replacement surgeries (right and left) he would not have been employable due to the pain. Initially, the examiner placed the onset of unemployability to be a year or two before the 2005 hip replacement (which would be after the effective date assigned by the Board for a TDIU). On request for reconsideration in July 2015, she stated the onset would be in 2001 based upon the Social Security Administration's finding of disability, which places it within the time frame that the Board has granted TDIU. As for the period after November 1, 2006, the VA treatment records and the April 2015 VA examination reports and subsequent addendum clearly demonstrate that the Veteran's right hip disability improved significantly after his total hip arthroplasty and that he was not considered to be unemployable for sedentary types of employment. Therefore, the Board finds that the preponderance of the evidence fails to show that the Veteran was unable to perform all work due solely to his service-connected right hip disability prior to August 10, 2001 and as of November 1, 2006. However, the preponderance of the evidence is in favor of granting entitlement to a TDIU for the period of August 10, 2001 to September 11, 2005 and, to that extent, the appeal is granted. ORDER Entitlement to an initial disability rating in excess of 10 percent for service-connected right hip disability prior to March 21, 2001, is denied. Entitlement to an initial disability rating of 20 percent for service-connected right hip disability is granted from March 21, 2001 to August 9, 2001, subject to controlling regulations governing the payment of monetary benefits. Entitlement to an initial disability rating of 60 percent for service-connected right hip disability is granted from August 10, 2001 to September 11, 2005, subject to controlling regulations governing the payment of monetary benefits. Entitlement to an initial disability rating in excess of 30 percent for service-connected right hip disability as of November 1, 2006, is denied. Entitlement to a TDIU from August 10, 2001 to September 11, 2005, is granted, subject to controlling regulations governing the payment of monetary benefits. REMAND The Board is obligated by law to ensure compliance with its directives, as well as those of the appellate courts. Where the remand orders of the Board or the courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). In its February 2015 remand, the Board directed the AOJ to consider the Veteran's claim of CUE in a September 1988 rating decision that denied service connection for bilateral exotropia that was made in March 2010 statement, specially that the RO failed to apply 38 U.S.C.A. § 1111 as to a presumption of sound condition in the September 1988 decision. The Board also directed that the RO should also consider the application of 38 U.S.C.A. § 1153 as to aggravation of a preexisting injury or disease. In response to the Board's remand, the RO issued a Supplemental Statement of the Case in December 2015. In addressing the Board's remand directive, the RO stated: "The issue of alleged Clear and Unmistakable Error in the rating decision dated September 8, 1988 was remanded by the Board of Veterans Appeals for the VA regional office to readjudicate the claim. This has been done. No clear and unmistakable error has been found." The Veteran's representative argues that statement lacks sufficient reasons and bases as required by 38 C.F.R. § 3.103. The Board cannot disagree as a blanket statement that an action was done and a mere conclusion of the finding does not set forth "reason(s) for the decision." See 38 C.F.R. § 3.103(b). Consequently, the Board finds that its prior remand has not been substantially complied with and it must remand for again for such compliance. Accordingly, the case is REMANDED for the following action: 1. Adjudicate the issue of whether there was clear and unmistakable error in the September 1988 rating decision that denied service connection for bilateral exotropia. In so doing, the RO should consider the merits of the March 2010 and August 2014 arguments of the Veteran's representative regarding the failure to apply 38 U.S.C.A. § 1111 as to a presumption of sound condition in the September 1988 decision; the RO should also consider the application of 38 U.S.C.A. § 1153 as to aggravation of a preexisting injury or disease. 2. Thereafter, the Veteran's claim should be readjudicated. If such action does not resolve the claim, a Supplemental Statement of the Case should be issued to the Veteran and his representative. An appropriate period of time should be allowed for response. Thereafter, this claim should be returned to this Board for further appellate review, if in order. The Veteran has the right to submit additional evidence and argument on the matter 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 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 2014). ______________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs