Citation Nr: 1644129 Decision Date: 11/21/16 Archive Date: 12/01/16 DOCKET NO. 05-36 443 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for thyroid disability 2. Entitlement to a compensable disability rating for status post-excision of right hip osteochondroma. 3. Entitlement to a separate disability rating higher than 10 percent for limitation of right thigh motion associated with the status post-excision right hip osteochondroma. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Counsel INTRODUCTION The Veteran served on active duty from August 1981 to July 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Board denied the Veteran's claim for a compensable disability rating for the right hip residuals in a November 2008 decision. The Veteran appealed the denial of the claim to the United States Court of Appeals for Veterans Claims (Court). The Court issued a memorandum decision that vacated the Board's decision to the extent of the denial of this claim and remanded the issue to the Board for adjudication consistent with the Court decision. The Board remanded the claim for further development in August 2011, July 2012, October 2014, and October 2015. The Board denied entitlement to service connection for a thyroid disorder in an October 2010 decision. The Veteran also appealed the denial of this claim to the Court. The parties to the appeal agreed to a Joint Motion for Remand (Joint Motion) that vacated the portion of the October 2010 decision that denied the service connection claim and the Court issued a decision remanding the issue to the Board. The Board remanded the claim for further development in July 2012, October 2014, and October 2015. The Veteran testified at hearing before an RO Decision Review Officer in January 2006. He also testified at hearing before the undersigned in August 2013. Hearing transcripts are of record. In a March 2016 rating decision, following the October 2015 Board remand of the Veteran's appeal, the AOJ granted a separate 10 percent disability rating for limitation of right thigh motion associated with the status post-excision of right hip osteochondroma, effective December 2, 2015. As the Board specifically remanded the issue of entitlement to a compensable rating for orthopedic residuals of a right hip osteochondroma excision in the October 2015 remand, it deems that the issue for a higher separate rating for the orthopedic impairment, involving limitation of right hip motion, remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). In the October 2015 remand, the Board also referred a claim to reopen a previously denied claim of entitlement to service connection for a back disability to the AOJ. The claim was raised by the record as a result of the receipt of VA treatment records dated from 2012 to 2014. The claim, however, has still not been adjudicated by the AOJ. Therefore, it is again referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016); cf. 79 Fed. Reg. 57,696 (Sept. 25, 2014) (effective March 24, 2015) (requiring that claims and notices of disagreement be filed on standard forms). The issue of entitlement to a separate disability rating higher than 10 percent for limitation of right thigh motion associated with status post-excision right hip osteochondroma, to include the issue of entitlement to an extraschedular rating based upon the combined effect of the Veteran's service-connected disabilities, is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran's current thyroid disability is not the result of a disease or injury in active service, and is not proximately due to, or aggravated by, service-connected residuals of tonsillectomy and tracheostomy. 2. The Veteran's residual scar associated with status post-excision of right hip osteochondroma is manifested by a stable, non-painful scar comprising an area of less than 39 square centimeters. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a thyroid disability, including as secondary to service-connected tonsillectomy and tracheostomy residuals, have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2016). 2. The criteria for an initial compensable disability rating for residual scar associated with status post-excision of right hip osteochondroma have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.21, 4.118, Diagnostic Codes (DCs) 7801-7805 (2008 & 2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See, e.g., 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2016). In this case, VA provided adequate notice in letters sent to the Veteran with respect to the claims on appeal in July 2004 and October 2005. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The AOJ has obtained the Veteran's VA treatment records and identified private treatment records. VA has also afforded the Veteran multiple VA examinations, which collectively are adequate for making determinations on the claims decided herein. The AOJ substantially complied with the Board's October 2015 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In relevant part, the Board remanded the appeal to obtain VA treatment records dated since May 2014, and to schedule the Veteran for new VA thyroid examination. VA employees, including Board personnel, have two distinct duties when conducting hearings-the duty to explain fully the issues, and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam) (interpreting the provisions of 38 C.F.R. § 3.103(c) (2)). At his September 2013 Board hearing, the Veteran was asked about his treatment history and the symptomatology that he believed to be associated with his thyroid disability. He was also asked detailed questions pertaining to the current severity of his status post-excision right hip osteochondroma. The Veteran generally showed understanding of what was necessary to substantiate his service connection and increased rating claims. Moreover, there has been no allegation of a failure to comply with Bryant duties. Therefore, the Bryant duties were met. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claims decided herein. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'- the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Veteran has a diagnosed thyroid disability. A March 2013 VA examination noted a diagnosis of hyperthyroidism made in 2001. A December 2015 VA examination report concluded that the Veteran had a diagnosis of multinodular goiter with symptoms of hyperthyroidism. The Veteran's service treatment records (STRs) do not reflect complaints of or treatment for a thyroid condition. Notably, a November 1982 clinical report showed normal thyroid functions. The STRs reveal that the Veteran was found to have a mass in the hypopharynx area in June 1982. A February 1983 CT scan revealed hypertrophied lymphoid tissue extending from the base of the tongue into the vallecula and epiglottis. Left jugulodigastric nodes and a mass at the base of the tongue were also found. A technetium scan revealed what was thought to be paratracheal thyroid tissue. He underwent a tracheostomy and lingual tonsillar biopsy excision of the left lingual tonsil in March 1983, followed by a tracheostomy and laser excision of the hypertrophic lingual tonsils in April 1983. Later, December 1986 laboratory results showed that the Veteran's TSH (thyroid stimulating hormone) level was slightly less than normal. Laboratory results from later that month reflected that the TSH level was within normal limits. After the Veteran's separation from service, a January 2002 private treatment report noted complaints of diarrhea and weight loss over the preceding two months. The report further noted increased T3 and T4 levels, a decreased TSH level and a diagnosis of hyperthyroidism. He was prescribed Tapazole. A February 2002 treatment note reflected diagnoses of probable Graves' disease and hyperthyroidism, improved on anti-thyroid treatment. A private February 2004 report also noted that laboratory findings showed hyperthyroidism. A February 2005 VA treatment note reflected a history of neck surgery in service that the endocrinologist thought was probably a left hemithyroidectomy but noted that the service treatment records were needed to confirm. A June 2005 therapy report indicated that both lobes of the thyroid were present. A February 2006 VA treatment report reflected a diagnosis of hyperthyroidism due to toxic multinodular goiter. A later March 2006 VA clinical note indicated that he was clinically and biochemically euthyroid. An August 2009 VA examination report noted that during service, the Veteran underwent a tracheostomy laser excision of lymphoid tissue involving the base of the tongue vallecula and epiglottis, and that a technetium scan showed what was thought to be paratracheal thyroid tissue. The examiner noted that the Veteran had been diagnosed with hyperthyroidism following service after falling asleep at the wheel. He had been evaluated by a VA endocrinologist, who suspected that part of the left thyroid may have been affected by the tonsillar surgery. During a March 2013 VA examination, the examiner noted the Veteran's hyperthyroid diagnosis without current signs or symptoms. The examiner noted the Veteran's complaints of daily fatigue and indicated that the fatigue was likely due to sleep apnea. The examiner gave the opinion that the Veteran's thyroid disability was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner noted that the Veteran underwent a February 1983 tracheostomy, laryngoscopy, and biopsy; that the biopsies were consistent with thyroid tissue; and that his thyroid functions were normal at the time of surgery. The examiner concluded that there was no other evidence that any thyroid problem existed during service. The examiner further noted that it was not clear if the Veteran had Graves' disease or toxic multinodular goiter at the time of his hyperthyroidism diagnosis in 2001, as both conditions caused hyperthyroidism. The examiner concluded that based on review of the Veteran's STRs, he was not treated for a thyroid related condition during service. She further concluded that there was no evidence that thyroid tissue was removed during any of his surgeries performed in 1983. The examiner noted the Veteran's post-service history of thyroid treatment and that a June 2011 ultrasound revealed the presence of both thyroid lobes with multiple nodules. Even if thyroid tissue was removed, the examiner maintained that this should cause hypothyroidism, not hyperthyroidism. Thus, the examiner concluded that neither Graves' disease nor toxic nodular goiter would be caused by tonsillectomy or any other neck surgery. Thus, the Veteran's thyroid disorder did not have its onset during service and was not otherwise related to service. A new VA opinion with respect to the etiology of the Veteran's claimed thyroid disorder was obtained in November 2014. The examiner again noted the Veteran's treatment history for biopsy of hypertrophied lingular tissue and tracheostomy. The examiner noted that although a technetium scan report reflected that there was thought to be thyroid tissue paratracheal, no thyroid tissue appeared on the biopsy to suggest injury, and the examiner noted normal thyroid studies in 1982 and a normal TSH level in 1987. The examiner again concluded that there was nothing in the Veteran's STRs that documented injury to the thyroid. The examiner also noted that the Veteran's hyperthyroidism diagnosis was not made until 2002, when he was found to have abnormal thyroid function tests, after he reported several months of diarrhea and weight loss. The examiner concluded that it would not have taken 20 years for a thyroid condition to manifest if it was related to a surgical injury during service. Based on this evidence, the examiner opined that it was less likely as not that the Veteran's current thyroid disorder had its onset during service. The examiner also clarified that the March 2013 VA examiner did not necessarily indicate that the Veteran suffered from hypothyroidism during service, but that symptoms of fatigue are a symptom of hypothyroidism, not hyperthyroidism. In short, fatigue would not be a symptom consistent with diagnosed hyperthyroidism. The Veteran was afforded his most recent thyroid examination in December 2015. That examiner again concluded that there was no objective documentation of damage to the Veteran's thyroid gland, of laboratory abnormalities of the thyroid, or of abnormal physical examinations of his thyroid gland found in his STRs. The examiner noted that the Veteran remained free of thyroid related symptoms following service for nearly 20 years. The examiner again noted that at the time of his diagnosis in 2002, the Veteran presented with symptoms of thirst, diarrhea, and weight loss, but that after undergoing radioactive iodine (RAI) treatment in June 2005, he became clinically and biochemical euthyroid; that is, his laboratory findings normalized and his hyperthyroidism symptoms improved. The examiner also again noted that the Veteran's reported fatigue symptoms were not consistent with a diagnosis of hyperthyroidism. The examiner noted that the Veteran continued to be followed by endocrinology with ongoing complaints of fatigue but that there was no biochemical evidence of hypothyroidism. She noted that fatigue was a symptom associated with underactive thyroid which could happen, status post RAI ablation. She further indicated, however, that after multiple thyroid nodule biopsies and serial ultrasounds his had been noted as having remained biochemically euthyroid. The examiner also noted that the Veteran was diagnosed with obstructive sleep apnea (OSA) in April 2006, and that his STRs documented symptoms of OSA as early as March 1982, to include fatigue. On examination he reported having no fatigue as long as his used his CPAP mask to treat the OSA. Based on the evidence, the examiner opined that the Veteran's complaints of fatigue were less likely as not an early manifestation of his subsequent thyroid diagnosis, and thus, that his current thyroid condition was less likely as not first manifested during service or otherwise related to his service. The examiner further opined that the Veteran's symptoms of fatigue in service were at least as likely as not due to his service-connected OSA. The Board finds the March 2013, November 2014, and December 2015 VA opinions of records are fully informed, well-reasoned, and fully articulated. The examiners all demonstrated that they had reviewed the Veteran's medical history and were familiar with his reports and treatment history as regarding his thyroid disability, and the examiners provided descriptive opinions explaining that the Veteran's post-service diagnosis of hyperthyroidism would not have been consistent with any sort of thyroid injury during service, to include as result of surgery; or consistent with complaints of fatigue during service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Based on these opinions, the Board cannot make a finding that the Veteran's current hyperthyroidism is at least as likely as not etiologically related to service. See Holton, supra. While a December 2015 VA primary care clinical report indicated that the Veteran had had a left hemithyroidectomy in 1984, this report appears to be based on the Veteran's own statements and is inconsistent with evidence of record that has shown that as recently as June 2011 that both lobes of the Veteran's thyroid were intact. Additionally, while the Veteran has asserted his belief that his claimed thyroid disability was the result of in-service tracheostomy and lingual tonsillar biopsy excision, or was otherwise indicated by symptoms of fatigue, such a etiology opinion requires medical expertise as it is complex in nature and not capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Where he lacks such expertise, his opinions are of little probative value. Secondary Service Connection The Board has considered whether the Veteran's thyroid disability was caused by or aggravated by service-connected residuals of tonsillectomy with tracheostomy. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310 (a). Service connection will also be granted on a secondary basis for additional disability that results from aggravation of a non-service connected disability by a service connected disability. See 38 C.F.R. § 3.310 (b). The evidence does not show that the Veteran's thyroid disability is at least as likely as not caused by or aggravated by the service-connected tonsillectomy and tracheostomy residuals. The VA examination reports have specifically shown that there was no objective documentation of damage to the Veteran's thyroid gland during the in-service surgical procedures, and that even if so, the March 2013 VA examiner explained that this would have resulted in hypothyroidism, rather than hyperthyroidism. Additionally, the March 2013 VA examiner gave the opinion that neither Graves' disease or toxic nodular goiter, the possible causes of the Veteran's hyperthyroidism, are caused or aggravated by a tonsillectomy or any other neck surgery. The examiner specifically concluded that the current thyroid condition was not aggravated or made permanently worse beyond its natural progression by the service-connected tonsillectomy with tracheostomy. Again, where the examiner was familiar with the Veteran's treatment history, and clearly explained that the tonsillectomy and tracheostomy would be more likely to cause hypothyroidism, the Board finds the examiner's opinion to be fully informed, well-reasoned, and fully articulated. Based on the evidence, the Board cannot make a finding that the Veteran's current thyroid disability was caused by or aggravated by service-connected disability. A preponderance of the evidence is against the claim for service connection for a thyroid disability; therefore, the claim must be denied. See 38 U.S.C.A. § 5107. III. Increased Rating Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Although the Veteran's entire history is reviewed when assigning a disability evaluation, as required under 38 C.F.R. § 4.1, where the evidence demonstrates distinct periods in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings may be necessary. Hart v. Mansfield, 21 Vet. App. 505 (2007). All disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. A claimant may not be compensated twice for the same symptomatology, as this would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. Nonetheless, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994). The Veteran bears the burden of presenting and supporting his claims for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any material issue, the Board gives the benefit of the doubt to the claimant. Id. A. Rating Criteria and Analysis The Veteran's residuals of a right hip osteochondroma excision were initially rated under the rating criteria for rating scars. Scars are rated under the criteria for rating skin disabilities found at 38 C.F.R. § 4.118. The criteria were revised effective October 23, 2008. The rating schedule in effect when the Veteran filed his claim included Diagnostic Code 7803, titled "Scars, superficial, unstable," which provided for a 10 percent rating; and Diagnostic Code 7804, titled "Scars, superficial, painful on examination," which provided for a 10 percent rating. 38 C.F.R. § 4.118 (2008). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7803, Note (1) (2008). A superficial scar is one not associated with underlying soft tissue damage. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7803, Note (1) (2008). Under the revised criteria, scars that are not of the head, face, or neck, that are unstable or painful are to be assigned a 10 percent rating if there are one or two such scars; higher ratings are available where there are more than two such scars. 38 C.F.R. § 4.118, DC 7804 (2016). Note (2) under that Diagnostic Code provides that for scars that are both unstable and painful a 10 percent is to be added to the evaluation. Note (3) provides that scars evaluated under Diagnostic Code 7805 may also receive a rating under Diagnostic Code 7804. The definition of an unstable scar was unchanged from the earlier version. The unrevised Diagnostic Code 7805 previously directed the rater to rate "scars, other" on limitation of function of the part affected. The revised Diagnostic Code 7805 directs the rater to evaluate any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate diagnostic code. Other Diagnostic Codes for rating scars are not for application because the Veteran's scars are not of the head, face, or neck and are superficial and have been noted to encompass an area of less than 39 square centimeters (sq. cm.). See 38 C.F.R. § 4.118 (2008 & 2016). During a December 2004 VA examination, the Veteran denied having pain or discomfort of the hip, and did not present complaints of limitation of motion at the right hip joint. On examination, the scar was noted to be a well-healed, linear scar along the iliac crest of the right hip. There was no pain or discomfort associated with movement of the hip, and right hip range of motion was entirely within normal limits. No residual deficits were found on examination. During a subsequent August 2006 VA examination, the Veteran's residual right hip osteochondroma scar was noted to have lack of sensitivity to soft touch and monofilament testing of the scar. The scar was measured to be 20 cm by two millimeters. The scar presented no adherence to underlying tissue, no area of inflexibility, and the scar was stable and superficial. The scar was mildly depressed but there was no irregularity or elevation of the surface contour of the scar on palpation, and there was no pain, inflammation, edema, or keloid formation. There was no limitation of motion due to the scar. The color of the scar was noted to be slightly hyperpigmented. The examiner diagnosed mild functional impairment. Later VA examination reports described the mild functional impairment as including limitation of right thigh motion and sensory neuropathy. A September 2011 VA examination report provided substantially similar findings with respect to the right hip scar, with the exception that the scar was noted to be one cm wide at the widest and 23cm long. The Veteran reported that since his osteochondroma excision, he has been unable to cross his right leg over the left (to rest right ankle on his left thigh) without lifting his right leg with his arm. He denied having difficulty with other leg movement or activities due to his osteochondroma excision. A November 2014 VA examination report indicated that the Veteran's right hip scar was not painful or unstable, and did not encompass an area equal to or greater than 39 sq. cm. A March 2015 addendum to the November 2014 VA examination report indicated that the Veteran had an area of numbness overlying the surgical scar that was as likely as not the result of a mild (sensory only), superficial cutaneous nerve injury. No other peripheral nerve injury related to the right hip condition was found. Based on the evidence, the Veteran's residual right hip scar has not been found to be painful or unstable, and it does not encompass an area greater than 39 sq. cm. Thus, the evidence shows that the Veteran is not entitled to a compensable disability rating for the right hip osteochondroma excision residuals based on the criteria for rating scars. The Board notes that a separate 10 percent disability rating has been granted for the Veteran's sensory neuropathy as found on the March 2015 VA examination addendum, pursuant to the criteria for disease of the peripheral nerves. See 38 C.F.R. § 4.124a (2016). Additionally, the AOJ granted service connection for diagnosed gluteal muscle atrophy as secondary to the right hip osteochondroma excision residuals, assigning a noncompensable disability rating. The Veteran has not expressed disagreement with the rating assignments made for either secondary disability. As noted in the introduction, the issue of entitlement to a higher separate disability rating for right thigh limitation of motion associated with the status post-excision right hip osteochondroma is addressed in the remand portion below. B. Extraschedular Consideration and TDIU The Board has considered the question of entitlement to an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The evidence in this case does not show that the symptoms associated with the Veteran's residual right hip scar present an exceptional disability picture. Comparison between his symptoms and the criteria found in the rating schedule shows that the rating criteria reasonably describe his disability level and symptomatology. His residual scar has not been found to be painful or unstable and has not, in itself, resulted in limitation of function. The criteria specifically contemplate a compensable rating for scars that are painful, unstable, or that are deep, nonlinear, and cover an area of at least 39 sq. cm. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. As the Board is remanding the issue of entitlement to a separate disability rating higher than 10 percent for limitation of right thigh motion associated with the status post-excision right hip osteochondroma, it will defer consideration of entitlement to an extraschedular rating based upon the combined effect of the Veteran's service-connected disabilities until the issue of entitlement to a higher rating for the right thigh limitation of motion is finally adjudicated. A claim for total rating based on individual unemployability (TDIU) due to service-connected disability is a potential part of an initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In the instant case, the Veteran has not asserted that his residual right hip scar or associated disability has prevented him from employment. Rather, the evidence, including specifically the VA examination reports, specifically concluded that his right hip osteochondroma residuals do not impact his ability to work. Thus, there is no evidence of record to suggest that the Veteran's residuals of a right hip osteochondroma excision have rendered him unable to obtain and maintain substantially gainful employment. Therefore, consideration of a TDIU is not warranted. For the foregoing reasons, the Board concludes that the preponderance of evidence is against assigning a compensable schedular rating for the Veteran's residual right hip scar. Hence, the appeal as to this issue must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. ORDER Entitlement to service connection for a thyroid disorder is denied. Entitlement to an initial compensable disability rating for residuals of a right hip osteochondroma excision is denied. REMAND A March 2014 VA examination evaluated orthopedic residuals of the Veteran's right hip osteochondroma excision. The examiner equivocally indicated that the examination was not being conducted during a flare-up of right thigh disability, but then noted that the examination supported the Veteran's statement describing functional loss during flare-ups, as the examination was being conducted during a flare-up. There were no findings as to any additional limitation of function, to include limitation of motion, due to pain during flare-ups. Similarly, a December 2015 VA examination report noted that no response was provided with respect to whether the Veteran suffered from flare-ups of right thigh disability, and then the report later indicated that the Veteran did not report flare-ups of the thigh disability. Clarification is required. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Additionally, a recent decision of the United States Court of Appeals for Veterans Claims (Court) provided a precedential interpretation of the final sentence of 38 C.F.R. § 4.59, and held that the sentence creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Board interprets the Court's decision as requiring that VA examinations must include range of motion testing of the pertinent joint in active motion, passive motion, and in weight-bearing and nonweight-bearing. The October 2014 VA examination report does not provide the results of such range of motion testing. The associated issue of entitlement to an extraschedular rating based upon the combined effect of the Veteran's service-connected disabilities is deferred until the issue of entitlement to a higher separate rating for the right thigh limitation of motion is adjudicated. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA orthopedic examination of his right hip. The examiner should review the claims file, including this REMAND. All necessary studies and tests should be conducted. A) The examiner should report the Veteran's ranges of right thigh motion in degrees in passive motion, active motion, and in weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she must clearly explain why that is so. B) The examiner should determine the extent the right hip disability is manifested by weakened movement, excess fatigability, incoordination, or pain due to flare-ups. This determination should be made in terms of the degree of additional range-of-motion loss. The examiner must ask the Veteran if he has current flare-ups. The examiner must, to the extent possible, opine as to the amount of additional range-of-motion loss resulting from functional loss during any flare-ups. The examiner must provide reasons for all opinions, addressing the relevant medical and lay evidence. 2. If the benefits sought on appeal are not granted in full, issue a supplemental statement of the case; and return the appeal to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs