Citation Nr: 1751136 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 12-20 785A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an initial compensable evaluation for right ilio-inguinal nerve entrapment, for the period prior to December 12, 2016. 2. Entitlement to an evaluation in excess of 10 percent for right ilio-inguinal nerve entrapment, for the period from December 12, 2016. 3. Entitlement to an initial compensable evaluation for left ilio-inguinal nerve entrapment, for the period prior to December 12, 2016. 4. Entitlement to an evaluation in excess of 10 percent for left ilio-inguinal nerve entrapment, for the period from December 12, 2016. 5. Entitlement to a separate evaluation for radiculopathy of the right lower extremity. 6. Entitlement to a separate evaluation for radiculopathy of the left lower extremity. 7. Entitlement to an initial evaluation in excess of 10 percent for residuals of bilateral inguinal hernia repair with scars and bilateral hip flexor ligament strain. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. Gallagher, Associate Counsel INTRODUCTION The Veteran served on active duty from April 2006 to January 2009. This appeal is before the Board of Veterans' Appeals (Board) from July 2009 and March 2010 rating decisions of the abovementioned Department of Veterans Affairs (VA) Regional Office (RO). In June 2013, the Veteran testified during a Board hearing before a Veterans Law Judge (VLJ) via videoconference. Because the VLJ subsequently retired, in February 2016 the Veteran testified in another Board hearing before the undersigned VLJ via videoconference. Transcripts of both hearings are included in the claims file. In January 2014, the Board remanded the Veteran's appeal with instruction to obtain relevant records from the Social Security Administration (SSA) and to provide the Veteran with current VA examinations. VA examinations were conducted in March 2014 and relevant records were received from the SSA in May 2014. In November 2014, the Board again remanded the appeal with instruction to provide the Veteran with another hearing, which occurred in February 2016. In April 2016, the Board denied an increased rating for a cervical spine disability and remanded the remaining issues with instruction to assist in obtaining relevant private treatment records and provide another VA examination. The appropriate records were obtained and VA examinations were conducted in December 2016. The April 2016 remand also instructed that a statement of the case be issued regarding claim for an increased rating for repair residuals. There were procedural errors in carrying out this instruction. Specifically, instead of an initial statement of the case, the issue was added to supplemental statements of the case issued in September 2016, February 2017, and April 2017. The Board finds that this procedure, while technically improper, did not prejudice the Veteran and additional remand is not necessary. The September 2016 supplemental statement of the case contained the governing regulations as would a proper statement of the case. The Veteran filed subsequent statements that served the essential functions of a substantive appeal. The Board thus finds that remand for the sole purpose of recharacterizing the most recent supplemental statement of the case as a statement of the case would not benefit the Veteran in any way, but would rather burden him with unnecessary delay to having his appeal decided. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant). For these reasons, the Board is satisfied that the instructions in its remands of January 2014, March 2014, and April 2016 have been complied with to the extent necessary to decide this appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The title page reflects that the Board has incorporated the issues of separate evaluations for radiculopathy of the left and right lower extremities. The Board recognizes that the issue of radiculopathy has not been explicitly appealed. However, for the reasons set forth in the decision below, the Board takes jurisdiction over these issues as the Veteran has appealed his rating of his nerve-related pain in his lower extremities, and it is not incumbent upon him to specifically identify the nerve from which this pain arises. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). There is significant confusion in the records as to whether the Veteran desires a third hearing before the Board. It appears that a September 2016 hearing selection letter was sent to the Veteran in error. In response, his representative informed VA via an October 2016 statement that another hearing was not necessary and the appeal should be returned to the Board. The Veteran then requested a videoconference Board hearing in December 2016. VA contacted the Veteran in March 2017 in an attempt to resolve the confusion, at which time he indicated that a hearing was not necessary. He subsequently submitted further requests for a videoconference hearing in May 2017, June 2017, and August 2017. To the extent that the Veteran has requested an additional hearing, the Board denies the request. He has already provided testimony relevant to the issues on appeal at his prior hearings. Neither the Veteran nor his representative has shown good cause for why a third Board hearing is necessary. The Board will thus decide the Veteran's appeal without further delay. FINDINGS OF FACT 1. For the period prior to December 12, 2016, the Veteran's right ilio-inguinal nerve entrapment was productive of the equivalent of severe paralysis. 2. For the period prior to December 12, 2016, the Veteran's left ilio-inguinal nerve entrapment was productive of the equivalent of severe paralysis. 3. For the period from December 12, 2016, the Veteran is in receipt of the maximum schedular rating for right ilio-inguinal nerve entrapment. 4. For the period from December 12, 2016, the Veteran is in receipt of the maximum schedular rating for left ilio-inguinal nerve entrapment. 5. For the period from October 6, 2015, the Veteran exhibited radiculopathy of the right lower extremity productive of moderately severe incomplete paralysis of the sciatic nerve, but not productive of complete paralysis or severe incomplete paralysis with marked muscular atrophy. 6. For the period from October 6, 2015, the Veteran exhibited radiculopathy of the left lower extremity productive of moderately severe incomplete paralysis of the sciatic nerve, but not productive of complete paralysis or severe incomplete paralysis with marked muscular atrophy. 7. Residuals of the Veteran's bilateral inguinal hernia repair are not productive of current hernias; scars that are deep, painful, unstable, or greater than 929 square centimeters in area; or musculoskeletal residuals of the hip or thigh. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 10 percent, but not in excess thereof, for right ilio-inguinal nerve entrapment, for the period prior to December 12, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8530 (2017). 2. The criteria for an evaluation of 10 percent, but not in excess thereof, for left ilio-inguinal nerve entrapment, for the period prior to December 12, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8530 (2017). 3. The criteria for an evaluation in excess of 10 percent for right ilio-inguinal nerve entrapment, for the period from December 12, 2016, have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8530 (2017). 4. The criteria for an evaluation in excess of 10 percent for left ilio-inguinal nerve entrapment, for the period from December 12, 2016, have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8530 (2017). 5. The criteria for a separate evaluation of 40 percent, but not in excess thereof, for radiculopathy of the right lower extremity, for the period from October 6, 2015, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 6. The criteria for a separate evaluation of 40 percent, but not in excess thereof, for radiculopathy of the left lower extremity, for the period from October 6, 2015, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 7. The criteria for an initial evaluation in excess of 10 percent for residuals of bilateral inguinal hernia repair with scars and bilateral hip flexor ligament strain have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8530 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). There is thus no prejudice to the Veteran in deciding this appeal. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Nerve Disabilities The Veteran claims increases to his evaluations for entrapment of the ilio-inguinal nerve. For the period prior to December 12, 2016, the Veteran is in receipt of a single 0 percent rating for a bilateral ilio-inguinal nerve entrapment. Effective that date, he was assigned two separate 10 percent ratings for the left and right sides. The Veteran's nerve entrapment is rated as paralysis of the ilio-inguinal nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8530. The Veteran's prior noncompensable rating is warranted for mild or moderate paralysis of the ilio-inguinal nerve. A maximum rating of 10 percent is warranted for severe to complete paralysis of the ilio-inguinal nerve. Additionally, disabilities of the sciatic nerve are evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under this code, incomplete paralysis is rated at 10 percent for mild, 20 percent for moderate, 40 percent for moderately severe, and 60 percent for severe with marked muscular atrophy. Complete paralysis is rated at 80 percent and is present when the foot dangles and drops with no active movement possible of the muscles below the knee and flexion of the knee is weakened or (very rarely) lost. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. VA treatment records reflect that in June and August of 2009 the Veteran sought treatment for nerve pain. His physicians requested records of his prior surgery and ordered diagnostic tests. An electromyography study (EMG) was performed in September 2009, which was normal. He was diagnosed with ilio-inguinal nerve entrapment in October 2009, and underwent nerve block injections in December 2009 and February 2010, 10 minutes after which he reported almost complete relief of pain. In his July 2010 notice of disagreement, the Veteran reported that his nerve entrapment causes him to use crutches, a cane, and a wheelchair. Private treatment records reflect that in December 2010 the Veteran reported a history of pain in his right lower quadrant related to inguinal hernia surgery and an associated suspected pinched nerve. In his July 2012 substantive appeal, the Veteran reported that his pain is severe. He furthermore reported that although the nerve blocks removed pain in the short run, after a few weeks they wore off. Pain was reduced in the long run after nerve block injections, but only from 8/10 to 5/10. Private treatment records reflect that in September 2012, the Veteran reported chronic pain. He was diagnosed with neuritis, neuropathy, and neuralgia. In June 2013 he reported use of a manual wheelchair. At his July 2013 hearing, the Veteran reported use of crutches and a wheelchair to move about the house. He reported that movement in his leg causes sharp and sudden pain. Private treatment records reflect that in January 2014 the Veteran reported that he had used a wheelchair for over 4 years due to his nerve entrapment. He was able to ambulate with crutches for a very short distance of approximately 20 steps per day. The Veteran underwent a VA examination in March 2014. He reported significant right inguinal region pain localized in the general distribution of the right ilio-inguinal nerve. Pain was rated at 3-4/10 with periodic exacerbations to 5-6/10. He reported inability to place any weight on his right lower extremity and any movement of his trunk, pelvis, or right lower extremity causes him severe pain. His examiner noted mild constant pain and moderate intermittent pain, paresthesia, and numbness in the right lower extremity. Muscle strength and reflexes were normal. Sensory examination showed decreased sensation to pinprick and light touch in the right thigh to the knee. There were no trophic changes. Gait was abnormal with significant subjective claims of increased pain with any weight-bearing, causing the Veteran regular use of crutches and a wheelchair. The examiner noted that the ilio-inguinal nerve is a sensory nerve that does not control motor function of the lower extremities, and that motor deficits therefore cannot be associated with this nerve. The examiner diagnosed neuralgia resulting in mild incomplete paralysis of the ilio-inguinal nerve. The examiner found that the Veteran's nerve entrapment impacts his ability to work through difficulty with prolonged ambulation, limited bending and twisting of the lumbar spine and hips, and limited lifting. The examiner further noted that the Veteran and his spouse described a profound amount of physical impairment that greatly exceeds the level of objective medical findings consistent with neuralgia of a sensory-only nerve, concluding that there was a great deal of pain catastrophization and heightened level of perceived disability in the subjective history and general presentation. In an August 2014 statement, the Veteran reported severe right side hernia pain issues, including loss of full use of his right lower extremity. VA treatment records reflect that in August 2015, the Veteran requested a pain clinic follow-up due to his nerve entrapment. At a September 2015 appointment, he reported pain radiating into his right thigh and right testicle. He underwent several nerve block injections through October 2015. The Veteran underwent another VA examination on October 6, 2015. The examiner found moderate incomplete paralysis of the right ilio-inguinal nerve. The examiner confusingly also found mild incomplete paralysis of the right obturator and external cutaneous nerves, and moderate incomplete paralysis of the right sciatic nerve. No opinion was given as to whether these other nerves were related to the Veteran's inguinal disabilities. Private treatment records reflect that in November 2015 the Veteran's diagnoses were updated to a lesion on the femoral nerve and femoral neuropathy. In a January 2016 letter, the Veteran's private physician reported that he had been treated for 4-5 years for neuralgia due to entrapment of the ilio-inguinal nerve. He had been prescribed medication and used crutches. At his February 2016 hearing, the Veteran reported that he suffered debilitating pain due to his nerve entrapment. He stated that his pain level spikes up to 8-9/10 whenever he gets out of bed, into a sitting position, or into or out of his car. His pain was in the right side of the groin. He reported that the nerve block treatments did not work. He stated that he always used crutches when walking. His representative requested that the Board refer for extraschedular consideration. Private treatment records reflect that in March 2016, the Veteran underwent pulsed radiofrequency to the ilio-inguinal nerve. Several weeks later he reported that this alleviated 25 percent of his pain. He stated that he continued to use wheelchair and crutches. Physical examination showed tenderness and decreased sensation along the distribution of the right ilio-inguinal nerve. Gross sensation was intact throughout the remaining lower extremities. Muscle strength was full throughout the entirety of the lower extremities. VA treatment records reflect that in April 2016 the Veteran reported chronic pain and neuritis due to right ilio-inguinal nerve entrapment. He reported an inability to work due to 7/10 pain, right leg weakness, and medication side effects. The Veteran underwent another VA examination on December 12, 2016. He reported severe constant pain, numbness, and paresthesia in his right lower extremity and moderate constant pain, numbness, and paresthesia in his left lower extremity. He reported constant use of a wheelchair and regular use of crutches. Sensation was decreased in the bilateral thighs, knees, lower legs, ankles, feet, and toes. The examiner found that the Veteran's abnormal gait and wheelchair use were due to his spinal pathology. The examiner diagnosed moderate incomplete paralysis of the bilateral ilio-inguinal nerves. The impact of the peripheral neuropathy on the Veteran's ability to work was that it is hard for him to walk or stand for long periods of time due to ilio-inguinal nerve entrapment. Additionally, the examiner found no objective evidence of impairment of the obturator nerve or the external cutaneous nerve. The examiner found bilateral moderately severe incomplete paralysis of the sciatic nerve and opined that it was a progression of his service-connected lumbosacral strain. The Board finds that staging is inappropriate to the Veteran's disabilities and 10 percent ratings are therefore warranted for right and left ilio-inguinal nerve entrapment for the period prior to December 12, 2016. Despite both the normal EMG and the pain "catastrophization" noted by the March 2014 VA examiner, the Veteran has been consistent in his presentation and in his reports of severe pain since separation from service. Although moderate incomplete paralysis, in contrast to severe, was found at the October 2015 VA examination, the Board finds that affording all doubt in favor of the Veteran, his complaints of severe pain throughout the appeal period are more probative than the October 2015 VA examiner's evaluation of moderate paralysis. Thus, if he is to be awarded 10 percent evaluations on the basis of the VA examination conducted on December 12, 2016, such evaluations should apply to the entirety of the appeal period, as the evidence weighs against a finding that his ilio-inguinal disability worsened as of that date. Furthermore, as 10 percent is the maximum schedular rating for this disability, evaluations in excess of 10 percent are denied for the entirety of the appeal period. The Board further finds that the evidence weighs in favor of granting separate evaluations of 40 percent for moderately severe radiculopathy of the sciatic nerve, effective October 6, 2015. On that date, the VA examiner found paralysis of the sciatic nerve in the extremity being examined. While the Board remanded to determine whether this paralysis was related to the Veteran's ilio-inguinal nerve entrapment, the December 2016 VA examiner subsequently opined that such paralysis is instead related to his service-connected lumbosacral strain. There is no evidence in the record to contradict the opinion of the December 2016 VA examiner. Because the March 2014 explicitly found no sciatic nerve impairment, ratings are not granted for the entirety of the period on appeal. The Board recognizes that the issue of radiculopathy has not been explicitly appealed. Nevertheless, the Board takes jurisdiction as the Veteran has appealed his rating of his nerve-related pain in his lower extremities, and it is not incumbent upon him to specifically identify the nerve from which this pain arises. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Additionally, the Board finds that evaluations in excess of 40 percent are not warranted for the Veteran's sciatic nerve radiculopathy. Higher ratings are available for complete paralysis or for severe incomplete paralysis with marked muscular atrophy. The evidence weighs against manifestations of such severity. No VA examiner has evaluated the Veteran's radiculopathy as such, and in any event there is no evidence of marked muscular atrophy. Furthermore, although the Veteran regularly uses a wheelchair, his occasional use of crutches indicates that complete paralysis is not present. As discussed above, the Veteran's representative has requested that the Board refer his ilio-inguinal nerve claims for extraschedular consideration. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran's service connected disabilities, including pain, tingling, and numbness, are specifically contemplated by or the anticipated consequences of the schedular rating criteria, and no referral for extraschedular consideration is required. As was explained in the merits decision above in denying higher ratings, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate. The Board recognizes that the Veteran reports severe, debilitating pain; this pain, however, is in part reflected in the additional ratings for sciatic nerve radiculopathy granted herein. In view of the circumstances, the Board finds that the rating schedule is adequate, particularly in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Hernia Residuals The Veteran seeks an increase to his rating for hernia residuals. The Veteran's hernia residuals are currently rated under 38 C.F.R. § 4.114, Diagnostic Code 7338. A 0 percent rating is warranted for a small, reducible inguinal hernia without true hernia protrusion. His current 10 percent rating is warranted for a postoperative recurrent inguinal hernia, readily reducible and well supported by truss or belt. A higher 30 percent rating is warranted for a small, postoperative recurrent or unoperated irremediable inguinal hernia not well supported by truss or not readily reducible. A maximum 60 percent rating is warranted for a large, postoperative, recurrent inguinal hernia, not well supported under ordinary conditions and not readily reducible, when considered inoperable. A rating under this code is to be increased by 10 percent for bilateral involvement, provided that the second hernia is compensable. Additional ratings for scars not of the head, face, or neck are available under Diagnostic Codes 7801, 7802, and 7804, as follows: Deep scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7801. A 10 percent rating is warranted for scarred areas of 39 to 77 square centimeters, a 20 percent rating is warranted for scarred areas of 77 to 465 square centimeters, a 30 percent rating is warranted for scarred areas of 465 to 929 square centimeters, and a 40 percent rating is warranted for scarred areas greater than 929 square centimeters. A deep scar is defined as one associated with underlying soft tissue damage. Superficial scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7802. A maximum 10 percent rating is warranted for scarred areas greater than 929 square centimeters. Unstable or painful scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7804. A 10 percent rating is warranted for 1 or 2 such scars, a 20 percent rating is warranted for 3 or 4 such scars, and a 30 percent rating is warranted for 5 or more such scars. Additional ratings for residuals involving the hip and thigh are available under 38 C.F.R. § 4.71a, as follows: Ankylosis of the hip is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5250. A 60 percent rating is warranted for favorable ankylosis, in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. A 70 percent rating is warranted for intermediate ankylosis. A 90 percent rating is warranted for extremely unfavorable ankylosis, with the foot not reaching the ground and crutches necessitated. Limitation of extension of the thigh is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5251. A 10 percent rating is warranted for extension limited to 5 degrees. Limitation of flexion of the thigh is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5252. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A 40 percent rating is warranted for flexion limited to 10 degrees. Other thigh impairment is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5253. A 10 percent rating is warranted for limitation of rotation, such that it cannot toe-out more than 15 degrees; or for limitation of adduction, such that the legs cannot be crossed. A 20 percent rating is warranted for limitation of abduction, such that motion is lost beyond 10 degrees. Flail joint of the hip is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5254, and warrants an 80 percent rating. Impairment of the femur is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5255. Malunion of the femur with knee or hip disability is rated at 10 percent for slight disability, 20 percent for moderate disability, and 30 percent for marked disability. Fracture of the cervical neck of the femur with a false joint warrants a 60 percent rating. Fracture of the shaft or anatomical neck of the femur warrants a rating of 60 percent for nonunion, without loose motion, with weightbearing preserved with the aid of a brace; and a rating of 80 percent for nonunion, with loose motion (spiral or oblique fracture). The Veteran underwent a pre-discharge VA examination in October 2008. He reported that he had undergone inguinal hernia repair on the right in September 1996 and on the left in December 2006. He reported current chronic daily dull pain with occasional sharp severe pain 3 to 4 times per day lasting for several seconds. He had no bowel or bladder incontinence. Pain was aggravated by prolonged lifting and carrying. On examination, his scars were well-healed, nontender, stable, and superficial without adhesions, inflammation, induration, or limitation of motion. Examination of the lower body and pelvic girdle indicated no significant atrophy and well-developed muscle groups, which the examiner found to be inconsistent with his history of chronic severe debilitating pain. He was diagnosed with bilateral inguinal hernia repairs with a ligament strain of the bilateral hip flexor. VA treatment records reflect that in December 2009, the Veteran was treated for nerve pain. He was diagnosed with ilioinguinal nerve entrapment and chronic pain syndrome. Gait was normal and unassisted with full active range of motion. There was no pain with active or passive motion. Range of motion was also full at a February 2010 follow-up. In his July 2010 notice of disagreement, the Veteran reported constant pain, greater on the right side, which prevents him from being fully mobile in his home. He reported use of crutches, a cane, and a wheelchair. Private treatment records reflect that in December 2010 the Veteran reported a history of pain in his right lower quadrant related to inguinal hernia surgery and an associated suspected pinched nerve. On examination, both lower extremities had normal ranges of motion. The Veteran underwent a VA examination of his hernia residuals in December 2016. Surgeries were noted on a left inguinal hernia in 2007 and a right inguinal hernia in 2008. On examination there was no current hernia and no indication for support. He had two 7-centimeter linear scars in the anterior lower abdomen. They were neither painful nor unstable. The examiner found no limitation of function due to scars. As to his hip pain, he reported constant bilateral hip pain. He reported flare-ups in the form of sharp stabbing pain from his right thigh to his right big toe. Flare-ups on his left side only happened when he put weight on the extremity. He reported use of a wheelchair and crutches. The Veteran stated that he had not taken his medication that day and was therefore under too much pain for objective range of motion testing. The Board finds that an evaluation in excess of 10 percent for hernia residuals is not warranted. Higher ratings are available for current hernias; scars that are deep, painful, unstable, or greater than 929 square centimeters in area; or musculoskeletal residuals of the hip or thigh. The evidence weighs against such manifestations. There is no evidence of current hernias or scars that are deep, painful, unstable, or greater than 929 square centimeters in area. Furthermore, the ranges of motion of the Veteran's lower extremities have been full at every point they have been measured. While the Veteran did not permit testing at his December 2016 VA examination due to pain, the Board attributes this pain to his ilio-inguinal and sciatic nerve disabilities. Indeed, the entirety of the Veteran's treatment records indicates treatment for nerve disabilities and not musculoskeletal residuals. As such, the Board finds that an evaluation in excess of 10 percent for hernia residuals is not warranted. [CONTINUED ON THE NEXT PAGE] ORDER An evaluation of 10 percent, but not in excess thereof, for right ilio-inguinal nerve entrapment, for the period prior to December 12, 2016, is granted, subject to the laws and regulations governing the payment of VA benefits. An evaluation of 10 percent, but not in excess thereof, for left ilio-inguinal nerve entrapment, for the period prior to December 12, 2016, is granted, subject to the laws and regulations governing the payment of VA benefits. An evaluation in excess of 10 percent for right ilio-inguinal nerve entrapment, for the period from December 12, 2016, is denied. An evaluation in excess of 10 percent for left ilio-inguinal nerve entrapment, for the period from December 12, 2016, is denied. An evaluation of 40 percent, but not in excess thereof, for radiculopathy of the right lower extremity, for the period prior to October 6, 2015, is granted, subject to the laws and regulations governing the payment of VA benefits. An evaluation of 40 percent, but not in excess thereof, for radiculopathy of the left lower extremity, for the period prior to October 6, 2015, is granted, subject to the laws and regulations governing the payment of VA benefits. An initial evaluation in excess of 10 percent for residuals of bilateral inguinal hernia repair with scars and bilateral hip flexor ligament strain is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs