Citation Nr: 1758096 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 09-14 431 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to a disability rating greater than 10 percent for service-connected status post fracture of the right femur, resolved, with arthralgia of the hip. 2. Entitlement to a compensable disability rating for service-connected status post fracture of the left femur, resolved, with arthralgia of the hip prior to January 4, 2016. 3. Entitlement to a disability rating greater than 10 percent for impairment of left hip (previously rated as status post fracture of the left femur, resolved, with arthralgia of the hip) for the period from January 4, 2016. 4. Entitlement to a compensable disability rating for limitation of flexion in the right hip. 5. Entitlement to a compensable disability rating for limitation of extension of the right hip. 6. Entitlement to a compensable disability rating for limitation of flexion of the left hip. 7. Entitlement to a compensable disability rating for limitation of extension of the left hip. 8. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran had active service from August 1994 to January 1996. These matters came before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating action of the Department of Veterans Affairs (VA), Regional Office (RO), located in Los Angeles, California. In April 2010, the Veteran testified at a Board video conference hearing. A transcript of that hearing has been associated with her claims file. This matter was previously before the Board in December 2015 at which time it was remanded for additional development. In a February 2016 rating decision, the RO awarded service connection for limitation of extension and limitation of flexion in the left hip, assigning separate 10 percent ratings, effective January 4, 2016. In an April 2016 rating decision, the RO awarded service connection for limitation of extension and limitation of flexion in the right hip, assigning separate 10 percent ratings, effective January 4, 2016. The Board took jurisdiction of these issues as they are part and parcel of the other ratings in appellate status. The issues were remanded in February 2017. The issue of entitlement to service connection for left foot peroneal nerve disability has been raised by the record during the January 2016 VA examination. The examiner did not specifically attribute this neurological disability to her service-connected residuals of stress fractures of the left foot. The Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9 (b) (2017). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Status post fracture of the right femur, resolved, with arthralgia of the hip, is not manifested by an inability to toe-out more than 15 degrees, not manifested by an inability to cross his legs, and not manifested by abduction of motion lost beyond 10 degrees, nor malunion of the femur with moderate knee or hip disability. 2. For the period from July 21, 2006, status post fracture of the left femur, resolved, with arthralgia of the hip, is manifested by functional limitations manifested by pain, and is not manifested by an inability to toe-out more than 15 degrees, not manifested by an inability to cross his legs, and not manifested by abduction of motion lost beyond 10 degrees, nor malunion of the femur with moderate knee or hip disability. 3. The right hip is manifested by limitation of flexion without flexion limited to 45 degrees. 4. The right hip is manifested by limitation of extension without extension limited to 5 degrees. 5. The left hip is manifested by limitation of flexion without flexion limited to 45 degrees. 6. The left hip is manifested by limitation of extension without extension limited to 5 degrees. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent for status post fracture of the right femur, resolved, with arthralgia of the hip, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5255 (2017). 2. The criteria for a 10 percent disability rating (but no higher) for status post fracture of the left femur, resolved, with arthralgia of the hip for the period from July 21, 2006, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5255 (2017). 3. The criteria for entitlement to a disability rating greater than 10 percent for impairment of left hip (previously rated as status post fracture of the left femur, resolved, with arthralgia of the hip) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5255 (2017). 4. The criteria for entitlement to a compensable disability rating for limitation of flexion in the right hip have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5252 (2017). 5. The criteria for entitlement to a compensable disability rating for limitation of extension of the right hip have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5251 (2017). 6. The criteria for entitlement to a compensable disability rating for limitation of flexion of the left hip. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5252 (2017). 7. The criteria for entitlement to a compensable disability rating for limitation of extension of the left hip have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.71a, Diagnostic Code 5251 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In November 2006 and February 2009, the Veteran was provided notice with regard to his increased rating claim. The Veteran has not asserted any prejudice in the notice issued. Regarding the duty to assist, the evidence of record contains VA treatment records and lay statements and testimony from the Veteran. There is otherwise no indication of relevant, outstanding records which would support the increased rating claims. The Veteran was afforded VA examinations with regard to his claims which will be discussed in detail below. Criteria & Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202, 205-08 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the DCs predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Also, functional loss due to pain must be supported by pathology and shown through objective observation. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997) (citing 38 C.F.R. § 4.40); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011) (relying on DeLuca for proposition that an adequate joint examination report must comply with § 4.40 and include an "opinion on whether pain could significantly limit functional ability during flare-ups or when the [joint] is used repeatedly over a period of time"). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court of Appeals for Veterans Claims has held that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The Board has reviewed all the evidence in the Virtual folders, which includes: his contentions, service treatment records, post-service treatment reports, and VA examination reports. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). According to VA standards, full hip range of motion is defined as 0 to 125 degrees hip flexion and 0 to 45 degrees hip abduction. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5251, limitation of extension of the thigh to 5 degrees warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Under Diagnostic Code 5252, limitation of flexion of the thigh to 45 degrees warrants a 10 percent evaluation; limitation to 30 degrees warrants a 20 percent evaluation; limitation to 20 degrees warrants a 30 percent evaluation; and limitation to 10 degrees warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Under Diagnostic Code 5253, limitation of rotation of the thigh, cannot toe-out more than 15 degrees or limitation of adduction, cannot cross legs warrants a 10 percent evaluation. Limitation of abduction of, motion lost beyond 10 degrees warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Under Diagnostic Code 5255, malunion of the femur with slight knee or hip disability warrants a 10 percent evaluation. Malunion of the femur with moderate knee or hip disability warrants a 20 percent evaluation. Malunion of the femur with marked knee or hip disability warrants a 30 percent evaluation. Fracture of surgical neck of the femur, with false joint or fracture of the shaft or anatomical neck of the femur with nonunion, without loose motion, weight bearing preserved with aid of brace warrants a 60 percent evaluation. Fracture of the shaft or anatomical neck of the femur with nonunion, with loose motion, (spiral or oblique fracture) warrants an 80 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5255. Diagnostic Code 5003, for degenerative arthritis provides that degenerative arthritis, established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003. The Veteran's status post fracture of the right femur, resolved with arthralgia of the hip is rated 10 percent disabling pursuant to Diagnostic Code 5255. From January 4, 2016, right hip extension is rated noncompensably disabling pursuant to Diagnostic Code 5251, and right hip flexion is rated noncompensably disabling pursuant to Diagnostic Code 5252. Prior to January 4, 2016, the Veteran's status post fracture of the left femur, resolved, with arthralgia of the hip, is rated noncompensably disabling pursuant to Diagnostic Code 5255. From January 4, 2016, the Veteran's impairment of left hip (previously rated as status post fracture of the left femur, resolved, with arthralgia of the hip) is rated 10 percent disabling pursuant to Diagnostic Code 5253. From January 4, 2016, limitation of extension of the left hip is rated noncompensably disabling pursuant to Diagnostic Code 5251, and limitation of flexion of the left hip is rated noncompensably disabling pursuant to Diagnostic Code 5252. The November 2006 VA examination reflects the Veteran's complaints of more pain in the left hip than the right hip describing her pain as aching, squeezing, and burning, sometimes constant and sometimes intermittent usually brought on by prolonged standing or climbing upstairs or attempting to run. Her treatments have included physical therapy, cortisone injection and cream, and prescription medication, with continued pain. On objective examination, her gait was slightly antalgic favoring the left hip as she walks. She carries a cane in her right hand which she uses intermittently to lessen the pain in her left hip. She can walk without the cane. Both femurs were within normal limits. On range of motion testing, in the right hip flexion was to 125, extension was to 40, adduction was to 25, abduction was to 45, external rotation was to 45, and internal rotation was to 10 with pain at the limits. In the left hip, flexion was to 100, extension was to 30, adduction was to 25, abduction was to 40, external rotation was to 45 with pain and internal rotation to 10 with pain. On repetitive motion, hip functions were additionally limited by pain and lack of endurance but not fatigue, weakness, or incoordination with any additional limitation of motion. Both knees were normal with full range of motion. There was osteoarthritis of the hips with arthralgias and limited range of motion. X-rays of the femurs showed no abnormality. The November 2010 VA examination report reflects left hip flexion 0 to 80 degrees; extension 0 to 15 degrees; and, abduction 0 to 25 degrees. With regard to the right hip, there was flexion 0 to 100 degrees; extension 0 to 25 degrees; and, abduction 0 to 40 degrees. There was pain with motion. She could cross each leg over the other, and can toe out more than 15 degrees. There was pain following repetitive motion without additional limitations. She experiences decreased mobility, weakness, fatigue, decreased strength, and pain associated with her lower extremities. The examiner specifically stated that the Veteran does not have ankylosis and flail joint of the hips, nor malunion of the femurs. There was no nerve impairment associated with her disabilities. The August 2012 VA examination reflects right and left hip flexion 125 or greater; right hip extension greater than 5 degrees with no painful motion. There was no abduction lost beyond 10 degrees; the Veteran could cross her legs; and, the Veteran could toe out more than 15 degrees. The examiner found less movement than normal and pain on movement with regard to both hips. Right and left hip adduction ended at 25 degrees, right and left hip abduction ended at 45 degrees with painful motion at 35 degrees. On repetitive motion, abduction ended at 35 degrees in both hips, and left hip adduction ended at 25 degrees. Right hip internal rotation ended at 30 degrees and right hip external rotation ended at 60 degrees. Left hip internal rotation ended at 40 degrees and left hip external rotation ended at 60 degrees. The January 2016 VA examination report reflects the Veteran's reports of bilateral hip pain with prolonged walking, standing, and climbing. Right hip flexion was to 100 degrees, extension was to 30 degrees, internal rotation was to 25 degrees, external rotation was to 40 degrees, abduction to 25 degrees, and adduction was to 15 degrees. Left hip flexion was to 100 degrees, extension was to 30 degrees, rotation was to 25 degrees, internal rotation was to 25 degrees, external rotation was to 40 degrees, abduction was to 25 degrees, and adduction was to 15 degrees. Adduction was not limited in either hip such that she could not cross her legs. The abnormal range of motion was caused by pain which limits the Veteran's ability to walk or climb for prolonged periods. With regard to both hips, pain was noted on all forms of motion and there was pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no crepitus. There was no change in range of motion after repetitive testing. Pain significantly limits functional ability with repeated use over a period of time. Based on such pain affecting functional ability, the examiner estimated that range of motion was reduced by 5 degrees with regard to each measurement. Additional factors contributing to her disabilities were less movement than normal, weakened movement, disturbance of locomotion, and interference with standing. On muscle strength testing, there was active movement against some resistance with a reduction in muscle strength. There was no muscle atrophy and no ankylosis. There was no malunion or nonunion of the femur, flail hip joint or leg length discrepancy. Arthritis is not documented. A March 2017 VA examination reflects active and passive range of motion testing. The Veteran reported constant anterior right hip pain located at the groin. The left hip pain is lateral and travels down the lateral aspect of the leg to the little toe. The pain is worse with activity. She has intermittent instability of the left hip. The hips flare with activity. Right hip flexion was to 115 degrees, extension was to 25 degrees, internal rotation was to 25 degrees, external rotation was to 55 degrees, abduction to 40 degrees, and adduction was to 40 degrees. Left hip flexion was to 120 degrees, extension was to 25 degrees, internal rotation was to 35 degrees, external rotation was to 55 degrees, abduction was to 40 degrees, and adduction was to 15 degrees. Adduction was not limited in either hip such that she could not cross her legs. With regard to both hips, pain was noted on all forms of motion and there was pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no crepitus. There was evidence of pain on passive range of motion testing and evidence of pain when the joints are used in non-weight bearing. There was no change in range of motion after repetitive testing. There was no further limitation of motion based on pain, fatigue, weakness, lack of endurance, or incoordination Additional factors contributing to her disabilities are less movement than normal and weakened movement. On muscle strength testing, there was active movement against some resistance with a reduction in muscle strength. There was no muscle atrophy and no ankylosis. There was no malunion or nonunion of the femur, flail hip joint or leg length discrepancy. Arthritis was not documented. A March 2017 x-ray of the hips reflects no osseous abnormalities. Initially, the Board notes that the Board has given consideration to assignment of a rating per Diagnostic Code 5003 in light of the November 2006 VA examiner's diagnosis of osteoarthritis of the hips, but there is no X-ray evidence of arthritis. A July 2006 X-ray examination does not reflect arthritis, rather the impression was normal study. There was a specific finding of no evidence of arthritis at the left joint. 11/02/2006 Medical Treatment Record-Government Facility at 30. The July 2010 X-ray reflects no changes since the July 2006 X-ray examination. The August 2012, January 2016, and March 2017 VA examination reports reflect that degenerative or traumatic arthritis was not documented. Also, on VA examination in November 2006 and August 2012, an X-ray examination of the femur showed no abnormality. In consideration of the period prior to January 4, 2016, while there are no specific findings of impairment of the femur associated with the left femur/hip disability, it is clear that the Veteran has left hip symptomatology in the form of limited flexion, pain, and lack of endurance. VA treatment records also reflect complaints of left hip pain and undergoing a steroid injection due to her pain. 11/02/2006 Medical Treatment Record-Government Facility at 1, 6, 11, 20. While the flexion is not compensable, the Board finds that a 10 percent rating is warranted for the functional impairment associated with her left hip disability per 38 C.F.R. §§ 4.40 and 4.45 and DeLuca and Mitchell. Specifically, flexion was to 90 degrees with pain with decreased mobility, weakness, fatigue, and decreased strength. Such rating compensates her for functional impairment associated with her left hip for the period from July 21, 2006 (date of claim) and for the period prior to January 4, 2016. The Board has determined that disability ratings in excess of 10 percent are not warranted for either the left or right hip in consideration of Diagnostic Codes 5253 and 5255. None of the examinations of record nor treatment records reflect that there is limitation of abduction of motion lost beyond 10 degrees in either thigh. Abduction was to 45 degrees in the right hip and 40 degrees in the left hip in November 2006; abduction was to 25 degrees in the left hip and 40 degrees in the right hip in November 2010. Abduction ended at 45 degrees with painful motion at 35 degrees in August 2012. The January 2016 VA examination reflects abduction to 25 degrees in both extremities, and the March 2017 VA examination reflects abduction to 40 degrees in both extremities. The Veteran has been able to cross her legs and toe out more than 15 degrees. Impairment of the femur with nonunion or malunion has not been shown. The foregoing evidence of reported ranges of motion, compared to the limitation-of-motion codes, indicate that the Veteran's right and left hip disorders are noncompensably disabling under those codes. As detailed hereinabove, flexion has not been limited to 45 degrees in either hip even in consideration of pain and flare-ups, and extension has not been limited to 5 degrees. These findings do not warrant a compensable rating under the criteria based on limitation of flexion and extension. 38 C.F.R. § 4.71, Plate II, Diagnostic Codes 5252, 5251. The Board has determined that based on the Veteran's symptomatology, there is no other diagnostic code which could provide a higher rating for the Veteran's left and right hip disabilities. See Schafrath, 1 Vet. App. at 592-593. Diagnostic Code 5250 relates to ankylosis of the hip and Diagnostic Code 5254 requires a flail joint of the hip. There is no medical evidence of ankylosis or flail joint of either hip and, therefore, any application of these codes would be inappropriate. ORDER Entitlement to a disability rating greater than 10 percent for service-connected status post fracture of the right femur, resolved, with arthralgia of the hip is denied. Entitlement to a 10 percent disability rating for status post fracture of the left femur, resolved, with arthralgia of the hip, from July 21, 2006, is granted. Entitlement to a disability rating in excess of 10 percent for status post fracture of the left femur, resolved, with arthralgia of the hip from July 21, 2006, is denied. Entitlement to a compensable disability rating for limitation of flexion in the right hip is denied. Entitlement to a compensable disability rating for limitation of extension of the right hip is denied. Entitlement to a compensable disability rating for limitation of flexion of the left hip is denied. Entitlement to a compensable disability rating for limitation of extension of the left hip is denied. REMAND Service connection is in effect for status post fracture of the right femur, resolved, with arthralgia of the hip (10% 01/27/1996); mild chronic lumbosacral strain with spondylosis L2-4 and DDD L2-3 (10% 07/21/2006); status post stress fracture of the right foot (0% 01/27/1996; 10% 07/21/2006); status post fracture of the left foot (0% 01/27/1996; 10% 07/21/2006); impairment of left hip (10% 01/04/2016); status post fracture of the left femur, resolved, with arthralgia of the hip (0% 01/27/96-07/20/2006; 10% 07/21/2006-01/03/2016); limitation of extension of the left hip (0% 01/04/2016); right hip extension (0% 01/04/2016); right hip flexion (0% 01/04/2016); limitation of flexion of the left hip (0% 01/04/2016). Her combined rating is 40 percent disabling from July 21, 2006. The Veteran has submitted multiple statements from co-workers with regard to the effect her disabilities have on her employment. 03/09/2009 Buddy/Lay Statement. She has also submitted statements from supervisors with regard to tardiness and absences and the effect her disabilities have on her employment 03/09/2009 Buddy/Lay Statement. The August 2012 VA examination reflects that his hip disabilities impact his ability to work in that she experiences impaired prolonged sitting, standing, walking, repetitive bending and heavy lifting. An April 2013 statement from the Veteran reflects that she has been unemployed for the past 16 months. She described symptoms associated with her feet and hips. 04/17/2014 VA 21-4138 Statement in Support of Claim. The Veteran reported that she began working on June 20, 2014 but was unsure if her left foot and hips could endure the daily rigors of her new position. A week later she began to experience pain in her right foot and discovered a fracture. 08/05/2014 Correspondence. It is not clear if she is still working. An August 2014 statement from the Veteran's treating VA physician reflects that her new job has resulted on her being on her feet in excess of eight hours per day, and that due to the stress on her right foot she developed a fracture to the right foot. 08/05/2014 Medical Treatment Record-Government Facility. The Veteran should be requested to complete a VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability regarding her employment during the entire period of this appeal-July 21, 2006, to the present. A vocational assessment should be completed to assess the impact of the Veteran's service-connected disabilities on her ability to maintain gainful employment for the period from July 21, 2006. Thereafter, the TDIU matter should be submitted to the Director, Compensation Service, for extraschedular consideration per § 4.16(b). Accordingly, the case is REMANDED for the following actions: 1. Request that the Veteran complete a VA Form 21-8940 regarding her employment for the period from July 21, 2006 to the present. 2. Request a vocational assessment with an examiner with appropriate expertise to evaluate the impact of the Veteran's service-connected disabilities on her ability to function in an occupational setting for the period from July 21, 2006. In this regard, comment on the Veteran's ability to function in an occupational environment, document any education and work experience reported by the Veteran during the examination, and/or describe any functional impairment caused solely by the service-connected disabilities. If a vocational expert is not available (efforts to obtain one must be documented in the claims file), then request VA clinicians, with appropriate expertise, to include in orthopedics, to comment on the Veteran's ability to function in an occupational environment, document any education and work experience reported by the Veteran during the exam, and/or describe any functional impairment caused solely by the service-connected disabilities for the period from July 21, 2006. A comprehensive rationale is to be provided for all opinions expressed. 3. Refer the Veteran's claim for a TDIU per § 4.16(b) to the Director, Compensation Service, for extraschedular consideration as to whether her service-connected disabilities (status post fracture of the right femur, resolved, with arthralgia of the hip 10% 01/27/1996; mild chronic lumbosacral strain with spondylosis L2 to L4 and DDD L2-3 10% 07/21/2006; status post stress fracture of the right foot 0% 01/27/1996; 10% 07/21/2006; status post fracture of the left foot 0% 01/27/1996; 10% 07/21/2006); impairment of left hip 10% 01/04/2016; status post fracture of the left femur, resolved, with arthralgia of the hip 0% 01/27/96-07/20/2006; 10% 07/21/2006-01/03/2016; limitation of extension of the left hip 0% 01/04/2016; right hip extension 0% 01/04/2016; right hip flexion 0% 01/04/2016; limitation of flexion of the left hip 0% 01/04/2016) preclude the Veteran from participating in gainful employment for any period from July 21, 2006. 4. After completion of the above, readjudicate entitlement to a TDIU considering all relevant evidence. If the benefit sought is not granted in full, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran and his representative have 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 remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs