Citation Nr: 18144646 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-03 807 DATE: October 25, 2018 ORDER The claim for entitlement to restoration of a 10 percent rating for limitation of extension of the left thigh, associated with status post total right knee replacement, is granted. The claim for entitlement to restoration of a 10 percent rating for left hip bursitis, associated with status post total right knee replacement, is granted. REMANDED The claim for entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) is remanded. FINDINGS OF FACT 1. The Veteran’s left hip bursitis, associated with status post total right knee replacement, is manifested by painful but noncompensable degree of limitation of motion in abduction, adduction, or rotation which causes functional impairment. 2. The Veteran’s limitation of extension of the left thigh, associated with status post total right knee replacement, is manifested by painful but noncompensable degree of limitation of extension of the left thigh which causes functional impairment. CONCLUSIONS OF LAW 1. The criteria for restoration of a 10 percent disability rating for left hip bursitis, associated with status post total right knee replacement, are met. 38 U.S.C. § 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Codes 5019 – 5003, 5253 (2017). 2. The criteria for restoration of a 10 percent disability rating for limitation of extension of the left thigh, associated with status post total right knee replacement, are met. 38 U.S.C. § 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5251 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 9, 1976, to May 8, 1976. This matter comes before the Board of Veterans’ Appeals (Board) from decisions of a Department of Veterans Affairs (VA) Regional Office (RO). TDIU In part, a November 2012 rating decision granted service connection for left hip bursitis, which was assigned an initial 10 percent disability rating under Diagnostic Code 5253; granted service connection for limitation of flexion of the left thigh, which was assigned an initial 10 percent disability rating under Diagnostic Code 5252 ; granted service connection for limitation of extension of the left thigh, which was assigned an initial 10 percent disability rating under Diagnostic Code 5251; all as associated with service-connected SP total right knee replacement and all effective March 16, 2012. That rating decision also denied a TDIU rating. The Veteran was notified of that rating decision by RO letter of December 3, 2012, which stated that “In reply Refer to: 330/21C1/klg.” A March 4, 2013, rating decision confirmed and continued the denial of a TDIU rating and also denied other claims. A typed letter dated March 4, 2014, from the Veteran entitled “Notice of Disagreement” and referencing “330/21C1/klg” was received on March 7, 2014, in which the Veteran disagreed with the denial of a TDIU rating. By RO letter of March 17, 2014, the Veteran was notified that his March 2014 NOD was not timely as to claims denied in the November 2012; however, his NOD was timely as to the denial of a TDIU rating. That appeal was subsequently perfected. Thus, this appeal does not arise from the assignment of any initial disability ratings. Ratings on Appeal In pertinent part, a December 31, 2014, rating decision proposed to reduce a 10 percent rating for left hip bursitis, associated with status post total right knee replacement, to a noncompensable disability rating; and proposed to reduce a 10 percent rating for limitation of extension of the left thigh, associated with status post total right knee replacement, to a noncompensable disability rating. The proposed reductions were predicated on examination findings as to range of motion of the left hip, under Diagnostic Code 5253, and as to left hip extension, under Diagnostic Code 5251. Those 10 percent ratings had been in effect since March 16, 2012. Service connection was denied for an acquired psychiatric disorder and reopening of claims for service connection for a right hip disorder and lumbar degenerative disc disease (DDD) was denied. The Veteran was notified of that proposed rating decision by RO letter dated January 6, 2015. A May 1, 2015, rating decision effectuated the proposed reductions effective August 1, 2015. The Veteran has appealed this rating decision. This rating decision resulted in a reduction of the combined disability rating of 50 percent to 40 percent, effective August 1, 2015. A January 12, 2016, rating decision granted service connection for degenerative joint disease (DJD), SP total left knee replacement, secondary to service-connected total right knee replacement, which was assigned a temporary total rating of 100 percent effective September 29, 2015, and a 30 percent schedular rating was resumed as of September 1, 2016. Also, special monthly compensation based on housebound criteria was granted from September 29, 2015, to September 1, 2016. However, it was determined that new and material evidence had not been submitted to reopen a claim for service connection for a right hip condition (also claimed as bursitis). In the January 22, 2016, VA Form 9, it was alleged that the Veteran had not received the January 6, 2015, notice of the reduction which was proposed in the December 31, 2014 rating decision. However, the Board observes that the January 6, 2015, RO letter was sent to the same address which was listed on the May 29, 2015, Notice of Disagreement (NOD) and the VA Form 9 received on January 22, 2016. No other argument is set forth as to any alleged nonreceipt of the January 6, 2015, RO letter. As to this, more than a mere allegation of nonreceipt is required to obviate the finality of the December 31, 2014, rating decision which proposed to reduce the 10 percent ratings for left hip bursitis and for limitation of extension of the left thigh. 38 U.S.C. §§ 5104(a) and 7104(e) require that rating and Board decisions must be mailed to a claimant at the last known address. See Clark v. Principi, 15 Vet. App. 61, 63 (2001). Based on the presumption of regularity, it is presumed that this was done. See Clarke, 21 Vet. App. 130, 133 (2007) (quoting Woods v. Gober, 14 Vet. App. 214, 220 (2000)). In order for this presumption to attach, VA must provide notice to the latest address of record for the claimant. Crain v. Principi, 17 Vet. App. 182, 186 (2003). This presumption is not absolute and may be rebutted with "clear evidence that VA did not follow its regular mailing practices or that its practices were not regular.” Boyd v. McDonald, 27 Vet. App. 63, 72 (2014). The mere assertion of nonreceipt by an appellant is not enough to establish the clear evidence needed to overcome the presumption of regularity in the mailing of the VA decisions. Davis v. Principi, 17 Vet. App. 29, 37 (2003). However, the presumption of regularity may be rebutted where there is (1) evidence that VA used an incorrect address on the Board mailing, or (2) evidence that the mailing was returned as undeliverable and there were other possible and plausible addresses available to VA at the time of the Board decision. See Clarke, 21 Vet. App. at 134. In this case, the RO did not use the incorrect mailing address and the January 6, 2015, RO notification letter was not returned as undeliverable. Consequently, the argument that the proposed rating reduction was invalid must fail. This appeal is comprised of documents contained in the Veterans Benefits Management System (VBMS) and the Virtual VA system. All future documents should be incorporated into the Veteran's VBMS file. Background A November 2010 Medical Report from Dr. N. Krishnam reflects that the Veteran had a total right knee replacement, other than replacement of the right patella, on July 27, 2010. Records of the Social Security Administration (SSA) reflect that clinical records revealed complaints of hip pain in September, October, and December 2011 as well as April 2012. The Veteran reported that among the disabilities that limited his ability to work was left hip bursitis. Private clinical records show that in August 2011 he had mild pain in the left hip on external rotation. In October 2011 the Veteran had a Rheumatology Consult due to bilateral hip pain which was aggravated by walking, bending or standing for too long. He had moderate pain over the lateral aspect of the left hip with flexion, as well as internal and external rotation. His bilateral hip pain and tenderness was suggestive of bilateral hip trochanteric bursitis. A December 2011 Orthopedic Consultation reflects that he was in physical therapy for his hips. An April 2014 decision by an SSA Administrative Law Judge (ALJ) reflects that the Veteran was awarded SSA disability benefits from September 2011 due to pain in his low back, hips, and lower extremities. The Veteran’s VA Form 21-4138, Statement in Support of Claim, received on March 16, 2012, was deemed to be a claim for, in part, bursitis of the left hip and limitation of extension of the left thigh. Entered into VBMS on May 10, 2012, was the Veteran’s VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in which he reported that as of September 14, 2011, his disabilities had affected his full-time employment, he had last worked full-time, and had become too disabled to work. He had worked for the World Council of Credit Unions from February 1988 to December 2011. He had left his last employment because of disability and he had four years of college education. Received in May 2012 were multiple lay statements attesting to the Veteran’s difficulty with and pain when ambulating. VA Form 21-4192, Employment Information In Connection With Claim for Disability Benefits, of August 2012 from the World Council of Credit Unions reflects that the Veteran was employed full-time in Project Development from January 1998 until laid off on September 13, 2011. On October 4, 2012, the Veteran was afforded a VA orthopedic examination which included examination of his hips and knees. The Veteran reported having had a severe limp with bilateral leg weakness prior to the total right knee replacement and he had developed left hip bursitis in 2009. He had had two injections in the left hip in 2012 with only temporary improvement in symptoms for one month. His stated that his right leg was 1 inch shorter than the left leg, due to which he used a lift in his right shoe. His known lumbar degenerative disc disease (DDD) contributed to his left hips symptoms. He related that he had constant left hip pain, and this had worsened after a January 2010 fall. He reported that weekly flare-ups impacted function of the left hip and/or thigh and these episodes generally lasted 3 to 4 days. The symptoms improved with narcotic medications. On examination left hip flexion was to 100 degrees and the examination report reflects that there was no objective evidence of painful motion. Left hip extension was to greater than 5 degrees and, again, the examination report reflects that there was no objective evidence of painful motion. Left hip abduction was not lost beyond 10 degrees and adduction was not limited such that he could not cross his legs, nor was rotation limited such that he could not toe-out more than 15 degrees. He was able to perform repetitive-use testing, with 3 repetitions, following which there were no change in these ranges of left hip motion. It was reported that he had functional loss or impairment due to limited left hip motion. He did not have localized tenderness or pain to palpation of the joints or soft tissue of either hip. He had full strength in left hip flexion, abduction, and extension. His right leg was 6 cms. shorter than the left leg. He occasionally used a cane as an ambulatory aid. The examiner reported that the left hip condition did not impact the Veteran’s ability to work. The examiner also opined that the left hip bursitis was as likely as not related to the Veteran’s right knee degenerative joint disease (DJD) prior to his total right knee replacement because his hip symptoms worsened after a fall due to the right knee disability. Some of his left hip pain was most likely also due to his degenerative disc disease (DDD) of the low back but it was impossible to determine the percentages with resorting to speculation. The examiner then reported that left hip flexion was to 100 degrees, extension was to 10 degrees, adduction was to 25 degrees, abduction was to 45 degrees, and both internal and external rotation were to 40 degrees. All of these motions were painless and there was no additional functional impairment after 3 repetitions of motion due to pain, weakness, fatigability or incoordination. The examiner reported that there was no vocational limitations due to the Veteran’s left hip disability. On October 4, 2012, VA orthopedic examination of the Veteran’s knees he reported that he had tingling in both legs with he was told was due to bulging disc in his low back. On examination there was no examination or testing of ranges of motion of his left knee. On VA examination of July 30, 2014, the diagnosis was chronic greater trochanteric bursitis of the left hip. The Veteran reported that his symptoms had increased significantly the past two years. His pain was mainly localized to the area of the greater trochanter on the lateral aspect of the left hip. He stated that the pain occasionally radiated distally, approximately 4 to 5 inches. He denied any groin pain, signifying absence of hip articular pathology. He was currently undergoing physical therapy for his back and left hip, which he stated was helping his symptoms somewhat. He reported that flare-ups impacted the function of the hip and/or thigh. His sensitive symptoms were increased with cold-weather and physical activities such as ambulation or kneeling. He was currently retired but complained of decreased functional capacity with his activities of daily living secondary to his left hip pain. On examination the Veteran’s left hip flexion was to 110 degrees, with pain beginning at 60 degrees. Left hip extension was to greater than 5 degrees with no objective evidence of painful motion. Left hip abduction was not lost beyond 10 degrees and adduction was not limited such that he could not cross his legs, nor was rotation limited such that he could not toe-out more than 15 degrees. He was able to perform repetitive-use testing, with 3 repetitions, following which there were no change in these ranges of left hip motion. It was reported that he had functional loss or impairment due to limited and painful left hip motion. He did not have localized tenderness or pain to palpation of the joints or soft tissue of either hip. He had full strength in left hip flexion, abduction, and extension. He had tenderness over the left greater trochanter. He constantly used a cane as an ambulatory aid. The examiner reported that the left hip condition impacted the Veteran’s ability to work. The examiner further explained the ranges of left hip motion, stating that internal rotation was to 15°, and painful at 15°, but no changes in these ranges were noted after three repetitions. External rotation was 40° and painless, with no changes noted after three repetitions. Abduction was to 40°, and painful at 40°, with no changes noted after three repetitions. Adduction was to 30°, and painful at 30°, with no changes noted after three repetitions. The examiner reported that the Veteran was not having a flare up at the time of the examination and in the absence of additional available objective evidence, the examiner could not state whether pain, weakness, fatigability, or incoordination could significantly limited function during flare ups or when used repeatedly over time as this would be conjecture. VA outpatient treatment (VAOPT) records show that in September 2014 it was noted that low back extension caused some radiation of pain into the lateral aspect of both hips, and had point tenderness over the lateral aspect of each hip. He had had several injections to the lateral aspect of his hips in the past with only moderate short-term relief of pain. In October 2014 he complained of pain which was greater in the left hip than the right hip. In March 2015 it was reported that activity was always prematurely discontinued due to pain in the Veteran’s knees and hips. Information on file indicates that the Veteran underwent VA hospitalization from the 6th of July 2015 until discharged on July 8th, for a total left knee replacement. Information on file indicates that the Veteran underwent VA hospitalization from the 9th of September 2015 until discharged on September 11th but the information is not clear as to why he was hospitalized. In VA Form 21-4138, Statement in Support of Claim, in September 2015, the Veteran reported that VA had performed a left knee replacement in July 2015. He still had bursitis, bilaterally, due to his bad knees. He underwent VA hospitalization in September 2015 due to bleeding ulcers due to medication for his bursitis and his knees. In VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in September 2015 the Veteran reported that the disabilities which prevented him from securing or following substantially gainful employment were bilateral knee replacements, arthritis of his hands and hips, and ulcers. On VA examination on October 15, 2015, for evaluation of left hip bursitis with limitation of flexion and extension, the Veteran reported that he had constant left hip pain and also had flare-ups. The flare-ups were random but were also caused by repeated use, such as significant walking. He had functional loss or impairment because he had difficulty walking or sitting during a flare-up. He had had a steroid shot a few weeks ago which helped with some of the pain but not all of it. On examination flexion of the Veteran’s left hip was to only 110 degrees, extension was normal to 30 degrees; abduction was normal to 45 degrees, and adduction was normal to 25 degrees. External rotation was normal to 60 degrees and internal rotation was normal to 40 degrees. It was reported that the limited motion did not itself contribute to a functional loss. There was pain noted on examination in all motions but it did not result in or cause functional loss. There was no pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue consisting of moderate lateral hip tenderness. There was no additional loss of function or range of motion after three repetitions of motion. The examiner was unable to state, without resorting to speculation, whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time because repeated use testing was not conducted. However, the examiner also reported that the Veteran able to perform repetitive use testing with at least three repetitions and that there was no additional loss of function or range of motion after three repetitions. The examiner was unable to state, without mere speculation, whether pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups because the examination was conducted when the Veteran was not having a flare-up. The Veteran had no reduction in muscle strength in the left hip and no muscle atrophy. He constantly used a cane as an ambulatory aid because of his left hip and right knee disabilities. The examiner reported that the left hip disability impacted the Veteran’s ability to perform any type of occupational task in that it restricted him from working at jobs that required a lot of lifting or walking or standing. Rating Principles Ratings for a service-connected disability are determined by comparing current symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Disabilities are viewed, and examinations are interpreted, historically, to accurately reflect the elements of disability present. 38 C.F.R. §§ 4.1, 4.2. A higher rating is assigned if it more nearly approximates such rating. 38 C.F.R. §§ 4.7, 4.21. Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999) (initial staged ratings). Also, the alleviating effects of medication may not be considered in schedular ratings unless explicitly provided in the applicable schedular rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5019, the Veteran’s bursitis of the left hip is rated as degenerative arthritis. DC 5003, applicable to degenerative arthritis, provides that degenerative arthritis is rated on the basis of limitation of motion under appropriate diagnostic codes for the specific joint or joints involved, but that when limitation of motion of the specific joint is noncompensable, a 10 percent rating is warranted for limitation of motion of a major joint or group of minor joints. With X-ray evidence of arthritis of two or more joint groups without compensable limitation of motion a single disability evaluation of 10 percent may be assigned. Where, however, the limitation of motion of a specific joint or joints involved is noncompensable under the code for rating based on limited motion, a raging of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under DC 5251 limitation of extension of a hip to 5 degrees warranted a 10 percent rating. Under DC 5252 limitation of hip flexion to 45 degrees warrants a 10 percent rating; limitation to 30 degrees warranted a 20 percent rating; limitation to 20 degrees warrants a 30 percent rating; and limitation to 10 degrees warranted a 40 percent rating. Under DC 5253 limitation of abduction of the thigh, with motion lost beyond 10 degrees, warrants a 20 percent rating. Limitation of adduction, with an inability to cross one’s legs or limitation of rotation, with an inability to toe-out more than 15 degrees, warrants a 10 percent rating. Under DC 5261, which evaluates limitation of extension of a knee, a zero percent rating is assigned when extension is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5261. Under Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) pain, by itself, does not constitute a functional loss warranting a higher rating under VA regulations that evaluate disability based upon range-of-motion loss in the musculoskeletal system; rather, “pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed coordination, and endurance in order to constitute functional loss.” However, the regulatory provisions describing functional loss due to musculoskeletal disability, e.g., 38 C.F.R. §§ 4.40 (functional loss), 4.41 (History of injury), 4.45 (the Joints) , and 4.49 (Painful Motion), are intended to be used in understanding the nature of service-connected disabilities, after which a rating is determined based on explicitly listed rating criteria and the discussions of functional loss in the general regulatory provisions do not supersede requirements for a higher rating specified in schedule of ratings or provide a basis for a separate rating. Thompson v. McDonald, 815 F.3d 781 (Fed.Cir. March 8, 2016). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59 apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Because DC 5003 (rating arthritis) requires that “satisfactory of evidence of pain” be “objectively confirmed,” a Veteran's testimony, alone, is not enough. For the minimum compensable rating for painful joint motion which is not actually limited to a compensable degree, a claimant’s bare statement is not satisfactory evidence of painful motion. Petitti v. McDonald, 27 Vet. App. 415 (2015) (per curiam) (painful motion may be “objectively confirmed” by either a clinician, including a claimant's assertion of painful joint motion that is confirmed by a clinician’s statement there is a history of "recurrent" joint pain or a layperson who witnessed the Veteran experience difficulty walking, standing, or sitting, or display a facial expression, such as wincing, indicative of pain). In other words, satisfactory lay evidence includes lay descriptions from other than the Veteran of painful motion; lay observations of witnesses of painful motion, lay statements of observed visible behavior or facial expressions during painful motion, as well as lay reports of difficulty walking, standing, sitting, or undertaking other activity. Petitti v. McDonald, 27 Vet. App. 415 (2015) (per curiam). Under 38 C.F.R. § 3.344, rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction. Ratings for diseases subject to temporary or episodic improvement will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). However, 38 C.F.R. § 3.344(c) specifies that the above considerations are required for ratings which have continued for long periods at the same level (five years or more); they do not apply to disabilities which have not become stabilized and are likely to improve. Therefore, reexaminations disclosing improvement, physical or mental, in these disabilities will warrant a reduction in rating. Id. Reasonable doubt will be favorably resolved and it exists when there is an approximate balance of positive and negative evidence. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed.Cir. 2001). Analysis Initially the Board must note that the 10 percent ratings for left hip bursitis and for limitation of extension of the left thigh were not in effect for five (5) years. Accordingly, under 38 C.F.R. § 3.344(c), the provisions of 38 C.F.R. § 3.344(a) are not applicable. 1. The claim for entitlement to restoration of a 10 percent rating for limitation of extension of the left thigh, associated with status post total right knee replacement The 2014 VA examination found that abduction was not lost beyond 10 degrees; rather, it was to 40 degrees with pain at that point. The 2015 VA examination found that abduction was normal. The 2014 VA examination found that adduction was not limited such that the Veteran could not cross his legs; rather, it was to 30 degrees, with pain at that point. The 2015 VA examination found that adduction was normal at 25 degrees. The 2014 VA examination found that rotation was not such that Veteran could not toe-out more than 15 degrees; rather, it was to 40 degrees and painless. The 2015 VA examination found that external rotation was normal. Significantly, the 2014 VA examiner found that the Veteran had painful and limited left hip motions which caused functional loss or functional impairment. In contrast, the 2015 VA examination found that while the Veteran had pain on all motions of the left hip, the painful motion did not cause functional loss. In essence, the reduction of the 10 percent rating was premised on the 2015 examination finding that any noncompensable degree of limited left hip motion in abduction, adduction, and rotation, even if painful, did not cause functional loss. The Board is aware that one examiner has reported that at least some of the Veteran’s left hip pain stems from nonservice-connected lumbar DDD. However, that examiner could not determine how much of the pain was due to the nonservice-connected lumbar DDD and how much was due to the service-connected left hip bursitis. Thus, for rating purposes, the Board must consider all of the left hip pain which the Veteran now has to be due to the service-connected left hip bursitis, and not the nonservice-connected lumbar DDD. Next, addressing the matter of functional loss, while the 2015 VA examination stated that painful left hip motions did not cause functional loss, the 2015 VA examination also stated that the left hip disability impacted on the Veteran’s ability to engage in any occupational task requiring lifting, walking, or standing. There is also evidence that the Veteran’s use of a cane, as an ambulatory aid, is due at least in part to his service-connected left hip bursitis. While the Veteran’s statements of pain causing functional impact are insufficient, standing alone, to warrant the minimum compensable disability rating of 10 percent, there are numerous lay statements from acquaintances which attest to the Veteran’s limited mobility and functional impairment. Although these lay statements did not parse out how much functional impairment was due to the Veteran’s service-connected total right knee replacement, as opposed to his left hip bursitis, when resolving doubt in favor of the Veteran, the Board concludes that the Veteran does not have a compensable degree of limited left hip abduction, adduction or rotation but that motion of the left hip in these planes does cause pain which, in turn, results in impairment or some degree of loss of function. Accordingly, restoration of a 10 percent rating for left hip bursitis is warranted. However, the preponderance of the evidence is against finding that a disability evaluation in excess of 10 percent for left hip bursitis is warranted. 2. The claim for entitlement to restoration of a 10 percent rating for left hip bursitis, associated with status post total right knee replacement, The 2014 VA examination found that the Veteran did not have limitation of extension to only 5 degrees, and was reportedly without objective evidence of painful motion. However, that examiner also stated that the Veteran had functional loss or impairment due to painful left hip motions. The 2015 VA examination found that extension was normal, to 30 degrees. The examiner stated that there was pain in all motions, painful motion did not result in or cause functional loss. The 2015 VA examiner also stated that the left hip disability impacted on the Veteran’s ability to engage in any occupational task requiring lifting, walking, or standing. While the Veteran’s statements of pain causing functional impact are insufficient, standing alone, to warrant the minimum compensable disability rating of 10 percent, there are numerous lay statements from acquaintances which attest to the Veteran’s limited mobility and functional impairment. Although these lay statements did not parse out how much functional impairment was due to the Veteran’s service-connected total right knee replacement, or his left hip bursitis, as opposed to his limited extension of the left thigh, when resolving doubt in favor of the Veteran, the Board concludes that the Veteran does not have a compensable degree of limited extension of the left thigh but that extension of the left thigh does cause pain which, in turn, results in impairment or some degree of loss of function. Accordingly, restoration of a 10 percent rating for limited extension of the left thigh is warranted. However, the preponderance of the evidence is against finding that a disability evaluation in excess of 10 percent for limited extension of the left thigh is warranted. REASONS FOR REMAND 1. The claim for entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) is remanded. An August 22, 2011, letter to the Veteran acknowledge that he had completed an application for VA Vocational Rehabilitation and Employment Services. However, a September 7, 2011, Report of Contact shows that the Veteran was no longer interested in pursuing Chapter 31 services. The evidence does not show that the Veteran ever actively participated in any VA Vocational Rehabilitation and Employment Services. In A December 18, 2017, letter the Veteran’s attorney requested that the Veteran be provided 90 days after the attorney was provided a copy of the claim file in which to submit additional evidence but that, as yet, no copy of the claim file had been provided to the attorney. Another request for a copy of the Veteran’s claim file was made by the attorney in a letter dated January 26, 2018. An RO letter of February 15, 2018, to the Veteran’s attorney reflects that a copy of the Veteran’s claim file was provided on a compact disc. A letter from the Board dated April 10, 2018, shows that the Veteran’s attorney was provided an up-dated copy of the Veteran’s claim file. By letter of June 28, 2018, from the Deputy Vice Chairman of the Board, the attorney’s December 18, 2017, request for an extension of time of 90 days to submit additional evidence was granted as of 90 days of the Board’s letter. On August 23, 2018, the Veteran’s attorney submitted a report of a Vocational Assessment from Clifford Vocational Services, dated August 3, 2018, in which it was opined that after reviewing the Veteran’s claim file that due to the chronic symptoms [as described] that the Veteran had been unable to maintain substantially gainful employment on a regular and consistent basis even at the sedentary level of work since September 14, 2011 when he was granted total disability by the Social Security disability administration. More to the point, the restoration of the 10 percent ratings for left hip bursitis and for limitation of extension of the left thigh could impact upon the Veteran’s potential entitlement to a TDIU rating. In this regard, the Board notes that, without consideration of the restoration of the 10 percent ratings herein, the Veteran has only met the schedular criteria for a TDIU rating under 38 C.F.R. § 4.16(a) during the time from September 29, 2015, until the 40 percent rating for service-connected gastric ulcers and gastrointestinal bleed, associated with SP total right knee replacement, was reduced to a noncompensable disability rating effective July 1, 2018, by an April 17, 2018 rating decision. In light of the foregoing, the Veteran should be provided a VA examination for the purpose of obtaining full description of the effects of his multiple service-connected disabilities upon his ordinary activity, under 38 C.F.R. § 4.10, and to request that an examiner comment on the Veteran’s ability to function in an occupational environment, and describe functional impairment caused solely by service-connected disabilities. Thereafter, the RO should readjudicate the claim for a TDIU rating and ensure that consideration is given to the procedures for assignment of an extraschedular TDIU rating. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA general medical examination for a medical opinion to assist in determining the nature and extent of the combined impact of all of his service-connected disabilities. Any and all indicated history, evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The Veteran’s electronic records should be made available to the examiner for review, and the examination report should reflect that such review was accomplished. The examiner should also provide an opinion as to the extent of the occupational impairment attributable to the combined impact of the Veteran’s service-connected disabilities. The examiner should not consider his age or the impairment caused by his nonservice-connected disabilities. 2. Then, after restoration of the 10 percent ratings for left hip bursitis and limitation of extension of the left thigh has been accomplished, readjudicate the claim for a TDIU rating. However, refer the claim for a TDIU rating for any time during which the Veteran has been not been found to warrant a schedular TDIU rating, to VA’s Director of Compensation Services for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b). Thereafter, in light of the submission of additional evidence during this appeal, and following all development requested herein including referral of the above-mentioned matter to the Director of Compensation Services for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b), the RO should readjudicate the claim for a TDIU rating. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs