Citation Nr: 18153309 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 09-14 048 DATE: November 27, 2018 ORDER 1. Entitlement to an initial disability rating in excess of 10 percent for status-post stress fracture of the right femur with a slight hip disability is denied. 2. Entitlement to an initial disability rating in excess of 10 percent for a left hip strain is denied. 3. Entitlement to a disability rating in excess of 10 percent for status-post stress fracture of the right tibia prior to July 2, 2008, in excess of 20 percent from July 2, 2008, to March 7, 2012, and in excess of a noncompensable disability rating since March 8, 2012, is denied. 4. Entitlement to a disability rating in excess of 10 percent for status post stress fracture of the left tibia prior to July 2, 2008, in excess of 20 percent from July 2, 2008, to March 7, 2012, and in excess of a noncompensable disability rating since March 8, 2012, is denied. REMANDED 5. Entitlement to an initial disability rating in excess of 30 percent for depression prior to September 14, 2011, and in excess of 70 percent since September 14, 2011, is remanded. 6. Entitlement to an effective date prior to September 14, 2011, for the grant of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s right status-post stress fracture of the right femur with a slight hip disability has not manifested with a moderate knee or hip disability, fracture of the surgical neck of the femur with false joint, or fracture of shaft or anatomical neck of the femur with nonunion and with or without loose motion, to include weight bearing preserved with the aid of a brace, during the appeal. 2. The Veteran’s left strain disability has not manifested with limited range of motion in flexion of the left thigh to 30 degrees or less. 3. The Veteran’s status-post stress fracture of the right tibia disability did not manifest with a malunion of the tibia and fibula with a moderate knee or ankle disability from May 4, 2000, to July 1, 2008, as malunion of the tibia and fibula with marked knee or ankle disability from July 2, 2008, to March 7, 2012, and as malunion of the tibia and fibula with a slight knee or ankle disability since March 8, 2012. 4. The Veteran’s status-post stress fracture of the left tibia disability did not manifest with a malunion of the tibia and fibula with a moderate knee or ankle disability from May 4, 2000, to July 1, 2008, as malunion of the tibia and fibula with marked knee or ankle disability from July 2, 2008, to March 7, 2012, and as malunion of the tibia and fibula with a slight knee or ankle disability since March 8, 2012. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for status-post stress fracture of the right femur with a slight hip disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5299-5255 (2017). 2. The criteria for an initial disability rating in excess of 10 percent for a left hip strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5299-5252 (2017). 3. The criteria for a disability rating in excess of 10 percent for status-post stress fracture of the right tibia prior to July 2, 2008, in excess of 20 percent from July 2, 2008, to March 7, 2012, and in excess of a noncompensable disability rating since March 8, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5299-5262 (2017). 4. The criteria for a disability rating in excess of 10 percent for status-post stress fracture of the left tibia prior to July 2, 2008, in excess of 20 percent from July 2, 2008, to March 7, 2012, and in excess of a noncompensable disability rating since March 8, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5299-5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1993 to March 1994. This case was previously before the Board in January 2007, July 2014, May 2016, and July 2017. Most recently in July 2017, the Board remanded the case to associate with the claims file outstanding VA treatment records since July 2012, schedule the Veteran for VA examinations to determine the current severity of the Veteran’s left hip, right femur, and left and right tibia disabilities, and issue a supplemental statement of the case if any benefit was denied by the Agency of Original Jurisdiction (AOJ). There was substantial compliance with the Board’s remand directives for the claims the Board is adjudicating below. See Stegall v. West, 11 Vet. App. 268 (1998). In July 2014, the Board remanded this case to schedule the Veteran for a videoconference hearing before the Board. However, in a February 2016 letter, the Veteran withdrew his request for a hearing. Thus, the Veteran’s hearing request is withdrawn. Increased Ratings, Generally The Veteran contends that his service-connected right femur, left hip, and right and left tibia disabilities should be rated higher than the currently-assigned disability ratings. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” The record shows that the appeal period for the right femur and right and left tibia disabilities stems from May 4, 2000, and that the appeal period for the left hip strain disability stems from June 2, 2003. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. The provisions of 38 C.F.R. § 4.40 allow for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Furthermore, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a) (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. – 2. Status-Post Stress Fracture of the Right Femur and Left Hip Strain Disabilities The Veteran contends that his right femur and left hip disabilities should be rated higher than the currently-assigned 10 percent disability ratings. Because the evidence pertaining to the severity of these disabilities is located in the same or similar documents, the Board shall analyze them together below. The Veteran’s right femur disability is rated under 38 C.F.R. § 4.71a, DC 5299-5255, while his left hip disability is rated under 38 C.F.R. § 4.71a, DC 5299-5252. DC 5255 provides ratings for impairment of the femur. A 10 percent rating is assigned for malunion of the femur with slight knee or hip disability. A 20 percent rating is assigned for malunion of the femur with moderate knee or hip disability. A 30 percent rating is assigned for malunion of the femur with marked knee or hip disability. A 60 percent disability rating applies when there is fracture of the surgical neck of the femur with false joint, or fracture of shaft or anatomical neck of the femur with nonunion, without loose motion, weight bearing preserved with aid of brace. An 80 percent disability rating, the highest rating assignable under this DC, contemplates fracture of shaft or anatomical neck of the femur with nonunion, with loose motion (spiral or oblique fracture). Moreover, DC 5252 rates limitation of flexion of the thigh, assigning a 10 percent rating for flexion limited to 45 degrees; a 20 percent rating for flexion limited to 30 degrees; a 30 percent rating for flexion limited to 20 degrees; and, a 40 percent rating for flexion limited to 10 degrees. Normal range of motion for the hip is flexion from zero to 125 degrees and abduction from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II (2017). The record shows that the Veteran filed claims for service connection for the right femur and left hip disabilities in May 2000. An August 2000 VA examination of the right femur showed the Veteran’s complaints of pain in the upper right leg and right knee. A physical examination showed that he did not have any tenderness over the femur or the shins. The examiner noted that the Veteran’s right hip moved well and that the right hip had 100 degrees of flexion, 25 degrees of extension, 30 degrees of abduction, and 20 degrees of adduction. The Veteran’s right hip also had 90 degrees of external rotation and 70 degrees of internal rotation. The examiner diagnosed the Veteran’s right femur disability with status-post stress fracture of the right femur with mild residual discomfort, and noted that the x-ray reports of the right femur were negative. The Board notes that this this examination also showed the limitation of motion of the Veteran’s knees and ankles; however, as discussed in more detail below, the rating criteria for the Veteran’s right and left tibia disabilities contemplate the degrees of severity of the knees and ankles. Thus, considering the symptomatology of the Veteran’s right knee to assign a disability rating for his right femur disability would amount to pyramiding. See 38 C.F.R. § 4.14 (2017). A November 2002 VA treatment record showed that the Veteran’s lower extremity range of motion was within normal limits in the ankles, knees, and hips. He complained of nonspecific pain mostly in the right knee and hip. Both hips showed four out of a possible five for flexion, abduction, adduction, and extension. The medical professional noted that the Veteran’s lower extremity strength was at least partially limited by pain or apprehension from pain. The Veteran’s hip flexors appeared to be tight as assessed by prone knee bending. A June 2003 VA examination of the right femur and left hip disabilities showed that the Veteran complained of hip pain that was a zero out of a possible 10 when at rest, but an 8 out of a possible 10 during flare-ups. The pain did not radiate to other parts of the body. The Veteran did not report any decreased range of motion or limitation of motion, or any functional impairment as a result of any limitation of motion. A physical examination showed that the Veteran’s right hip forward flexed to 125 degrees and that the left hip forward flexed to 130 degrees. Abduction was 40 degrees, external rotation was 45 degrees, and internal rotation was 30 degrees on the left and right sides. The examiner noted that the Veteran had excellent strength of the hip flexors, as well as good strength to the quadriceps; however, he had a slight weakness in the right hamstrings compared to the left leg. X-ray diagnostic reports showed mild bilateral hip osteoarthritis with some osteophyte formation over the superolateral margin of the bilateral acetabulum. Mild hip arthritis in the right hip region was also noted in an October 2004 VA physical medicine rehabilitation consultation. The Veteran complained of chronic polyarthralgias. A physical evaluation showed that the Veteran’s lower extremity alignment appeared alright and his gait was independent without a limp. The Veteran’s passive range of motion of the hips was without pain. A May 2006 VA internal medicine attending note showed that the Veteran’s right hip had pain with abduction and rotation. The medical professional noted that his right hip flexion and his bilateral lower extremity strength were intact. The Veteran was diagnosed with a long-standing history of chronic right hip pain. An October 2006 medical treatment record from the Social Security Administration (SSA) showed that the Veteran complained of pain in his hips, knees, legs, and heels from multiple stress fractures. A physical valuation of the musculoskeletal system showed that the Veteran’s muscles were well-developed without any atrophy. Range of motion testing showed that all of his joints appeared normal. The medical professional indicated that both knees were flexed maximally without crepitation and that straight leg raising was negative to 60 degrees. The Veteran’s gait was normal and he could make a full squat with support; however, he could not walk on his heels because of plantar fasciitis symptoms. The Veteran complained of chronic hip and back pain in a December 2007 VA emergency department note. A July 2008 VA examination for both hips showed that the Veteran was using Tylenol and trazodone medication to treat his symptoms. The Veteran did not have any deformity, giving way, effusion, weakness, episode of locking, dislocation, subluxation, or instability, but he did have pain and stiffness in his hips. The Veteran reported flare-ups of joint disease that resulted in moderate functional impairment. A physical examination showed that active and passive ranges of motion were garnered for both hips. Forward flexion of the right hip was from zero to 110 degrees with pain beginning at 100 degrees, and passive range of motion was from zero to 115 degrees with pain beginning at 100 degrees. The examiner noted that the Veteran was able to forward flex to 100 degrees after three repetitions. Active range of motion of the right hip extension was to 20 degrees with pain beginning at 15 degrees, and passive range of motion was to 25 degrees with pain beginning at 15 degrees. Similarly, the left hip showed forward flexion to 120 degrees with pain beginning at 110 degrees, and passive range of motion was from zero to 125 degrees with pain beginning at 110 degrees. The examiner noted that the Veteran was able to forward flex to 110 degrees after three repetitions. Active range of motion of the left hip extension was to 25 degrees with pain beginning at 20 degrees, and passive range of motion was to 30 degrees with pain beginning at 30 degrees. Right and left adduction was to 15 degrees with pain beginning at 10 degrees in active range of motion, but adduction was to 20 degrees with pain beginning at 10 degrees in passive range of motion. Likewise, right and left abduction was to 30 degrees with pain beginning at 20 degrees in active range of motion, and to 35 degrees with pain beginning at 20 degrees in passive range of motion. Similar results were noted following repetitive use testing. Right and left internal rotation was from zero to 30 degrees with pain beginning at 25 degrees in active range of motion, and from zero to 35 degrees with pain beginning at 25 degrees in passive range of motion. Right and left external rotation was from zero to 45 degrees with pain beginning at 35 degrees in active range of motion and from zero to 50 degrees with pain beginning at 35 degrees in passive range of motion. The examiner noted that the Veteran had normal X-ray studies of the hips but that he had decreased mobility due to his right and left hip disabilities, which moderately impacted his ability to shop, exercise, and perform chores. These disabilities also prevented the Veteran from participating in sports and recreational activities, and mildly impacted his travelling, but did not impact his ability to feed, bathe, dress, or groom himself. A March 2012 VA examination for the hips showed that the Veteran complained of bilateral hip pain and flare-ups. Flare-ups were precipitated by prolonged sitting and alleviated by rest and Tylenol. Initial range of motion showed forward flexion to 120 degrees with no pain noted in the right hip and forward flexion to 120 degrees with pain beginning at 120 degrees in the left hip. Right and left hip extension was to 5 degrees or greater. Abduction was not lost beyond 10 degrees and the Veteran was able to cross his legs and toe-out more than 15 degrees for each leg. No additional limitation of motion was noted after repetitive-use testing. The Veteran did not have pain to palpation or localized tenderness, his muscle strength testing was normal, and he did not have ankylosis in either hip joint. An x-ray report of the right hip showed a normal study. An October 2017 VA examination report showed that the Veteran complained of persistent bilateral hip pain. The examiner noted that the Veteran was not being treated for right femur and left hip disabilities. The Veteran stated that he did not have any flare-ups of these disabilities; however, he told the examiner that he had pain with sitting for extended periods time and while going down stairs, as well as instability. Range of motion testing of the right hip showed forward flexion to 115 degrees, extension to 30 degrees, abduction to 40 degrees, adduction to 25 degrees, external ration to 60 degrees and internal rotation to 40 degrees. Similarly, left hip forward flexion was to 125 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external ration to 60 degrees, and internal rotation to 40 degrees. The Veteran was able to cross his legs. The examiner noted that although there was pain noted during range of motion testing for the flexion and abduction of both hips, the pain did not result in or cause functional loss. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion after three repetitions. Muscle strength testing was normal and the Veteran did not have ankylosis. Given this evidence, the Board finds that the Veteran’s status-post stress fracture of the right femur with a slight hip disability has not manifested with a moderate knee or hip disability, fracture of the surgical neck of the femur with false joint, or fracture of shaft or anatomical neck of the femur with nonunion and with or without loose motion, to include weight bearing preserved with the aid of a brace during the appeal. Additionally, this evidence shows that the Veteran’s left hip strain disability has not manifested with limited range of motion in flexion of the left thigh to 30 degrees or less at any time during the appeal. Specifically, while the Veteran was noted to have bilateral hip pain throughout the appeal, including in an October 2004 VA treatment record and an October 2006 SSA treatment record, and that he has had osteoarthritis in both hips, as shown by x-ray evidence, the record does not indicate that his right femur disability manifested a with moderate knee or hip disability or that his left hip disability manifested with limitation of motion of flexion of the left thigh to 30 degrees or less at any time during the appeal. In fact, the initial and repetitive-use range of motion findings noted during the August 2000, June 2003, July 2008, March 2012, and October 2017 VA examinations do not show that flexion of the Veteran’s left high was limited to 30 degrees or less, or that his right femur disability manifested with a moderate knee or hip disability. The Board has considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that higher ratings are not warranted for the Veteran’s disability picture. The ranges of motion testing conducted during the medical evaluations considered the thresholds at which pain limited motion. The Veteran reported having flare-ups of his symptoms during certain evaluations and the medical examinations showed the presence of any additional functional impairment due to such symptoms as pain, pain on repeated use, fatigue, weakness, lack of endurance, and incoordination. However, even though there is evidence of reduced flexion and overall ranges of motion, and even after considering the effects of pain and functional loss, the evidence does not show that the Veteran’s right femur disability resulted in a moderate knee or hip disability, fracture of the surgical neck of the femur with false joint, or fracture of shaft or anatomical neck of the femur with nonunion and with or without loose motion, to include weight bearing preserved with the aid of a brace, or that his left hip strain resulted in limited range of motion in flexion of the left thigh to 30 degrees or less at any time during the appeal. Thus, higher ratings under these provisions are not approximated in the Veteran’s disability picture. Accordingly, as the preponderance of the evidence is against an initial disability rating in excess of 10 percent for status-post stress fracture of the right femur with a slight hip disability and an initial disability rating in excess of 10 percent for a left hip strain, the benefit-of-the-doubt rule does not apply, and the Veteran’s claims must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.71a, DCs 5299-5255, 5299-5252; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. – 4. Status-Post Stress Fractures of the Right and Left Tibias The Veteran contends that the disability ratings for his right and left tibia disabilities should be rated higher than the currently-assigned disability ratings. Because the evidence pertaining to these disabilities is located in the same or similar documents, the Board shall analyze them together below. The record shows that the Veteran’s bilateral tibia disabilities were rated as 10 percent disabling from May 4, 2000, to July 1, 2008, as 20 percent disabling from July 2, 2008, to March 7, 2012, and as noncompensable (zero percent disabling) since March 8, 2012. These disabilities are rated under DC 5299-5262, for impairment of the tibia and fibula. This DC assigns a 10 percent rating for malunion of the tibia and fibula with slight knee and or ankle disability. A 20 percent rating is assigned for malunion with moderate knee or ankle disability. A 30 percent rating is assigned for malunion with marked knee or ankle disability. A 40 percent rating is assigned for nonunion of the tibia and fibula with loose motion and requiring a brace. The Veteran filed increased rating claims for the right and left tibia disabilities in May 2000. An August 200 VA examination showed that the Veteran complained of bilateral shin pain, which was mild in severity. He also complained of bilateral knee and ankle pain. A physical examination showed that his knees moved well. The examiner noted that the knees did not have any instability, crepitus, or cracking. Range of motion testing of the knees showed flexion to 140 degrees and extension to zero degrees for both knees. The examiner noted that there was minimal tenderness over the lateral portion of the knee caps. Range of motion testing of the ankles showed flexion to 35 degrees, dorsiflexion to 30 degrees, inversion to 30 degrees, and eversion to 10 degrees for both ankles. The examiner determined that the Veteran’s ankles did not have increased laxity or tenderness and that his overall gait was normal. A November 2002 VA treatment record showed that the Veteran complained of constant pain that was aggravated by walking, exercise, and cold, wet weather. A physical evaluation showed that his gait was guarded, but that the range of motion of the lower extremities was grossly normal. The Veteran stated that he had nonspecific pain in his right knee. The medical professional noted that bilateral ankle inversion and eversion, as well as bilateral knee flexion, was a four out of a possible five, but that bilateral knee extension was a three out of a possible five. The evaluator noted that the Veteran’s bilateral ankle dorsiflexion was normal. An October 2004 VA physical medicine rehabilitation consultation showed that the Veteran complained of bilateral knee and ankle pain, which occurred while sitting, squatting, or using stairs. While the Veteran complained that the right knee “popped,” he did not have any locking or buckling of the knees. A physical evaluation showed that the Veteran was able to flex the knees so that the heel was within one hand breath of his buttock. The right knee was tender, but there was no erythema, warmth, swelling, or effusion in the knees. The Veteran was able to extend the knees fully. The evaluator noted that the Veteran’s ankles showed tenderness at the posterior to the medial malleolus, but there was also no swelling, erythema, or warmth at the ankles. Dorsiflexion was 10 degrees in the right ankle and 5 degrees in the left ankle. The evaluator noted that the Veteran did not have any tenderness at the Achilles tendon or pain with forced dorsiflexion. An October 2006 SSA treatment record showed that the Veteran was able to flex both knees maximally without crepitation. Straight leg raising was negative to 60 degrees, and the Veteran’s gait was normal. The Veteran’s range of motion of the lower extremities appeared normal and the Veteran was able to full squat with support. The Veteran stated that he could walk on his toes but could not walk on his heels because of plantar fasciitis. In a December 2007 VA emergency department note, the Veteran complained of chronic knee pain. However, the medical professional cited to several diagnostic reports from 2006 to show that he had negative plain films. Given this evidence, the Board finds that the Veteran’s status-post stress fractures of the right and left tibia disabilities did not manifest with a malunion of the tibia and fibula with a moderate knee or ankle disability from May 4, 2000, to July 1, 2008. Specifically, the right and left tibia symptoms, including the ranges of motion of the knees and ankles, shown during the August 2000 VA examination and in the October 2006 SSA treatment record, as well as the November 2002, October 2004, and December 2007 VA treatment records do not show that these disabilities resulted in moderate knee or ankle disabilities. While the Veteran was shown to have pain, tenderness, and limited motion of the knees and ankles, these symptoms amounted to no more than slight knee or ankle disabilities. Thus, disability ratings in excess of 10 percent are not warranted for the Veteran’s right and left tibia disabilities prior to July 2, 2008. However, as shown by the July 2008 VA examination report, the Veteran’s bilateral tibia symptoms worsened in severity. Specifically, this VA examination showed that the Veteran was taking Tylenol for his bilateral tibia disability symptoms. He complained of pain in his knees and ankles; however, a physical examination showed that the Veteran did not have any loss of motion in his ankles due to these disabilities. Range of motion testing showed right knee forward flexion to 110 degrees with pain at 100 degrees in active range of motion, and flexion to 120 degrees with pain at 100 degrees in passive range of motion. Range of motion testing of the left knee showed forward flexion to 120 degrees with pain at 110 degrees in active range of motion, and flexion to 130 degrees with pain at 110 degrees in passive range of motion. After three repetitions, right knee flexion was to 100 degrees and left knee flexion was to 110 degrees. The knees did not have any crepitation, mass behind the knee, grinding, instability, or abnormal patellar or meniscus symptoms, but the right knee did exhibit clicks or snaps. X-rays of the knees and tibia and fibula showed normal results. The examiner determined that the Veteran’s right and left tibia, as well as the right femur fracture, mildly impacted the Veteran’s ability to do chores, shop, exercise, and travel, and these disabilities also moderately impacted his ability to participate in sports and recreational activities due to such symptoms as decreased mobility and pain. Given this evidence, the Board finds that the Veteran’s status-post stress fractures of the right and left tibia disabilities did not manifest with a malunion of the tibia and fibula with a marked knee or ankle disability from July 2, 2008, to March 7, 2012. Specifically, as noted in the July 2008 VA examination report, the Veteran complained of pain in his ankles and knees, and the knees were noted to have slightly limited range of motion in flexion due to pain. However, this evidence does not show that the Veteran’s bilateral tibia disabilities amounted to marked knee or ankle disability. In fact, the examiner determined that the Veteran’s bilateral ankles did not have any loss of motion. Overall, the Veteran’s bilateral knee symptoms mildly or moderately affected his activities of daily living. Accordingly, disability ratings in excess of 20 percent are not warranted for the Veteran’s right and left tibia disabilities from July 2, 2008, to March 7, 2012. The record indicates that the AOJ decreased the disability rating for the right and left tibia disabilities from 20 percent disabling to zero percent disabling due the March 2012 VA examination report results, which showed that the Veteran’s bilateral tibia symptoms had improved. The Veteran reported that the pain in his bilateral shin areas came and went. The pain was stress induced, and made worse by running, stress, and prolonged walking. The pain was alleviated by Tylenol and rest. Range of motion testing of the knees showed bilateral knee flexion to 120 degrees with no painful motion, and extension to zero degrees or any degree of hyperextension with no painful motion. Same results were shown after repetitive-use testing. The examiner specifically determined that the Veteran did not have any tenderness or pain to palpation for the joint line or the soft tissue in either knee. Muscle strength and stability testing showed normal results, but the examiner noted that the Veteran had residual, intermittent, and achy pain in his shin splints, which were stress induced. Overall, the examiner determined that the Veteran’s bilateral tibia disabilities did not impact his ability to work. October 2017 VA examinations of the knees and ankles confirmed that the Veteran’s symptoms had improved since 2012. Specifically, the VA examination for the knees showed that although the Veteran complained of persistent bilateral ankle, leg, and knee pain, a physical examination showed normal initial and repetitive-use testing range of motion results in both knees. While the Veteran reported pain, the examiner determined that pain did not result in or cause functional loss. Additionally, the examiner determined that there was no evidence of localized tenderness or pain on palpation, crepitus, or pain with weight bearing in each knee. The Veteran denied having flare-ups, and the examination showed no ankylosis. The examiner determined that there was no additional functional loss, including less or weakened movement, due to these disabilities. Joint stability and muscle strength evaluations were normal. Similarly, the October 2017 VA examination of the ankles showed normal ranges of motion of the ankles. Additionally, while the right ankle showed pain in plantar flexion and the achilles area, this pain did not result in or cause functional loss. The Veteran’s left ankle did not have any evidence of pain. There was no additional loss of function or range of motion after repetitive use testing. The examiner determined that there was no evidence of pain on passive range of motion testing or in non-weight bearing testing. The examiner also noted that the Veteran did not experience any pain, fatigue, weakness, lack of endurance, or incoordination due to his right and left ankle symptoms. Muscle strength testing showed normal results and there was no evidence of ankylosis. Given this evidence, the Board finds that the Veteran’s right and left tibia disabilities have not manifested as malunion of the tibia and fibula with a slight knee or ankle disability since March 8, 2012. Specifically, while the March 2012 VA examination showed that the Veteran had very slight limited motion of the knees, the Veteran did not have any pain or functional loss as a result of this slightly limited range of motion. The examiner expressly noted that the Veteran’s bilateral tibia symptoms had improved. Similarly, while the October 2017 VA examination reports for the knees and ankles showed that the Veteran reported persistent bilateral ankle, leg, and knee pain, the examinations showed no loss of function or loss of range of motion in the ankles and knees. As noted above, pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell, 25 Vet. App. at 42-43. Overall, the record indicates that the Veteran’s right and left tibia disabilities do not warrant a compensable disability rating since March 8, 2012. The Board has also considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria for the entire appeal period but determines that higher ratings are not warranted for the Veteran’s disability picture. The ranges of motion testing conducted during the medical evaluations considered the thresholds at which pain limited motion. The Veteran reported having flare-ups of his symptoms during certain evaluations and the medical examinations showed the presence of any additional functional impairment due to such symptoms as pain, pain on repeated use, fatigue, weakness, lack of endurance, and incoordination. However, even though there is evidence of reduced knee and ankle range of motion prior to the October 2017 VA examinations, and even after considering the effects of pain and functional loss, the evidence does not show that the Veteran’s right and left tibia disabilities manifested with a malunion of the tibia and fibula with a moderate knee or ankle disability from May 4, 2000, to July 1, 2008, as a marked knee or ankle disability from July 2, 2008, to March 7, 2012, or as a slight knee or ankle disability since March 8, 2012. Thus, higher ratings under these provisions are not approximated in the Veteran’s disability picture. Accordingly, the preponderance of the evidence is against entitlement to a disability rating in excess of 10 percent for status-post stress fracture of the right and left tibias prior to July 2, 2008, in excess of 20 percent from July 2, 2008, to March 7, 2012, and in excess of a noncompensable disability rating since March 8, 2012. The benefit-of-the-doubt rule does not apply, and the Veteran’s claims must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.71a, DCs 5299-5262; Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND The Board must remand the Veteran’s increased rating claim for depression and the earlier effective date claim for the grant of TDIU for additional evidentiary and procedural development. The Board must remand the increased rating claim for depression for an addendum VA medical opinion in order to substantially comply with the Board’s July 2017 remand directives. See Stegall v. West, 11 Vet. App. at 268. In the July 2017 remand, the Board requested that the VA examiner, if reasonably possible, differentiate the Veteran’s symptoms due to his service-connected depression from the symptoms due to his nonservice-connected mental disabilities. In this regard, the Board requested that the clinician consider the diagnoses of personality passive-aggressive disorder, antisocial personality, seasonal affective disorder, intermittent explosive disorder, and post-traumatic stress disorder (PTSD), as shown in various VA treatment records, including in October 2002, May 2003, October 2003, June 2008, August 2009, and October 2010 VA clinical records, and a 2006 SSA record. While the Veteran underwent a VA psychiatric examination in October 2017, which showed a diagnosis of chronic, persistent depressive disorder secondary to chronic pain, the examiner did not attempt to differentiate the symptoms caused by the service-connected depression from nonservice-connected psychiatric disorders. Rather, the examiner merely “checked off” a box indicating that the Veteran did not have more than one mental disorder diagnosed. The Board determines that the October 2017 VA examination is inadequate to the extent that the examiner did not discuss, or attempt to differentiate the Veteran’s symptoms due to his service-connected depression from the symptoms due to his nonservice-connected mental disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board notes that the appeal period for the Veteran’s depression stems from June 7, 2002, and that the Veteran has been diagnosed with various nonservice-connected psychiatric disorders during this long appeal period. Thus, on remand, the AOJ should ascertain an addendum VA medical opinion. The issue of entitlement to an earlier effective date for a grant of TDIU is inextricably intertwined with the issue of rating and evaluating the depression symptoms as a clinician’s opinion is being requested to differentiate symptoms of different psychiatric disabilities. Thus, the earlier effective date claim must also be remanded. The matters are REMANDED for the following actions: 1. Return the claims file to the October 2017 VA examiner who examined the Veteran’s depression symptoms, and request that she re-review the claims file and respond to the below inquiries regarding the Veteran’s increased rating claim. If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to evaluate the current severity of his depression symptoms. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, the October 2017 VA examination report, and sound medical principles, the VA examiner should: (a.) Attempt to clarify and differentiate, if reasonably possible, the Veteran’s symptoms due to his service-connected depression from the symptoms due to his nonservice-connected mental disabilities. 2. In rendering an opinion, the examiner should comment as to the significance of VA and SSA treatment records showing diagnoses of nonservice-connected psychiatric disabilities, including, PTSD and to rule out PTSD, antisocial personality disorder, personality passive-aggressive disorder, rule out bipolar spectrum disorder, intermittent explosive disorder, and personality disorder not otherwise specified (NOS), throughout the appeal period since June 2002. See (1) VBMS entry with document type “Medical Treatment-Record-Government Facility,” received 01/11/2011, at page 1; (2) VBMS entry with document type “VA Examination,” received 05/30/2003, at pages 1-5; (3) VBMS entry with document type “Medical Treatment-Record-Government Facility,” received 04/30/2007, at pages 30-31, 56; (4) VBMS entry with document type “VA Examination,” received 08/15/2008, at pages 39-46; (5) VBMS entry with document type “Medical Treatment Records- Furnished by SSA,” received 05/17/2016, at pages 3, 78-81. If the examiner is unable to differentiate between the Veteran’s service-connected depression symptoms and his nonservice-connected psychiatric symptoms, the examiner should provide a rationale why this is so, and what, if any, additional evidence would be necessary to differentiate these symptoms. The examiner must provide a rationale for each opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hodzic, Counsel