Citation Nr: 18153447 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-59 685 DATE: November 28, 2018 ORDER A compensable rating for left arm shrapnel wounds with scars is dismissed. A rating in excess of 40 percent for degenerative joint disease of the thoracic spine is denied. An initial rating in excess of 20 percent for right lower extremity radiculopathy is denied. Prior to May 23, 2016, a maximum schedular rating of 10 percent for limitation of extension of the right hip is granted. Prior to May 23, 2016, a compensable rating for limitation of flexion of the right hip is denied. Prior to May 23, 2016, a maximum schedular rating of 20 percent for impairment of the right thigh is granted. From June 1, 2017 forward, a rating of 50 percent, but no higher, for residuals of a total right hip replacement is granted. REMANDED Entitlement to a rating in excess of 10 percent for a right knee disability, to include a temporary total rating for a period of convalescence, is remanded. Entitlement to a compensable rating for right knee surgical scars is remanded. FINDINGS OF FACT 1. By an August 2015 notice of disagreement and a September 2016 substantive appeal, the Veteran had indicated that he was seeking compensation for his right shoulder and that the RO had improperly adjudicated his claim as an increased rating for his service-connected left arm disability. 2. The Veteran’s thoracic spine disability has not been manifested by ankylosis of any kind. 3. The Veteran’s right lower extremity radiculopathy was not manifested by moderately severe paralysis of the sciatic nerve. 4. Prior to May 23, 2016, resolving reasonable doubt in the Veteran’s favor, limitation of extension of his right hip was to 5 degrees. 5. Prior to May 23, 2016, the Veteran’s right hip disability was not manifested by limitation of flexion to 45 degrees or less. 6. Prior to May 23, 2016, resolving reasonable doubt in the Veteran’s favor, his right thigh impairment had limitation of abduction, adduction, external rotation, and internal rotation that more nearly approximated the next higher rating. 7. From July 1, 2017 forward, the Veteran’s service-connected total right hip replacement has been manifested by moderately severe residuals from abnormal flexion, external rotation, and internal rotation. CONCLUSIONS OF LAW 1. There is no issue in controversy pertaining to the Veteran’s service-connected left arm disability. 38 U.S.C. § 7105; see Sabonis v. Brown, 6 Vet. App. 426 (1994). 2. The criteria for a rating in excess of 40 percent for a thoracic spine disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 3. The criteria for an initial rating in excess of 20 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520. 4. Prior to May 23, 2016, the criteria for the maximum schedular rating of 10 percent for limitation of extension of the right hip has been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 5. Prior to May 23, 2016, the criteria for a compensable rating for limitation of flexion of the right hip has not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 6. Prior to May 23, 2016, the criteria for the maximum schedular rating of 20 percent for impairment of the right thigh has been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 7. From July 1, 2017 forward, the criteria for a rating of 50 percent, but no higher, for residuals from a total right hip replacement have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from February 1971 to January 1974 and in the U.S. Army from October 1989 to November 2006, during which he received two Purple Hearts. 1. Dismissal of an increased rating for service-connected left arm shrapnel wounds with scars; referral of service connection for a right shoulder disorder The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. In the present case, the Veteran filed a September 2015 notice of disagreement indicating that the RO had improperly adjudicated his claim for “limited flexion of forearm” as an increase rating for his service-connected residuals of shrapnel to his left arm. This was not corrected and the RO issued a September 2016 statement of the case pertaining to the Veteran’s left arm shrapnel wounds. The Veteran responded with a substantive appeal opining that his right shoulder hurts all the time. Based on the foregoing, the Board finds that certification of an increased rating claim for the Veteran’s service-connected left arm shrapnel wounds was in error. The Board is cognizant that the July 2018 informal hearing presentation argued that the Veteran’s claim for an increase rating for a left arm disability should be remanded for a new examination as the current examination was over 25 months old and thus was too old to adequately evaluate the disability. The Board rejects this argument, in the absence of specific allegations that the Veteran is seeking an increased rating for his left arm disability. See Daye v. Nicholson, 20 Vet. App. 512, 517 (2006) (observing that “boilerplate” language is ineffective unless used with precision); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The record, to include VA and private medical treatment records associated with the claims file, is devoid of any indication that the Veteran was seeking increased compensation for his left arm disability. Notably, during the June 2015 VA elbow and forearm examination, the Veteran denied having problems with these shrapnel residuals, reported not having any elbow problems, and indicated that he did not want to pursue a claim pertaining to his left arm disability. In fact, he reported that his left arm disability had improved. Ultimately, the examiner concluded that the Veteran’s left arm disability was asymptomatic. Based on the foregoing, there is no controversy to resolve and the increase rating claim for a left arm disability must be dismissed. In turn, the Board refers the Veteran’s service connection claim for a right shoulder disorder to the Agency of Original Jurisdiction (AOJ), as the AOJ has not adjudicated this claim. 38 C.F.R. § 19.9(b). Increased Rating Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. If two disability evaluations are potentially applicable, 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. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Contrary to the repeated contentions that the QTC examinations were inadequate, the Board finds that all of the VA examination reports and medical opinions that the Board relied upon in the decisions below were sufficient to adjudicate these claims. The Board cannot identify a specific contention by the Veteran regarding these examination’s contended inadequacy that is reflected in the corresponding examination reports. As discussed below, however, the Board has considered the Veteran’s lay statements when granting the increased benefits reflected in this decision. 2. Spine The Veteran contends that his spine disability is more severe than currently rated. The Veteran’s spine disability is rated as 40 percent disabling under Diagnostic Code 5242. Under this Diagnostic Code, a 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine, forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 through 5243. For VA purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. See General Rating Formula for Diseases and Injuries of the Spine, Note 5. The Board finds that the Veteran’s spine disability does not warrant a rating in excess of 40 percent at any time during the appeal because the evidence does not support a finding of ankylosis. The July 2015 VA spine examination found forward flexion to 20 degrees, and the June 2016 VA spine examination found forward flexion to 40 degrees. Both examinations found no further limitation of motion on repetitive use testing, and there were no findings of either favorable or unfavorable ankylosis. Consequently, these examinations demonstrate that while the Veteran has limited range of motion, he nonetheless has some degree of range of motion in his spine. Additionally, these examinations demonstrated evidence of pain on movement, excess fatigability, disturbance of locomotion, and interference with sitting, standing and weight-bearing. However, there was no evidence of any additional functional loss with repetitive motion testing and thus there is no suggestion of any functional impairment equivocal to unfavorable ankylosis. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). Similarly, private medical records are not suggestive of ankylosis. The Board has considered the holding of Sharp v. Shulkin, and observes that a higher rating is not warranted due to the Veteran’s reported flare-ups. 29 Vet. App. 26 (2017). During the July 2015 examination, the Veteran described flare-ups as being unable to lift or walk long distances and during the June 2016 examination he described flare-ups as “pain.” The July 2015 examiner estimated that additional functional loss during a flare-up would be 5 degrees. The rating criteria are clear that no higher rating can be assigned in the absence of ankylosis. Here, the estimated functional loss during a flare-up did not amount to ankylosis, rather the Veteran would maintain some movement of his spine however small. The Board has considered the lay statements in the record regarding the Veteran’s spine disability, however, they do not warrant a higher rating. The Veteran is competent to report his observations, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Such statements are consistent with the rating assigned. The Veteran is already in receipt of a compensable rating for limitation of motion, his complaints of pain on motion are fully contemplated by the current rating assigned. See 38 C.F.R. § 4.59. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion that have been clinically observed and measured in the evidence of record. Pertinently, pain alone is not sufficient to warrant a higher rating; as pain, in itself, does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 40-41 (2011). 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. Id. at 43; see 38 C.F.R. § 4.40. The Board considered the DeLuca factors, however, both examinations found no further limitation of motion on repetitive use testing and thus there is no suggestion that pain is akin to ankylosis. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). Finally, the Board acknowledges the contentions in the July 2018 informal hearing presentation that the last VA examination was over 25 months old. However, the mere passage of time, alone does not obligate VA to have the Veteran reexamined simply as a matter of course. The Board finds that a new examination is not warranted absent evidence suggestive of ankylosis due to the governing rating criteria. There is no objective evidence indicating that there has been a material change in the severity of the Veteran’s spine disability to amount to ankylosis. Under these facts, additional development by way of another examination would be redundant and, more importantly, would not bestow a basis for an increased rating for the Veteran’s spine disability. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). In sum, the preponderance of evidence is against a rating in excess of 40 percent for the Veteran’s spine disability. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Right lower extremity radiculopathy The Veteran contends that his lower right extremity nerve pain is more severe than currently rated. The Veteran’s right lower extremity nerve pain is rated as 20 percent disabling under Diagnostic Code 8520. Diagnostic Code 8520 provides that incomplete paralysis of the sciatic nerve that is moderate is assigned a 20 percent rating, moderately severe is assigned a 40 percent rating, and severe with marked muscular atrophy is assigned a 60 percent rating. An 80 percent rating is assigned for complete paralysis of the sciatic nerve, demonstrated by foot drop, no active movement possible of the muscles below the knee, and knee flexion that is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Disability ratings with respect to neurological conditions ordinarily are assigned in proportion to the impairment of motor, sensory, or mental function. 38 C.F.R. § 4.12. Therefore, when rating peripheral nerve injuries attention is given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory. Id. Special consideration is given to complete or partial loss of use of one or more extremities and disturbances of gait. 38 C.F.R. § 4.124a. The term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; Note prefacing Diagnostic Codes 8510 through 8730. Terms such as “mild,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. The use of such terms by VA examiners or other physicians will be considered, but are not dispositive when assigning an evaluation. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board finds that a rating in excess of 20 percent is not warranted at any time during the appeal. VA examinations conducted on July 2015 and June 2016 reported that the neurological symptoms of the Veteran’s right lower extremity were moderate. Private and VA treatment records associated with the claims file do not support a finding that the Veteran’s right lower extremity radiculopathy was more than moderate. No examiner or private doctor has opined that there is moderately severe paralysis of the sciatic nerve or moderately severe neuritis, nor does the evidence suggest that level of impairment. Consequently, the Board finds that the most probative evidence are these VA examinations, because they are the only medical opinion evidence regarding the severity of the Veteran’s neurological disability. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board is cognizant that in January 2015 the Veteran reported to the emergency room because his whole right leg went numb and had difficulty with bearing weight. However, the evidence does not show a severity of paralysis or functional limitation, such as to enable a finding that the disability picture more nearly approximates the next higher rating under Diagnostic Code 8520. By a private March 2015 EMG study, lumbar radiculopathy was ruled out as the results for the right lower limb were normal. Pain was attributable to lumbar neuritis and the Veteran was prescribed neuroleptics with no indication of further complaints. The Board has considered whether any other Diagnostic Codes would allow for a higher rating. All of the other Diagnostic Codes relevant to the Veteran’s right lower extremity nerve pain (Diagnostic Codes 8521 through 8530) use the same criteria of mild, moderate, and severe incomplete paralysis, and none provide for higher than a 20 percent rating for moderate incomplete paralysis or for moderate neuritis; therefore, none of them would allow for a higher rating. To the extent that the Veteran argues his symptomatology is more severe than shown on VA examinations, his statements must be weighed against the other evidence of record. Here, the findings of a trained health care professional during the June 2016 and July 2015 examinations supported by objective testing are of greater probative weight than the Veteran’s lay assertions. The assignment of greater probative weight to these medical opinions are bolstered by the lack of complaints regarding continued nerve pain in the treatment records associated with the claims file. Finally, the Board acknowledges the contentions in the July 2018 informal hearing presentation that the last VA examination was over 25 months old. However, the mere passage of time, alone does not obligate VA to have the Veteran reexamined simply as a matter of course. In this case, there is no objective evidence indicating that there has been a material change in the severity of the Veteran’s right lower extremity nerve disability. Neither the Veteran nor his representative have presented or identified any contrary evidence that supports his claim. As a result, although the Board notes the passage of time since the Veteran’s last examination, the Board finds that additional development by way of another examination would be redundant and unnecessary. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). In sum, the preponderance of evidence is against a rating in excess of 20 percent for the Veteran’s right lower extremity nerve disability. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Right Hip Strain, limitation of extension 5. Right Hip Strain, limitation of flexion 6. Right Hip Strain, thigh impairment 7. Total right hip replacement The Veteran contends that his right hip disability is more severe than what his assigned ratings reflect. The rating of the hip joint is before the Board from the date of claim to present under all relevant diagnostic codes, and thus the Board has included consideration of the rating for the right hip post-total hip replacement. Prior to May 23, 2016 Range of motion of the hip and thigh is evaluated under Diagnostic Codes 5251, 5252, and 5253. 38 C.F.R. § 4.71a. Prior to May 23, 2016, the Veteran had a noncompensable rating for limitation of extension under Diagnostic Code 5251, a noncompensable rating for limitation of flexion under Diagnostic Code 5252, and a 10 percent rating for limitation of adduction under Diagnostic Code 5253. Under Diagnostic Code 5251, limitation of extension of the thigh to 5 degrees is assigned a 10 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252, limitation of flexion of the thigh to 45 degrees is assigned a 10 percent rating, to 30 degrees is assigned a 20 percent rating, to 20 degrees is assigned a 30 percent rating, and to 10 degrees is assigned a 40 percent rating. Id. Under Diagnostic Code 5253 (thigh impairment), limitation of rotation of the thigh to the point where the affected leg cannot toe-out more than 15 degrees is assigned a 10 percent rating. Limitation of adduction to the point where the legs cannot be crossed is assigned a 10 percent rating. Limitation of abduction of the thigh, where motion is lost beyond 10 degrees, is assigned a 20 percent rating. Id. As defined by VA regulation, normal flexion of the hip is from 0 to 125 degrees, and normal abduction of the hip is from 0 to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Separate ratings may be assigned under Diagnostic Codes 5251, 5252, and 5253. Cf. VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 990 (2004). However, separate ratings for abduction, adduction, or rotation may not be assigned, as these are all contemplated under Diagnostic Code 5253. Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010). At the July 2015 VA examination, initial range of motion testing was flexion 100 degrees, extension to 10 degrees, abduction to 25 degrees, adduction to 5 degrees, external rotation to 20 degrees, and internal rotation to 15 degrees. Repetitive use testing could not be performed. Pain was noted with all range of motion testing, but there was no pain with weight-bearing. Additionally, the right hip disability caused instability of station, disturbance of locomotion and interference with standing. No ankylosis was found. Muscle strength testing was abnormal, but there was active movement against some resistance. There was no evidence of muscle atrophy. The Veteran reported symptoms of stiffness, aching, and daily pain. He described flare-ups as stiffness limiting mobility. He also reported functional loss as being unable to walk long distances, along with trouble bending, standing, and flexion being worse with sitting. The Veteran also constantly used a cane to ambulate. Private records from February 2015 indicated that range of motion of the right hip was 5 to about 130 degrees. Private treatment records from May 2016 indicated the Veteran’s right hip pain had worsened with weight-bearing. While there was preservation of motion of the right hip, the Veteran had “exquisite” pain with terminal internal and external rotation but no numerical values were provided for these ranges of motion. Also, his pelvis was level with a mildly positive Trendelendburger sign. Based on a careful review of the subjective and clinical evidence, the Board finds that resolving all reasonable doubt in favor of the Veteran, prior to May 23, 2016, the Veteran’s service-connected right hip disability warrants a 10 percent rating for limitation of extension, a noncompensable rating for limitation of flexion, and a 20 percent rating or impairment of the right thigh. In light of the Veteran’s inability to perform repetitive use testing during the VA examination, the Board has determined that those findings have diminished probative value and that the Veteran’s subjective reports at the examination are credible based on the other evidence of record; and thus, represent persuasive evidence in evaluating his right hip disability. In that regard, the Board has liberally considered the evidence prior to the Veteran’s total hip replacement based on the medical history. See 38 C.F.R. §§ 4.1 & 4.2. For extension, private orthopedic records reported extension to 5 degrees and therefore the maximum schedular rating of 10 percent is warranted under Diagnostic Code 5251. For flexion, the Board finds the Veteran’s right hip disability was most likely manifested by limitation of flexion to 80 to 90 degrees. The Board has considered the Veteran’s reporting during the July 2015 VA examination that pain was worse with sitting (representing flexion to 90 degrees), in conjunction with his June 2016 VA examination (following his total right hip replacement) finding flexion to 80 degrees. Eighty degrees of flexion is the most favorable measurement in the record. Even under the most sympathetic review of the claim, there is no indication that flexion was limited to 45 degrees. Even when considering the Veteran’s reported flare-ups at the July 2015 VA examination, the record has never indicated a limitation of flexion to 45 degrees or less. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Moreover, the Board acknowledges the argument in the July 2018 informal hearing presentation that the Veteran’s inability to preform repetitive use testing due to pain should warrant an increased rating under the DeLuca factors. The Board has considered the DeLuca factors in arriving at a determination that the Veteran had limitation of flexion to be around 80 to 90 degrees; however, this does not represent the severity as contemplated by the rating criteria. Consequently, even when considering the most favorable evidence of limited flexion of the right hip, there is no basis to assign a compensable rating under Diagnostic Code 5252. As for impairment of the right thigh, the Veteran’s leveled pelvis with a positive Trendelendburger sign indicated a problem with abduction, in addition to extreme pain with rotation of the hip. In conjunction with the Veteran’s reports of flare-ups, the Board liberally construes these medical findings immediately prior to the Veteran’s total right hip replacement and finds that the Veteran’s thigh impairment nearly approximates the next higher rating. As a result, the maximum schedular rating of 20 percent is warranted under Diagnostic Code 5253. In sum, prior to May 23, 2016, the Board finds that the Veteran is entitled to the maximum schedular ratings under Diagnostic Codes 5251 and 5253, and a noncompensable rating under Diagnostic Code 5252. July 1, 2017 forward Following the Veteran’s total right hip replacement, the diagnostic code was changed to Diagnostic Code 5045 for hip replacement (prosthesis). Under Diagnostic Code 5054, a 100 percent rating is awarded for one year following implantation of the prosthesis. After one year following implantation of the prosthesis, a 30 percent minimum rating is provided; a 50 percent rating is warranted where there are moderately severe residuals of weakness, pain, or limitation of motion; a 70 percent rating is warranted where there are markedly severe residual weakness, pain or limitation of motion; and a 90 percent rating is warranted where there is painful motion or weakness such as to require the use of crutches. 38 C.F.R. § 4.71a, Diagnostic Code 5054. Terms such as “mild,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. Here the Veteran was in receipt of a 100 percent rating from May 23, 2016 to June 30, 2017. Neither the Veteran nor the evidence reflects that an extension of the 100 percent rating is warranted beyond June 30, 2017. From July 1, 2017 forward, the Veteran was assigned the minimum 30 percent rating under Diagnostic Code 5054. From July 1, 2017 forward, the Board finds that the Veteran is entitled to a 50 percent rating based on limitation of motion. During the July 2017 VA examination, initial range of motion testing found flexion to 95 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 20 degrees, and internal rotation to 15 degrees. Pain was noted with all range of motion testing. Functional loss was attributed to pain and stiffness. Repetitive use testing was completed, but yielded no additional functional loss. There was objective evidence of pain on passive range of motion testing of the right hip, as well with non-weight bearing. The Veteran required regular use of a cane. During the examination, the Veteran reported flare-ups with standing up and walking, and described them as “constant pain.” He expressed functional limitation with prolonged standing and walking. X-rays revealed no complications with the prosthesis. Based on the presence of abnormal flexion and rotation, along with the July 2017 VA examination finding that repetitive use testing resulted in pain, fatigue, and lack of endurance; the Board finds that the Veteran has residuals from his total right hip replacement that more nearly approximate the 50 percent rating criteria. However, the evidence does not support a rating in excess of 50 percent. When comparing the July 2017 range of motion testing to the July 2015 testing (prior to his hip replacement), the Veteran had improvements with extension, abduction, and adduction. Consequently, the evidence as a whole does not support that the Veteran’s limitation of motion was markedly severe, because overall he had increased range of motion following his hip replacement despite it being abnormal. Similarly, his use of a cane dropped from constant to regular thereby indicating improvement post-hip replacement. See 38 C.F.R. §§ 4.2, 4.6. Moreover, despite the use of a cane, the Board does not find that the 90 percent rating criteria apply. February 2018 VA treatment records reported that the Veteran was still able to ambulate with a steady gait and had good sit/stand mechanics. Consequently, even though the Veteran had pain with weight bearing during the July 2017 VA examination and required an assistive device, he still was able to bear weight on his right leg and did not require crutches to ambulate. The Board has considered the holding of Sharp v. Shulkin, and observes that a higher rating is not warranted due to the Veteran’s reported flare-ups. 29 Vet. App. 26 (2017). The Veteran described a flare-up as “constant pain” and further indicated functional limitations with prolonged standing and walking. The Veteran already has a compensable rating for limitation of motion, and the evidence does not support that his flare-ups occurred at such a frequency or consistency to more nearly equate to markedly severe limitation of motion as considered by the next higher rating criteria. 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. Mitchell v. Shinseki, 25 Vet. App. 32, 43; see 38 C.F.R. § 4.40. Here, the Board considered the DeLuca factors, and has awarded a 50 percent rating based on the July 2017 VA examination finding that repetitive use testing resulted in pain, fatigue, and lack of endurance. The Board also notes that repetitive use testing did not result in additional functional loss in terms of range of motion, and therefore a higher rating based on the Veteran’s descriptions of his symptoms during flare ups is not warranted. The Board has considered the Veteran’s lay statements regarding the functional impact of his right hip disability (post-hip replacement), including pain and decreased mobility. The Veteran is competent to report his own observations with regard to the severity of his disability, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). His statements are consistent with the rating assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the evidence of record. To the extent that the Veteran argues his symptomatology is more severe than shown on examination, his statements must be weighed against the other evidence of record. Here, the examination findings of a trained health care professional supported by objective orthopedic testing are of greater probative weight than the Veteran’s general lay assertions. Based on the foregoing, from July 1, 2017 forward, the Board finds that the Veteran is entitled to a 50 percent rating, but no higher, for residuals from a total right hip replacement under Diagnostic Code 5045. REASONS FOR REMAND A remand is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim and to afford the Veteran every possible consideration. 8. Right knee disability, to include a meniscal disability The Board cannot make a fully-informed decision on the issue of the severity of the Veteran’s right knee disability. The evidence indicates that on July 29, 2015 the Veteran underwent a right knee surgery by a private orthopedist for arthroscopic debridement and chondroplasty to address meniscal degeneration. VA has a “well-established” duty to maximize a claimant’s benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). Under this duty to maximize benefits, SMC is to be afforded when a veteran becomes eligible without need for a separate claim. See Bradley v. Buie, 22 Vet. App. 280, 294 (2008). Here, the compensable service-connected disabilities in effect as of July 29, 2015 would have a combined rating in excess of 60 percent. Thus, if the Veteran’s right knee were to obtain a temporary total disability rating for a period of convalescence, he could be entitled to SMC at the housebound rate. See 38 C.F.R. § 3.350(i). Accordingly, an opportunity should be extended for the Veteran to provide private treatment records, which may have probative value in furthering his claim and maximizing his benefits for his right knee. Notwithstanding this, the September 2017 VA examination is insufficient to adjudicate this claim due to the opinion regarding flare-ups. During the pendency of this appeal, the Court in Sharp v. Shulkin noted that for a joint examination to be adequate, the examiner “must express an opinion on whether pain could significantly limit” a veteran’s functional ability, and that determination “should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” The Court stated that the examiner must “obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment [resulting from flare-ups] from the veterans themselves.” Sharp, 29 Vet. App. at 34. The examiner must also “offer flare opinions based on estimates derived from information procured from relevant sources, including the lay statements of veterans,” and the examiner’s determination should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. Id. at 35. As this matter is being remanded, the RO should also consider any possible entitlement the Veteran might have to a separate rating for his right knee meniscal disability. See Lyles v. Shulkin, No. 16-0994, slip op. at 8-10 (Vet. App. Nov. 29, 2017). 9. Right knee, scars The issue of entitlement to a compensable rating for right knee surgical scars is inextricably intertwined with the entitlement to an increase rating for right knee disability. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Consideration of a compensable rating for right knee surgical scars will be deferred until the intertwined issue is either resolved or prepared for appellate consideration. See Harris, 1 Vet. App. at 183 (where a claim is inextricably intertwined with another claim, the claims should be adjudicated together). The matters are REMANDED for the following action: 1. Ask the Veteran to identify any private medical care providers who treated him for his right knee, and make reasonable efforts to secure the necessary releases and to associate any such identified records with the claims file. In particular, request that the Veteran identify private providers who performed the July 2015 right knee surgery and post-operative care. 2. Thereafter, schedule the Veteran for an examination of the current severity of his right knee disability. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the right knee alone and discuss the effect of the Veteran’s right knee disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Thereafter, readjudicate the claim and give consideration as to whether a temporary total disability rating for convalesce is warranted and whether a separate rating is warranted for a right knee meniscal disability, in conjunction to whether an increase is warranted under the other applicable knee diagnostic codes. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Dellarco, Associate Counsel