Citation Nr: 18155213 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-27 428 DATE: December 4, 2018 ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for degenerative joint disease (DJD) of the cervical spine is denied. Entitlement to service connection for right hand degenerative joint disease (DJD) is denied. Entitlement to service connection for left hand degenerative joint disease (DJD) is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for right toe impairment is denied. Entitlement to an effective date prior to September 22, 2014, for the grant of 10 percent for right wrist scaphoid fracture is denied. Entitlement to a rating in excess of 10 percent for right wrist scaphoid fracture is denied. Entitlement to an initial rating in excess of 10 percent for recurrent tinnitus is denied. Entitlement to an initial compensable rating for left ear hearing loss is denied. Entitlement to a rating in excess of 30 percent for depression is denied. Entitlement to a compensable rating for service-connected right inguinal herniorrhaphy is denied. Entitlement to a rating in excess of 20 percent for service-connected lumbosacral strain is denied. Entitlement to a rating in excess of 30 percent for residuals of fracture of the left femur with moderate knee and hip disability is denied. REMANDED Entitlement to service connection for right foot DJD, to include as secondary to service-connected residuals of left femur fracture is remanded. Entitlement to service connection for right leg shortening, to include as secondary to service-connected residuals of left femur fracture and or right inguinal herniorrhaphy is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea. 2. The preponderance of the evidence is against finding that the Veteran has cervicogenic headaches due to a disease or injury in service, to include specific in-service event, injury, or disease. 3. The Veteran’s hypertension did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 4. The Veteran’s cervical spine DJD did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 5. The Veteran’s right hand DJD did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 6. The Veteran’s left hand DJD did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 7. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of right ear hearing loss. 8. The preponderance of the evidence is against finding that the Veteran’s right toe impairment began during active service, or is otherwise related to an in-service injury, event, or disease. 9. It was first factually ascertainable in the record that the criteria for the assignment of a 10 percent rating for right wrist scaphoid fracture had been met as of July 27, 2015. 10. The Veteran’s right wrist disability is manifested by painful motion of the wrist, with dorsiflexion limited to 60 degrees, palmar flexion limited to 35 degrees, ulnar deviation limited to 35 degrees and radial deviation limited to 20 degrees. 11. The Veteran is receiving the highest schedular rating for recurrent bilateral tinnitus. 12. The Veteran’s left ear has a puretone threshold average of 33.75 and speech discrimination score of 94 percent. 13. The Veteran’s depression is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. 14. The Veteran’s right inguinal herniorrhaphy has not been recurrent, or required a truss or belt. 15. The Veteran’s lumbosacral strain is manifested by flexion to 60 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 20 degrees, with some objective evidence of pain, but there was no additional range of motion loss due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use or during a flare-up. 16. The Veteran’s residuals of left femur fracture manifested by malunion of the femur with marked knee or hip disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, (2017). 2. The criteria for entitlement to service connection for cervicogenic headaches have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 4. The criteria for entitlement to service connection for cervical spine DJD have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 5. The criteria for entitlement to service connection for right hand DJD have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 6. The criteria for entitlement to service connection for left hand DJD have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 7. The criteria for entitlement to service connection for right hear hearing loss have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 8. The criteria for entitlement to service connection for right toe impairment have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 9. The criteria for an effective date prior to September 22, 2014, for the assignment of a 10 percent rating for right wrist scaphoid fracture, have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.400 (2017). 10. The criteria for an evaluation in excess of 10 percent for service-connected right wrist scaphoid fracture have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5214-5215 (2017). 11. The criteria for an evaluation in excess of 10 percent for service-connected recurrent bilateral tinnitus have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.87, Diagnostic Code (DC) 6260 (2017). 12. The criteria for an initial compensable evaluation for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100 (2017). 13. The criteria for an evaluation in excess of 30 percent for depression have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9434 (2017). 14. The criteria for a compensable evaluation for right inguinal herniorrhaphy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code (DC) 7338 (2017). 15. The criteria for an evaluation in excess of 20 percent for service-connected lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237 (2017). 16. The criteria for an evaluation in excess of 30 percent for service-connected residuals of fracture of the left femur with moderate knee and hip have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5255 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Marine Corps from May 1982 to June 1985 and from October 1985 to June 1987. This case comes before the Board on appeal from a July 2011 and August 2015 rating decision. The Veteran filed his notice of disagreement (NOD) in July 2011 and December 2015, respectively. Likewise, the Veteran timely filed his substantive appeal in June 2015 and June 2017. In his June 2015 substantive appeal, the Veteran requested a hearing at his local VA office. Subsequently, the Veteran contacted the VA and withdrew his request. See 38 C.F.R. § 20.704(e). Therefore, the Board considers the request withdrawn. The Board notes that in the December 2015 NOD, the Veteran appealed the RO’s August 2015 denial of his bilateral hand disability. However, the RO did not address the Veteran’s left-hand disability in the SOC and SSOC in June 2017. Generally, a manlincon remand would be warranted, but the RO submitted a May 2018 SSOC denying the left-hand claim. As the Veteran would be prejudiced due to the delay of the SOC, which prevented him from submitting a substantive appeal in time for this decision, the Board has added the claim. Service Connection Claims Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that an injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if pre-existing such service, was aggravated therein. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted through the application of statutory presumptions for chronic conditions, such as arthritis, sensorineural hearing loss, and hypertension. See 38 C.F.R. §§ 3.303(b), 3.309(a) (2017); see also 38 U.S.C. § 1101 (2012). First, a claimant may benefit from a presumption of service connection where a chronic disease has been shown during service. 38 C.F.R. § 3.303(b). In the alternative, if a chronic disease was not shown in service, but manifested to a degree of 10 percent or more within some specified time after separation from active service, such disease shall be presumed to have been incurred or aggravated in service, even if there is no evidence of such disease during service. 38 U.S.C. § 1112, 1137 (2012); 38 C.F.R. § 3.307(a)(3) (2017). The application of these presumptions operates to satisfy the “in-service incurrence or aggravation” element and establish a nexus between service and a present disability, which must be found before entitlement to service connection can be granted. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012). 1. Entitlement to service connection for sleep apnea Here, the Veteran claims he has sleep apnea related to his military service. However, the evidence of record fails to show that the Veteran has a current diagnosis of sleep apnea. Specifically, in a July 2015 VA examination report, the VA examiner indicated that the Veteran does not have nor ever had sleep apnea. The examiner indicated that the Veteran had no history of a sleep disorder and there was no diagnosis of sleep apnea. The Board acknowledges that the Veteran’s service treatment records (STRs) from March 1982 and June 1985 indicate that the Veteran had a history of frequent trouble sleeping, but there is no indication that this was related to a respiratory problem. Importantly, without a current diagnosis, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 233, 225 (1992) (noting that service connection presupposes a current diagnosis of the claimed disability); see also Chelte v. Brown, 10 Vet. App. 268 (1997) (observing that a “current disability” means a disability shown by competent medical evidence to exist at the time of the award of service connection). Accordingly, the Board finds that the evidence of record is against a finding of service connection for sleep apnea. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 2. Entitlement to service connection for chronic headaches The Veteran contends that his headaches are related to service. At the outset, the Board notes that the Veteran has been diagnosed with cervicogenic headaches. See the July 2015 VA examination report. Likewise, the Veteran’s STRs show that he suffered head trauma and was diagnosed with post concussive syndrome, as well as headaches associated with sinusitis. Therefore, the Veteran meets the first and second elements of service connection. Thus, the remaining element is whether the Veteran’s headaches during service are related to his current disability. In that regard, at the July 2015 examination, the Veteran reported a history of headaches in service. During the examination, the Veteran stated that he developed headaches approximately two years prior, that start from the neck and radiate forward. He reported that he always has neck pain when they occur. The Veteran added his headaches would last for almost two days and occur one time per week. The headaches range from a 2 to a 9, and radiate to the frontal area bilaterally. The VA physician opined that the Veteran’s current headaches are less likely than not related to his tension headaches during service. The physician explained that the Veteran had tension headaches in July 1982, but his separation examination from June 1985 was negative for any headache condition/complaint or treatment. The Veteran’s report of medical history completed as part of the July 2015 examination was also negative. Likewise, VAMC treatment records dating back to 2004 were negative for any recurrent headache condition or diagnosis. Moreover, the physician provided medical literature that supports the diagnosis of cervicogenic headaches. The physician concluded that the Veteran’s current disability is secondary to his cervical spine disorder, which is age related and diagnosed decades after his military service. Thus, the preponderance of the evidence is against a finding that the Veteran’s headaches were incurred during service, or that the Veteran had continuity of symptomatology. In fact, the Veteran reported that his current headaches had its onset approximately two years prior to the July 2015 examination. Although the Veteran suffered from headaches during service, it was caused by head trauma and sinusitis. Even more, his exit examination was negative for recurrent headaches. Likewise, the VA physician indicated that the Veteran’s current headaches are a result of his DDD of the cervical spine. The Board finds the physician’s opinion to be competent, credible and highly probative. The physician’s opinion was supported by an adequate rationale and medical literature. Accordingly, the Board finds that the evidence of record is against a finding of service connection for chronic headaches. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 3. Entitlement to service connection for hypertension The Veteran contends that his claimed hypertension had its onset during military service. For VA compensation purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm. or greater, or systolic blood pressure is predominantly 160 or more. 38 C.F.R. § 4.104, DC 7101 n.1 (2017). A diagnosis of hypertension “must be confirmed by readings two or more times on at least three different days.” Id. The requirement of multiple blood pressure readings to be taken over multiple days as specified in Note (1) of DC 7101 applies to confirming the existence of hypertension. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). The Board notes that the Veteran has not been diagnosed with hypertension. During service the Veteran’s blood pressure was routinely within limits. For example, in November 1983, the Veteran’s blood pressure was 100/74, in February 1984, 110/60, in April 1984, 102/80, in June 1984, the Veteran’s blood pressure was 102/68. Likewise, his VAMC treatment records showed that the Veteran’s blood pressure was within limits. In October 2009, he had a reading of 109/74, a reading of 129/86 in January 2010. He had readings of 115/84, 127/86 in April 2010. Likewise, in September 2010 the Veteran’s blood pressure was 108/69. In addition, his readings were 126/81, 120/75, and 132/89 in March 2016, September 2015, and July 2015. Thus, the evidence of record fails to show that the Veteran had hypertension during service or upon his discharge from service. In addition, the Veteran’s post-service treatment records are negative for any reports or diagnoses of hypertension within one year of his discharge. Additionally, the Veteran has not alleged that he had hypertension within one year of discharge. Therefore, the Board finds that the Veteran cannot avail himself of the presumption concerning chronic diseases because hypertension was not shown within one year of active service. The Board also finds that direct service connection cannot be established because the evidence does not show that the Veteran has a current diagnosis of hypertension. Accordingly, the Board finds that the evidence of record is against a finding of service connection for hypertension. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 4. Entitlement to service connection for DJD of the cervical spine In this instance, the Veteran contends that his cervical spine disability was incurred during service. At the outset, the Veteran is currently diagnosed with DJD of the cervical spine. See the July 2015 VA examination report. In addition, the Veteran suffered head trauma during service that caused a cervical strain. Thus, he meets both the first and second elements of service connection. Therefore, the Board must determine whether there a nexus between his current disability and the injury suffered during service. In this regard, the physician noted that the Veteran’s cervical spine DJD was diagnosed in 2015, decades after the Veteran left service. The physician explained that the Veteran’s cervical spine DJD is age related as the diagnosis was made decades after service. Likewise, there was no evidence of aggravation. Even more, the records do not indicate continuity of symptomatology. The Board finds the physician’s opinion to be competent, credible and highly probative. The physician’s opinion was supported by an adequate rationale and medical literature. Thus, the evidence of record fails to show that the Veteran had cervical spine DJD during service or upon his discharge from service. In addition, the Veteran’s post-service treatment records are negative for any reports or diagnoses of cervical spine within one year of his discharge. Additionally, the Veteran has not alleged that he had cervical spine disability within one year of discharge as his exit examination was normal. Therefore, the Board finds that the Veteran cannot avail himself of the presumption concerning chronic diseases because arthritis was not shown within one year of discharge from active service. The Board also finds that direct service connection cannot be established because there is no nexus between his current disability and his in-service injury. Accordingly, the Board finds that the evidence of record is against a finding of service connection for cervical spine DJD. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 5. Entitlement to service connection for right hand DJD Here, the Veteran asserts that his right hand DJD was incurred during service. At the outset, the Board notes that the Veteran has a diagnosis of DJD of the bilateral hands. See July 2015 VA Examination. Likewise, the Veteran had fractures of his 2-5 digits of his right hand during service. See STRs. Therefore, the Veteran meets the first and second elements of service connection. Thus, the Board must determine whether the Veteran’s current disability is related to his in-service injury, which is generally proven by medical evidence. In that regard, in the July 2015 examination, the VA physician opined that the Veteran’s bilateral hand condition is not caused by or a result of his in-service injury or secondary to his military service. The physician reasoned that the Veteran’s fracture of the bilateral hands in the service were noted to be healed with no residuals at the time of his discharge in June 1985. See June 1985 STR entry. The Veteran completed bilateral hand x-rays during the examination which was 30 years post military separation that documented diffuse DJD. The physician indicated the DJD is age related since it is diffuse and has no relationship to any fracture in service. The physician relied on medical literature to support his opinion and rationale. The Board finds the physician’s opinion to be competent, credible and highly probative. The physician reviewed the pertinent lay and medical evidence and provided an opinion supported by an adequate rationale coupled with medical literature. Thus, the evidence of record fails to show that the Veteran had right hand DJD during service or immediately upon his discharge from service. In addition, the Veteran’s post-service treatment records are negative for any reports or diagnoses of a right hand DJD within one year of his discharge. Additionally, the Veteran has not alleged that he had a right hand DJD within one year of discharge as his exit examination was normal. Therefore, the Board finds that the Veteran cannot avail himself of the presumption concerning chronic diseases because arthritis was not shown within one year of discharge from active service. The Board also finds that direct service connection cannot be established because there is no nexus between his current disability and his in-service injury. Accordingly, the Board finds that the evidence of record is against a finding of service connection for right hand DJD. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 6. Entitlement to service connection for left hand DJD Here, the Veteran asserts that his left hand DJD was incurred during service. At the outset, the Board notes that the Veteran has a diagnosis of DJD of the bilateral hands. See July 2015 VA Examination. Likewise, the Veteran had injuries to multiple fingers on his left hand during service. See STRs. Therefore, the Veteran meets the first and second elements of service connection. Thus, the Board must determine whether the Veteran’s current disability is related to his in-service injury, which is generally proven by medical evidence. In that regard, in the July 2015 examination, the VA physician opined that the Veteran’s bilateral hand condition is not caused by or a result of his in-service injury or secondary to his military service. The physician reasoned that the Veteran’s fracture of the bilateral hands in the service were noted to be healed with no residuals at the time of his discharge in June 1985. See June 1985 STR entry. The Veteran completed bilateral hand x-rays during the examination which was 30 years post military separation that documented diffuse DJD. The physician indicated that the DJD was age related since it is diffuse and has no relationship to any fracture in service. The physician relied on medical literature to support his opinion and rationale. The Board finds the physician’s opinion to be competent, credible and highly probative. The physician reviewed the pertinent lay and medical evidence and provided an opinion supported by an adequate rationale coupled with medical literature. Thus, the evidence of record fails to show that the Veteran had left hand DJD during service or upon his discharge from service. In addition, the Veteran’s post-service treatment records are negative for any reports or diagnoses of a left hand DJD within one year of his discharge. Additionally, the Veteran has not alleged that he had left hand DJD within one year of discharge as his exit examination was normal. Therefore, the Board finds that the Veteran cannot avail himself of the presumption concerning chronic diseases because arthritis was not shown within one year of discharge from active service. The Board also finds that direct service connection cannot be established because there is no nexus between his current disability and his in-service injury. Accordingly, the Board finds that the evidence of record is against a finding of service connection for left hand DJD. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54 7. Entitlement to service connection for right ear hearing loss Here, the Veteran contends that he has right ear hearing loss that was incurred during service. To begin, impaired hearing will be considered a disability when, in pertinent part, the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater. 38 C.F.R. § 3.385. 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a relationship between the Veteran’s service and his current disability. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In this instance, the Veteran does not have hearing loss for VA purposes. At the May 2015 VA examination, audiometric testing yielded the following findings: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 35 30 25 The Veteran’s right ear average puretone threshold was 29. Additionally, the Veteran’s Maryland CNC speech recognition score was 94 percent. Based on the audiometric findings, the Veteran does not have right ear hearing loss for VA purposes. The Veteran does not have an auditory threshold in any of the frequencies at 40 decibels or greater; nor, do at least three frequencies have a decibel of 26 or greater with a speech recognition score less than 94 percent. Thus, the preponderance of the evidence is against a finding that the Veteran has right ear hearing loss for VA purposes. Accordingly, the Board finds that the evidence of record is against a finding of service connection for right ear hearing loss. As the preponderance of the evidence is against the Veteran’s claim, the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 8. Entitlement to service connection for a right toe impairment The Veteran contends that his right toe impairment was incurred during service. At the outset, the Board notes that the Veteran does have a current right toe impairment. See August 2014 Podiatry Consult. The Veteran explained that his right toes were shortened in the 80’s due to infection. The podiatrist noted that the 4th and 5th toes on the right foot were short compared to the other toes with cicatrices. He added that there were no signs of acute trauma. However, the Veteran’s STRs are silent for any complaint of, treatment, or diagnosis of a right toe impairment. Although the Veteran reported that his toes were shaved down due to an infection, there is no record reflecting this operation during service or immediately following service. The Veteran’s private treatment record following service failed to show a right foot procedure. Thus, the preponderance of the evidence is against a finding that the Veteran’s current right toe impairment was incurred during service. Accordingly, the claim must be denied and the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 9. Entitlement to an effective date prior to September 22, 2014, for the grant of 10 percent for right wrist scaphoid fracture The Veteran seeks an effective date earlier than September 22, 2014, for a 10 percent rating for his service-connected right wrist scaphoid fracture. See June 2017 VA Form 9. The effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, but only if the claim for an increase is received within one year from such date. See 38 U.S.C. § 5110(b)(3); see also 38 C.F.R. § 3.400 (o)(2). Where the increase in disability occurs more than one year prior to the date of claim, the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); see also 38 C.F.R. § 3.400(o)(1); Gaston v. Shinseki, 605 F.3d 979, 980 (Fed. Cir. 2010); Swain v. McDonald, 27 Vet. App. 219, 224 (2015). In this case, the Board finds that it is first factually ascertainable in the record that the criteria for the assignment of a 10 percent rating for right wrist scaphoid fracture as of July 27, 2015, which is the date of the VA wrist examination. See July 2015 VA Examination. Under DC 5215, a 10 percent rating is warranted for dorsiflexion less than 15 degrees, or palmar flexion limited in line with forearm. Where a veteran has a noncompensable rating for a musculoskeletal disability and complains of pain on motion, he or she is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Id. Additionally, the Court has held that the plain language of § 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Here, the evidence shows that during the July 2015 examination, the Veteran indicated increased pain and decreased range of motion. He reported daily pain in his right wrist, most significantly when using a cane. During the examination, objective evidence of pain was shown and the Veteran’s ROM was limited. Even more, the record is devoid of any indication that the Veteran’s right wrist disability warranted a 10 percent rating within a year prior to September 22, 2014. In fact, in VA outpatient treatment records dated from 2013 to 2014, there was no medical evidence that the Veteran’s wrist disability worsened, until his informal increase claim. Thus, the Board finds that it is factually ascertainable that an increase in the Veteran’s right wrist scaphoid had occurred on July 27, 2015. Accordingly, the claim must be denied and the benefit of doubt doctrine is not applicable. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Rating Claims Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). As in the instant case, separate ratings for distinct periods of time, based on the facts may be for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 portrays the anatomical damage and the functional loss with respect to these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2017). Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45 (2017). Painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 43 (2011). 10. Entitlement to a rating in excess of 10 percent for service-connected right wrist scaphoid fracture The Veteran contends that his service-connected right wrist disability warrants a rating higher than 10 percent evaluation assigned. Under DC 5215, a 10 percent rating is warranted for dorsiflexion less than 15 degrees, or palmar flexion limited in line with forearm. This is the highest schedular rating under DC 5215. To warrant a higher rating for a wrist disability, under DC 5214, a 30 percent rating is warranted for favorable ankylosis of the wrist in 20 to 30 degrees dorsiflexion. A 40 percent rating is warranted for any other position, except favorable ankylosis. To warrant a 50 percent rating, there must be unfavorable ankylosis of the wrist in any degree of palmar flexion, or with ulnar or radial deviation. In this instance, the evidence of record shows that the Veteran’s service-connected right wrist disability most closely approximates to the 10 percent disability rating. Specifically, in the July 2015 examination, the Veteran complained of daily pain in his wrist especially when using a cane. The examination revealed painful motion of the wrist, with dorsiflexion limited to 60 degrees, palmar flexion limited to 35 degrees, ulnar deviation limited to 35 degrees and radial deviation limited to 20 degrees. Likewise, there was pain during the examination that caused functional loss with evidence of pain with weight bearing and localized tenderness or pain. There was no evidence of crepitus. The Veteran could perform repetitive use testing without additional loss of function or range of motion. He did not present with ankylosis and had no reduction in muscle strength or muscle atrophy. The examiner could not express any weakness, fatigability, or incoordination without resulting to mere speculation. Therefore, based on the evidence the Veteran’s service-connected right wrist disability most closely approximates to a 10 percent rating due to painful motion. See 38 C.F.R. § 4.59. Likewise, the Veteran is not entitled to a higher rating as there was no evidence of right wrist ankylosis, favorable or unfavorable. Accordingly, as the preponderance of the evidence is against a rating in excess of 10 percent for service-connected right wrist disability, the Veteran’s claim is denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 11. Entitlement to a rating in excess of 10 percent for recurrent bilateral tinnitus The Veteran is seeking an increased rating for bilateral tinnitus. DC 6260 provides a maximum rating of 10 percent for recurrent tinnitus. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit found that 38 C.F.R. § 4.25 (b) and 38 C.F.R. § 4.87, Diagnostic Code 6260, limits a veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. The Veteran’s service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus of 10 percent. 38 C.F.R. §4.87, DC 6260. As there is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear, the Veteran’s appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). 12. Entitlement to an initial compensable rating for left ear hearing loss The Veteran is seeking a compensable rating for left ear hearing loss. The Board finds that the Veteran’s left ear hearing loss does not warrant a compensable rating. Specifically, in the May 2016 VA examination, the Veteran’s left ear audiometric results yielded the following results: HERTZ 500 1000 2000 3000 4000 LEFT 25 25 40 30 40 The Veteran’s pure-tone threshold average was 33.75 with a speech discrimination score of 94 percent. Under Table VI, the Veteran’s left ear hearing loss most closely approximates to a noncompensable rating. Therefore, based on the preponderance of the evidence the Veteran’s left ear hearing loss does not warrant a compensable rating. Accordingly, the Veteran’s claim must be denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 13. Entitlement to a rating in excess of 30 percent for service-connected major depressive disorder (MDD) The Veteran contends that his service-connected MDD warrants a rating in excess of 30 percent pursuant to 38 C.F.R. § 4.130, DC 9434. Under DC 9434, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). See 38 C.F.R. § 4.130. Here, the Veteran’s MDD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In an April 2015 psychologist note, the Veteran’s mental status examination revealed that he denied any suicidal or homicidal ideation, plan or intent during the interview. He was euthymic, extremely enthusiastic mood with full range of affect, he made and maintained eye contact; alert and oriented to person, place, time and situation; speech was coherent and clear with normal rate, volume and tone. His thoughts were relevant, logical and organized, he denied auditory, visual and tactile hallucinations and was not observed to be responding to internal stimuli or to have delusional constructs. The Veteran’s intellectual performance, attention and concentration were sufficient. No psychomotor issues, he was dressed casually with near appearance. In addition, in the August 2015 VA examination, the Veteran’s depression was noted to be under control with medication. Veteran reported long standing anger issues. He reported that he tries to suppress anger related to abuse in childhood. Emotional dyscontrol is aggravated by alcohol abuse. The examination revealed that the Veteran’s depression manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. He was diagnosed by depressive disorder not otherwise specified, PTSD, and alcohol use disorder. During the examination, the Veteran endorsed continued symptoms of depression, including feeling down, insomnia, anhedonia, feelings of guilt, and low energy. Veteran reported drinking 2-3 30-ounce cans of alcohol almost daily. Veteran denied any recent symptoms of mania/hypomania or psychosis, including AVH, increased goal directed activity and grandiosity. Veteran also denied any suicidal or homicidal ideations, intent, or plan. Likewise, he displayed symptoms of anxiety, chronic sleep impairment, difficulty in adapting to stressful circumstances, including work or a worklike setting. On his mental status examination, the Veteran was well-groomed, calm and cooperative, with no psychomotor issues. His speech was coherent and of normal rate, volume, and tone. He had good eye contact with okay mood. His affect was euthymic with full range. His thought process was linear, coherent and goal directed. No circumstantiality; no tangentiality; no thought broadcasting/insertion noted; no flight of ideas or looseness of associations. His thought content was appropriate, no suicidal/homicidal ideation and did not appear to be responding to internal stimuli. No apparent delusions or paranoia. The Veteran was alert and oriented in all three phases, with good concentration. His memory immediate, recent, and remote memory were good, with good insight and judgment. The Veteran endorsed similar symptoms during his September 2015 psychiatry treatment note. He was well-groomed, calm and cooperative with coherent speech with normal, volume, and rate. His affect was euthymic with full range, his thought process was linear, coherent, goal directed. No circumstantiality, not tangential, no thought broadcasting/insertion noted, no flight of ideas or looseness of associations. He denied suicidal/homicidal ideation and did not appear to respond to internal stimuli. No apparent delusions or paranoia. He was alert and oriented in all three phases with memory intact and good insight and judgment. In treatment notes from February 2016 to June 2017, the Veteran’s mental status examination revealed that his appearance was casually, neatly dressed and well groomed. His speech was normal in rate, tone and volume and he appeared to be bright and articulate. He did not exhibit any psychomotor agitation or psychomotor retardation. The Veteran was always alert and oriented in all three phases. His mood was often okay, with congruent affect. His thought process was always logical and goal-oriented. He did endorse restlessness, nervousness, and easily startled. Often, the Veteran’s though content was appropriate with no auditory/visual hallucinations, no current suicidal/homicidal ideations and no delusions. Generally, his insight/judgment was intact. Likewise, during the examinations, his immediate, recent, and remote memory was good. Based on the preponderance of the evidence, the Veteran’s MDD manifested by occupational and social occupational with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. His symptoms were often depressed, anxious, suspiciousness, with chronic sleep impairment. The Veteran’s MDD did not warrant a higher rating as he did not exhibit symptoms of stereotyped speech, panic attacks, difficulty in understanding complex commands, or impairment of short and long-term memory. Thus, the preponderance of the evidence shows that the Veteran’s MDD most closely approximated to 30 percent disabling. Accordingly, the Veteran’s claim must be denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 14. Entitlement to a compensable rating for right inguinal herniorrhaphy The Veteran’s right inguinal herniorrhaphy is rated as noncompensable under DC 7338. Under DC 7338 for hernia, inguinal: large, postoperative, recurrent, not well supported under ordinary conditions and not readily reducible, when considered inoperable has 60 percent rating; small, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible has 30 percent rating; postoperative recurrent, readily reducible and well supported by truss or belt has 10 percent rating; not operated, but remediable, and small, reducible, or without true hernia protrusion have noncompensable ratings. The guidelines specify to add 10 percent for bilateral involvement, provided the second hernia is compensable. This means that the more severely disabling hernia is to be evaluated, and 10 percent, only, added for the second hernia, if the latter is of compensable degree. 38 C.F.R. § 4.114. The Veteran appeared for a VA examination in July 2015. The Veteran reported daily pain over the surgical site that is present with activity. The last surgery performed on his right hernia was in 1984. The examination revealed no detectable hernia. There was no indication for a supporting belt. The Veteran has a scar related to his condition but the scar was not painful and/or unstable nor was the total area of the related scar greater than 6 square inches. There were no additional findings or results. Therefore, the preponderance of the evidence shows that the Veteran right inguinal hernia did not warrant a compensable rating during the period on appeal. A higher rating is not warranted as the Veteran did not have a recurrent hernia and there was no indication for a supporting belt. In addition, the Veteran’s scar was not painful or unstable. The Veteran reported pain over his surgical site but did not indicate that the scar was painful. In fact, in the Veteran’s informal increase rating claim, the Veteran indicated he had a scar but did not report it to be painful. Accordingly, the Veteran’s claim must be denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 15. Entitlement to an evaluation in excess of 20 percent for service-connected lumbosacral strain The Veteran contends that his service-connected lumbosacral strain warrants an evaluation in excess of 20 percent disabling. Under DC 5237, a 40 percent disability is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability is warranted for unfavorable ankylosis of the entire spine. Note (1) to the General Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. If the service connected spine disability includes intervertebral disc syndrome (IVDS) it may alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Here, IVDS is not shown or alleged at any time. 38 C.F.R. § 4.71a. In a treatment note of June 2015 noted that prior to physical therapy treatment the Veteran’s spine had active extension to flexion of 56 degrees, 7 degrees, right lateral flexion to 2 degrees, and left lateral flexion to 10 degrees. In the September 2015 VA examination, the examination revealed range of motion of the lumbar spine with flexion limited to 60 degrees, extension limited to 20 degrees, right lateral flexion limited to 20 degrees, left lateral flexion limited to 20 degrees, right lateral rotation limited to 20 degrees, and left lateral rotation limited to 20 degrees. The examiner noted objective evidence of pain on rest. Likewise, the examiner noted there was no additional range of motion loss due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use, repetitive use over time, or during flare up. In addition, there was no ankylosis of the spine, nor were there any other neurologic abnormalities or radiculopathy found. Sensory and reflex examination were normal. In a December 2015 treatment note, the Veteran had lumbar spine range of motion pain, tenderness to palpation and pain bilaterally on facet loading. In subsequent treatment notes, in June and October 2016, and May-June 2017, the Veteran had lumbar spine range of motion pain, tenderness to palpation and pain bilaterally on facet loading. In October, it was indicated that his back was non-tender, with left sciatica. In May 2017, the lumbar spine showed good reversal of lumbar lordosis on forward flexion, good side-to-side motion, rotation and extension. Motor and sensory were normal. Deep tendon reflexes are normal and symmetric. In June, there was pain on palpation in paravertebral muscles thoracolumbar spine. Therefore, the preponderance of the evidence shows that the Veteran’s thoracolumbar spine most closely approximated to 20 percent disabling. It was shown that the Veteran had objective evidence of pain, and flexion limited to 60 degrees, extension limited to 20 degrees, right lateral flexion limited to 20 degrees, left lateral flexion limited to 20 degrees, right lateral rotation limited to 20 degrees, and left lateral rotation limited to 20 degrees. A higher evaluation is not warranted because the Veteran did not have any other objective findings or neurological abnormalities. Likewise, the Veteran’s thoracolumbar spine did not manifest with forward flexion to 30 degrees or less, or was there any evidence of ankylosis, either favorable or unfavorable. Likewise, there was no indication of IVDS. Accordingly, the Veteran’s claim must be denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 16. Entitlement to a rating in excess of 30 percent for residuals of fracture of the left femur with moderate knee and hip disability The Veteran contends that his service-connected residuals of left femur fracture warrants a rating in excess of 30 percent. Under DC 5255, a 10 percent rating is assigned for malunion of the femur with slight knee or hip disability. A 20 percent rating requires moderate knee or hip disability. A 30 percent rating requires marked knee or hip disability. A 60 percent rating requires either a fracture of the surgical neck of the femur with false joint or a fracture of the shaft or anatomical neck of the femur with nonunion, but without loose motion, and with weightbearing preserved with the aid of a brace. An 80 percent rating requires a fracture of the shaft or anatomical neck of the femur with nonunion, with loose motion (spiral or oblique fracture). See 38 C.F.R. § 4.71a, DC 5255. Under DC 5251, a maximum 10 percent disability evaluation is warranted for limitation of extension of the thigh to 5 degrees. 38 C.F.R. § 4.71a, DC 5251. Under DC 5252, a 10 percent disability evaluation is assigned for flexion of the thigh limited to 45 degrees. A 20 percent rating is warranted when there is limitation of flexion to 30 degrees. A 30 percent rating is contemplated for limitation of thigh flexion to 20 degrees, and a 40 percent rating is warranted for limitation of thigh flexion to 10 degrees. 38 C.F.R. § 4.71a, DC 5252. Under DC 5253, a 10 percent disability evaluation is assigned for limitation of thigh rotation, with an inability to toe-out in excess of 15 degrees or where there is limitation of adduction such that one cannot cross legs. A 20 percent disability evaluation is warranted for limitation of thigh abduction, where motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. Normal range of motion for the hip is flexion from zero degrees to 125 degrees, and abduction from zero degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. In treatment records since the Veteran’s notice of disagreement in July 2011, the Veteran has consistently complained of left hip pain. The Veteran often took steroid injections to alleviate his pain. He was diagnosed with left hip trochanteric bursitis. See VA Outpatient Treatment Records. In a July 2015 VA examination, the Veteran reported constant pain in left hip that ranges from a 4-9/10. It went to severe daily. He is forced to sit on pillows while sitting due to pain. His pain is often severe every morning and by 5pm. The examiner reported that the Veteran continues to have tenderness over the left greater trochanter but there were no other treatments left. At that time, the Veteran was receiving physical therapy for the condition that helped. The Veteran did not report flare-ups of this condition. He reported functional loss, as he was unable to run, he could only walk two blocks with a cane. He could not lift, no stairs, and difficulty getting out of the car. On examination, his ROM showed flexion limited to 90 degrees, extension limited to 10 degrees, adduction limited to 0 degrees, abduction limited to 0 degrees, external rotation limited to 0 degrees, and internal rotation limited to 35 degrees. The report showed there was no objective evidence of painful motion and tenderness. The examiner noted there was no additional range of motion loss due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use. The examiner added that it would be mere speculation to try to provide ROM findings after repetitive use over time since the Veteran was not being examiner immediately after repetitive use over time. The Veteran had additional symptoms that included extension of the thigh limited beyond 5 degrees, painful motion of the hip, limitation of abduction of the thigh for motion lost beyond 10 degrees, and flexion of the thigh limited beyond 45 degrees. Likewise, post the July 2015 examination, the Veteran had ongoing treatment for his left hip and leg issues, but the treatment notes are not sufficient to warrant an increased evaluation. Therefore, the preponderance of the evidence shows that the Veteran’s residuals of his left femur fracture most closely approximates to a 30 percent evaluation. A higher rating is not warranted as the Veteran did not have flexion of the thigh limited 10 degrees. Likewise, a higher evaluation is not warranted for impairment of the femur, as the evidence did not show a fracture of the surgical neck false joint; or, fracture of the shaft or anatomical neck with nonunion, without loose motion, weightbearing preserved with aid of brace. Moreover, other residuals of the Veteran’s left femur fracture are separately rated. Accordingly, the Veteran’s claim must be denied and the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for right foot DJD, to include as secondary to service-connected residuals of left femur fracture is remanded Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). Specifically, in an August 2014 treatment note, the Veteran was diagnosed with mild DJD of his right foot. The Veteran informed the VAMC examiner that his toes and right foot bother him because he has been favoring his right foot due to multiple left hip problems and surgeries. The Veteran’s contention can be considered a secondary service connection claim. Even more, the Veteran was never afforded a VA examination to determine the etiology of his right foot condition as it may be related to his service-connected left femur disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus, a remand is necessary to obtain a VA examination and opinion to determine the onset or cause of the Veteran’s right foot DJD. 2. Entitlement to service connection for right leg shortening, to include as secondary to left femur fracture and/or right inguinal herniorrhaphy is remanded Here, in the July 2015 VA examination, it was shown that the Veteran’s right leg is ½ inch shorter, indicating leg length discrepancy as part of his hip disability. However, the examiner did not describe the relationship between the Veteran’s leg length discrepancy and the Veteran’s hip disability. Therefore, as the Veteran’s right leg shortening may be related to his hip disability, a remand is necessary to obtain a nexus opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the record all relevant VA treatment and any private treatment records identified by the Veteran. All records/responses received must be associated with the claims file. 2. After the foregoing has been completed, schedule the Veteran for a VA examination which addresses the nature and etiology of his right foot DJD. The claims file must be provided to the examiner for review. All indicated tests and studies should be performed. The claims file, including a copy of this remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. 3. Additionally, if necessary to provide the below requested opinion, schedule the Veteran for a VA examination to address the etiology of his right leg length discrepancy. The examiner is asked to provide an opinion on the following: a) Is it at least as likely as not (50 percent or more probability) that the Veteran’s right foot DJD its onset in or is etiologically-related to the Veteran’s active duty service, or manifested to a compensable degree within a year of discharge from service? b) Is it at least as likely as not (50 percent probability or more) that the Veteran’s right foot DJD was proximately caused by or aggravated by the Veteran’s left femur disability? c) Is it at least as likely as not (50 percent probability or more) that the Veteran’s right leg length discrepancy was proximately caused by or aggravated by the Veteran’s left hip disability or right inguinal herniorrhaphy. The report of examination should include the complete rationale for all opinions expressed. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. Note: The term “aggravated” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Note: The requested opinions on aggravation should be premised on the baseline level of severity of the disorder before the onset of aggravation, or by the earliest medical evidence created at any time between the onset of aggravation and the examiner’s current findings. If an opinion cannot be rendered without resorting to speculation, the physician should explain why it would be speculative to respond. (Continued on the next page)   4. After completing the above actions, and any other development as may be indicated by any response received because of the action taken in the paragraph above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative and after the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Umo, Associate Counsel