Citation Nr: 18157659 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 10-36 526 DATE: December 13, 2018 ORDER Entitlement to a rating in excess of 30 percent for service-connected residuals of fracture of the right humerus (right humerus disability) is denied. Entitlement to an initial compensable rating for service-connected scar of the left wrist (left wrist scar) is denied. Entitlement to an initial rating in excess of 10 percent for service-connected scar of the lateral left thigh (left thigh scar) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to February 2, 2010, due to service-connected disabilities is denied. REMANDED Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a left thumb disorder is remanded. Entitlement to service connection for restless legs syndrome is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected degenerative changes of the right wrist (right wrist disability) is remanded. Entitlement to an initial compensable rating for service-connected post-traumatic deformity of the right fifth metacarpal is remanded. Entitlement to a rating in excess of 20 percent for service-connected residuals of fracture of left femur with degenerative joint disease, status post-open reduction internal fixation with intramedullary rod (left femur disability) is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected degenerative changes of the right elbow (right elbow disability) is remanded. Entitlement to an initial rating in excess of 10 percent prior to July 24, 2013, for service-connected degenerative joint disease, left knee (left knee disability) is remanded. Entitlement to an initial rating in excess of 10 percent prior to July 24, 2013 for lateral instability of the service-connected left knee disability is remanded. Entitlement to a rating in excess of 30 percent from September 1, 2014, to the present for service-connected total left knee replacement (left knee disability) is remanded. Entitlement to an initial compensable rating for service-connected scars left knee is remanded. FINDINGS OF FACT 1. The Veteran’s service-connected right humerus disability has not been manifested by ankylosis, loss of head, nonunion, or fibrous union; and it has not resulted in motion limited to 25 degrees from the Veteran’s side. 2. The Veteran’s service-connected left wrist scar is less than 39 square centimeters in area, is stable and not painful, and does not result in any limitation of function. 3. The Veteran’s service-connected left thigh scar is manifested as one linear painful scar that does not result in any limitation of function. 4. The evidence of record fails to demonstrate that the Veteran’s service-connected disabilities rendered him unable to secure or follow gainful employment prior to February 2, 2011. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for service-connected right humerus disability are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5202 (2018). 2. The criteria for an initial compensable rating for left wrist scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804, 7805 (2018). 3. The criteria for an initial rating in excess of 10 percent for service-connected left thigh scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. (2018) 4. The criteria for a TDIU prior to February 2, 2011, are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1961 to December 1965. I. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran’s service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Musculoskeletal Disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.40. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2014); DeLuca v. Brown, 8 Vet. App. 202 (1995). 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. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id. (quoting 38 C.F.R. § 4.40). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 1. Entitlement to a rating in excess of 30 percent for service-connected right humerus disability The Veteran’s service-connected right humerus disability is rated as 30 percent disabling under Diagnostic Code 5202. Under Diagnostic Code 5202, a 50 percent rating is warranted for fibrous union of the humerus; a 60 percent rating is warranted for nonunion of the humerus (false flail joint); and an 80 percent rating is warranted for loss of head of the humerus (flail shoulder). See 38 C.F.R. § 4.71a. During a May 2009 VA examination, the Veteran reported ongoing problems with pain, as well as having dull pain and flare-up pain with cold, damp weather and with repetitive use. Examination of his right humerus showed no apparent deformity with palpation; however, tenderness with palpation was noted along the distal humeral shaft, as well as discomfort on deep palpation. At the time, his right shoulder demonstrated normal range of motion. X-rays revealed no evidence of acute fracture or dislocation. There was a marked posttraumatic deformity of the distal humeral shaft with rotation and angulation, and long with a tendon anchor identified within the humeral head. In his January 2010 notice of disagreement, the Veteran argued that his service-connected right humerus disability warranted a higher rating because he was unable to move his right arm to 25 degrees from his side. He also indicated that he needed to use hot packs and warm towels to manage and cope with his pain. He also indicated that his right humerus increased in severity, to the point that, at least 10 times per week, he was unable to use his right arm. During a December 2010 VA examination, the Veteran reported ongoing problems with pain in his right arm. Range of motion testing revealed the following: active and passive abduction from zero to 90 degrees; flexion from zero to 90 degrees, external rotation from zero to 80 degrees; internal rotation from zero to 45 degrees; and adduction from zero to 30 degrees. The Veteran reported anterolateral pain at all extremes, and the examiner noted the presence of pain against resistance. The examiner noted that there was no specific increase in symptoms as the result of repeated activities during the examination. In February 2013, the Veteran underwent another VA examination. The examiner noted his history of a fracture of the distal humerus. The examiner noted that the Veteran tore his right rotator cuff in approximately 2002 while pushing a shopping cart. He subsequently underwent a surgical repair. Right shoulder flexion and abduction was to 90 degrees, even after repetitive use, with objective evidence of pain at 90 degrees. In July 2015, the Veteran underwent another VA examination. The examiner noted his history of a fracture of the distal humerus. The examiner noted that he tore his right rotator cuff in approximately 2002 while pushing a shopping cart. Right shoulder flexion was to 120 degrees; abduction was to 180 degrees; external rotation was to 90 degrees; and internal rotation was to 90 degrees. There was evidence of painful motion on flexion, but there was no evidence of pain with weight bearing, crepitus, or localized tenderness or pain on palpation of the joint or the associated soft tissue. The Veteran was able to perform repetitive-use testing, and there was no further loss of function or range of motion. Furthermore, pain, weakness, fatigability, or incoordination did not significantly limit the Veteran’s functional ability following repetitive use. Muscle strength testing was normal, and there was no evidence of ankylosis. The examiner noted that there was no evidence of loss of head, nonunion, or fibrous union. In May 2017, the Veteran underwent another VA examination, and the examiner noted his history of a fracture of the distal humerus, as well as his history of rotator cuff repair which occurred many years after discharge. The examiner concluded that the Veteran limited range of motion of the right shoulder was more likely due to his rotator cuff problem, and not his service-connected right humerus disability. Right shoulder flexion was to 125 degrees; abduction was to 180 degrees; external rotation was to 90 degrees; and internal rotation was to 90 degrees. There was evidence of painful motion on flexion and with weight bearing, but there was no evidence of crepitus, or localized tenderness or pain on palpation of the joint or the associated soft tissue. The Veteran was unable to perform repetitive-use testing, and there was no further loss of function or range of motion. Muscle strength testing was normal, and there was no evidence of ankylosis. The examiner noted that there was no evidence of loss of head, nonunion, or fibrous union. After a careful review of all the evidence, the Board finds that at no time during the pendency of the appeal has the Veteran’s service-connected right humerus disability more nearly approximated the criteria for a higher rating under any applicable diagnostic codes. With regard to the Diagnostic Code 5202, the evidence of record fails to demonstrate that the Veteran’s service-connected right humerus disability was manifested by fibrous union of the humerus; nonunion of the humerus (false flail joint); or loss of head of the humerus (flail shoulder). To the contrary, both the July 2015 and May 2017 VA examiners specifically note that there was no evidence of loss of head, nonunion, or fibrous union. Thus, a higher rating is not warranted under Diagnostic Code 5202. Furthermore, with regard to Diagnostic Code 5200, there is no evidence of ankylosis of scapulohumeral articulation. Once again, to the contrary, both the July 2015 and May 2017 VA examiners specifically note that there was no evidence of ankylosis. Thus, a higher rating is not warranted under Diagnostic Code 5200. Finally, with regard to the Veteran’s claim that his service-connected right humerus disability limits his range of motion to 25 degrees from his side, thus entitling him to a 40 percent disability rating under Diagnostic Code 5201, the Board notes that any limitation of motion has been attributed to his nonservice-connected right rotator cuff injury and repair. As noted above, the May 2017 VA examiner specifically concluded that the Veteran limited range of motion of the right shoulder was more likely due to his rotator cuff problem which occurred many years after his discharge, and not his service-connected right humerus disability. As such, a higher rating under Diagnostic Code 5201 is not warranted. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). While the Veteran has alleged he has additional limitation of motion due to his service-connected disability, he lacks the medical expertise to make a competent association. The Board places greater probative value on the competent findings of the medical examiner who, after examining the Veteran, determined that his limitation in motion is due to a nonservice-connected shoulder disability. In sum, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for his service-connected right humerus disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against a higher rating, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Scars The Veteran’s service-connected left thigh scar is rated as 10 percent disabling under Diagnostic Code 7804. His service-connected left wrist scar is rated as noncompensable under Diagnostic Code 7802. Scars not of the head, face, or neck are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 through 7805. Under Diagnostic Code 7801, scars other than on the head, face, or neck that are deep and nonlinear are rated as 10 percent disabling for areas exceeding 6 square inches (39 square centimeters), 20 percent disabling for areas exceeding 12 square inches (77 square centimeters), 30 percent disabling for areas exceeding 72 square inches (465 square centimeters), and 40 percent disabling for areas exceeding 144 square inches (929 square centimeters). Note (2) under Diagnostic Code 7802 provides that a deep scar is defined as one associated with underlying soft tissue damage. Under Diagnostic Code 7802, a 10 percent rating is warranted for superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater. Note (2) under Diagnostic Code 7802 provides that a superficial scar is defined as one not associated with underlying soft tissue damage. Under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) under Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. Note (2) under Diagnostic Code 7804 provides that a scar or scars that is both unstable and painful on examination may be assigned an additional 10 percent rating. Note (3) under Diagnostic Code 7804 provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code 7804, when applicable. Diagnostic Code 7805 directs that any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 should be rated under the appropriate code. 2. Entitlement to an initial compensable rating for service-connected left wrist scar In the May 2009 rating decision on appeal, the AOJ granted service connection for a left wrist scar, and assigned a noncompensable rating under Diagnostic Code 7802, effective March 13, 2009. During a May 2009 VA examination, the examiner noted the presence of an upside down “F” shaped 3.5 centimeter by 3-centimeter shiny scar. The Veteran denied pain associated with the scar, but did complain of a tingling sensation at times in the area. There was no evidence that the scar was adherent ot the underlying tissue. The texture was not irregular, atrophic, or scaly, and it was stable with no frequent loss of the covering skin such as from ulceration of breakdown. Elevation of the surface contour of the scar on palpation was absent, as was depression of the surface contour. The scar was superficial, with no underlying soft tissue damage, and it was not deep. There was no evidence of inflammation, edema, or keloid formation, and the color of the skin was normal compared to the area around it. There was no evidence of hypo- or hyperpigmentation, and there was no evidence of induration or inflexibility of the skin in the area of the scar, nor was there evidence of functional limitation associated with the scar. The covered less than one percent of the exposed area and less than one percent of the total body. In his January 2010 notice of disagreement, the Veteran argued that his left wrist scar caused a tingling sensation, and that it was sensitive, tender, and sore. He also indicated that it caused weakness and instability, especially when he had to pick something up. A July 2015 VA examination noted that the Veteran’s left wrist scar was not painful or unstable. The examiner noted the presence of an upside down “F” shaped 3.5 centimeter by 3-centimeter superficial non-linear scar. The examiner concluded that there was no functional limitation associated with the Veteran’s left wrist scar. A May 2017 VA examination noted that the Veteran’s left wrist scar was not painful or unstable, that it had an area greater than 39 centimeters. The examiner noted the presence of three linear scars on the Veteran’s left wrist measuring 3 centimeters, 2 centimeters, and 1.5 centimeters. The examiner concluded that there was no functional limitation associated with the Veteran’s left wrist scar. After a careful review of all the evidence, the Board finds that at no time during the pendency of the appeal has the Veteran’s service-connected left wrist scar more nearly approximated the criteria for an initial compensable rating under any applicable diagnostic codes. With regard to Diagnostic Code 7801, the preponderance of the evidence demonstrates that the Veteran’s left wrist scar is not deep, it covers an area less than 39 centimeters, and it does not result in limited motion. For example, both the May 2009 and July 2015 VA examiners specifically note that the Veteran’s “upside down F” scar was superficial. All three examiners noted that his left wrist scar covered an area less than 39 centimeters, and all three examiners indicated that there was no functional impairment associated with his left wrist scar. Thus, an initial compensable rating under Diagnostic Code 7801 is not warranted for the entire period on appeal. With regard to Diagnostic Code 7802, while the Veteran’s left wrist scar is superficial, as noted above, his scars cover an area less 39 centimeters; thus, an initial compensable rating under Diagnostic Code 7802, which requires superficial, non-linear scars that covers an area greater than 929 square centimeters, is not warranted. With regard to Diagnostic Code 7804, all three VA examiners specifically noted that the Veteran’s left wrist scar was not painful or unstable, contrary to the Veteran’s assertions to VA. The Board finds the Veteran’s reports to physicians for examination purposes to be more credible, and in turn, more probative than his assertions to VA to the contrary. Further, as the VA examiners specifically test for pain or tenderness of a given scar, and no such pain was identified on three occasions, the Board finds these consistent negative findings highly probative. Thus, an initial compensable rating under Diagnostic Code 7804 is not warranted for the entire period on appeal. Finally, with regard to Diagnostic Code 7805, the evidence shows that the left wrist scar does not cause any other disabling effects or limitation of function that may be rated under any diagnostic codes other than Diagnostic Codes 7800-7804. As noted above, the May 2009, July 2015, and May 2017 VA examiners all specifically noted that there was no evidence of functional limitation associated with the Veteran’s left wrist scar. While the Veteran has at times attributed functional impairment of his wrist to his scar, he is not competent to make such a medical correlation. The Board finds the VA examiners’ consistent findings to the contrary to be more probative, as each examiner is trained to observe and identify the functional impact of the scar under review, and no such impairment was shown upon interview and examination of the Veteran. Thus, an initial compensable rating under Diagnostic Code 7805 is not warranted for the entire period on appeal. The Board adds that the regulations pertaining to the evaluation of skin disabilities, including scars, were revised effective August 13, 2018. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). As this Veteran’s appeal was pending at the time of the regulation change, the Board has considered whether a compensable rating may be warranted from August 13, 2018 to the present day. However, given the small size of the Veteran’s scar, and its asymptomatic nature, no revision to the criteria allows for the assignment of a compensable rating. In sum, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an initial compensable rating for his service-connected left wrist scar. As the preponderance of the evidence is against a higher rating, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to an initial rating in excess of 10 percent for service-connected left thigh scar In the May 2009 rating decision on appeal, the AOJ granted service connection for a left thigh scar, and assigned a 10 percent disability rating under Diagnostic Code 7804, effective March 13, 2009. During a May 2009 VA examination, the examiner noted the presence of a 13-centimeter scar on the lateral thigh. The scar was mild, tender to touch, hyposensitive compared with the skin outside, and not adherent to the tissues underneath. In his January 2010 notice of disagreement, the Veteran argued that his left thigh scar was moderately to severely tender to the touch, very sensitive, and not adherent to the tissues underneath. He asserted the scar contributed to radiating pain from the low back to the feet. A February 2013 VA treatment record noted that the left thigh scar was tender to palpation. A February 2013 examiner indicated that the Veteran’s scar caused no limitation of function. A July 2015 VA examination noted that the Veteran’s left thigh scar was linear and measured 14 centimeters. It was not painful or unstable, and that it did not have a total area equal to or greater than 39 square centimeters. The examiner indicated that the Veteran’s scar did not cause limitation of function. When asked whether other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) is associated with any scar, the examiner indicated, “No.” A May 2017 VA examiner similarly noted that the Veteran’s left thigh scar was not painful or unstable. The left thigh scar was linear and measured 15 centimeters. The examiner concluded that there was no functional limitation associated with the Veteran’s left thigh scar. After a careful review of all the evidence, the Board finds that at no time during the pendency of the appeal has the Veteran’s service-connected left thigh scar more nearly approximated the criteria for a rating in excess of 10 percent under any applicable diagnostic codes. Initially, the Board notes that Diagnostic Codes 7801 and 7802 are not for applicable, as the preponderance of the evidence demonstrates that the Veteran’s left thigh scar is linear. With regard to Diagnostic Code 7804, a higher rating is not possible, as the evidence fails to demonstrate the presence of more than three scars that are painful or unstable. Thus, an initial rating in excess of 10 percent under Diagnostic Code 7804 is not warranted for the entire period on appeal. Finally, with regard to Diagnostic Code 7805, the evidence shows that Veteran’s left thigh scar does not cause any other disabling effects or limitation of function that may be rated under any diagnostic codes other than Diagnostic Codes 7800-7804. Indeed, February 2013, July 2015 and May 2017 VA examiners specifically concluded that there was no evidence of functional limitation associated with the Veteran’s left thigh scar. Although prior examiners have noted the presence of tenderness and pain, the examiners did not identify additional functional impairment. As above, although the Veteran has at times attributed functional impairment to his thigh scar, to include radiating pain from his back to his feet due to the scar, he is not competent to make such a medical correlation. The Board finds the VA examiners’ consistent findings to the contrary to be more probative, as each examiner is trained to observe and identify the functional impact of the scar under review, and no such impairment was shown upon interview and examination of the Veteran. Thus, an initial rating in excess of 10 percent under Diagnostic Code 7805 is not warranted for the entire period on appeal. The Board has considered whether a higher rating may be warranted from August 13, 2018 to the present day under the revised rating criteria. However, the revised criteria do not avail the Veteran, as his scar is of a size too small for an increase, and does not affect more than one zone of the body. It is also not one of many painful or unstable service-connected scars. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). In sum, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an initial rating in excess of 10 percent for his service-connected left thigh scar. As the preponderance of the evidence is against a higher rating, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Entitlement to a TDIU prior to February 2, 2011 Total disability ratings for compensation may be assigned, in circumstances where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more with sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). In a July 2011 rating decision, the AOJ granted entitlement to a TDIU, effective February 2, 2010. However, in his August 2011 notice of disagreement, the Veteran challenged the effective date for the award of a TDIU. Because the claim for a TDIU stems from the Veteran’s March 2009 claim, the question as to whether a TDIU is warranted prior to February 2, 2010 remains at issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009); AB v. Brown, 6 Vet. App. 35, 38 (1993). Effective March 13, 2009, through January 12, 2010, the Veteran was service connected for the following: right humerus disability, rated as 30 percent disabling; left femur disability, rated as 20 percent disabling; right elbow disability, rated as 10 percent disabling; right wrist disability, rated as 10 percent disabling; left knee disability, rated as 10 percent disabling; left knee instability, rated as 10 percent disabling; left thigh scar, rated as 10 percent disabling; post-traumatic deformity of the right fifth metacarpal, rated as noncompensable; and left wrist scar, rated as noncompensable. His combined disability rating from March 13, 2009, through January 12, 2010, was 70 percent, and because his service-connected disabilities result from a single accident, the Veteran met the schedular criteria for a TDIU March 13, 2009, through January 12, 2010. See 38 C.F.R. § 4.16(a). From January 13, 2010, through February 1, 2010, the Veteran was also service connected for chronic low back strain with spondylosis, rated as 10 percent disabling; and cervical spondylosis, rated as 10 percent disabling. His combined disability rating from January 13, 2010, through February 1, 2010, was 80 percent, and because his service-connected disabilities result from a single accident, the Veteran met the schedular criteria for a TDIU January 13, 2010, through February 1, 2010. See 38 C.F.R. § 4.16(a). Therefore, the remaining inquiry is whether the Veteran was unable to secure or follow substantially gainful employment due solely to his service-connected disabilities from March 13, 2009 through February 1, 2010. The evidence of record includes the Veteran’s January 13, 2010, VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. He indicated that, at that time, he was still working twenty hours a week as a door greeter at a retail store, and that for the past 12 months, he had earned $14,000, which is above the poverty threshold for himself and one dependent for the year 2009. He indicated that he his last date of employment would be January 30, 2010. Subsequently, in October 2010, the AOJ received a VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefit, from the Veteran’s former employer. The employer indicated that his last date of employment was in fact, February 1, 2010. As noted above, in his August 2011 notice of disagreement, the Veteran challenged the effective date for the award of a TDIU. Specifically, the Veteran indicated that his stopped working in January 2010. The Board finds that entitlement to a TDIU is not warranted prior to February 2, 2010. In this regard, the Board finds that the most probative evidence of record is the October 2010 VA Form 21-4192 which indicates that that the Veteran’s last date of employment was February 1, 2010. Although the Veteran indicated on his January 2010 VA Form 21-8940 that he planned to stop working on January 30, 2010, this is subsequently contradicted by his employer on the October 2010 VA Form 21-4192. Because the most probative evidence of record indicates that the Veteran was gainfully employed prior to February 2, 2010, the Board is unable to conclude that the Veteran was unable to secure or follow a substantially gainful occupation as a result of a service-connected disability or disabilities prior to that date. Thus, his claim of entitlement to a TDIU prior to February 2, 2010, must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a left wrist disorder and a left thumb disorder are remanded. The Veteran claims entitlement to service connection for a left wrist disorder and a left thumb disorder as a result of his military service. Specifically, the Veteran attributed his left wrist disorder and left thumb disorder to a motor vehicle accident during service. The Board notes that the Veteran is service-connected for a left wrist scar as a result of the in-service motor vehicle accident. The May 2009 rating decision on appeal denied service connection for a left wrist disorder and a left thumb disorder, finding that there was no evidence of a current disability for either the left wrist or the left thumb. This conclusion was based upon a May 2009 VA examination report. Subsequent VA treatment records, however, show current diagnoses related to the Veteran’s left thumb and left wrist. An April 2012 VA treatment record notes the presence of significant degenerative arthritis of the carpometacarpal joint of the left thumb. Furthermore, a February 2013 VA examination noted that the Veteran suffered from avascular necrosis of the lunate in both wrists. The examiner noted that this was Kienbock’s Disease which resulted from old injuries, but it was impossible to document exactly when the injury occurred to the lunate in the wrist. Thus, given the current diagnoses of record, and because the medical evidence is insufficient to resolve the Veteran’s claims, a new examination is necessary to address whether any current diagnoses related to the Veteran’s left thumb and left wrist are related to his military service. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (explaining that once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). 2. Entitlement to service connection for restless legs syndrome is remanded. The Veteran claims entitlement to service connection for restless legs syndrome as a direct result of his military service. Alternatively, he claims that his restless legs syndrome is secondary to his service-connected left femur disability, left knee disability, left thigh scar, and lumbar spine disability. See February 2013 Correspondence; July 2015 Correspondence. A February 2013 VA examiner opined that the Veteran’s restless legs syndrome had no connection to the Veteran’s in-service motor vehicle accident and his subsequent left femur fracture; however, no further rationale was provided. Additionally, the examiner did not address the Veteran’s contention that his restless legs syndrome was secondary to his service-connected left knee disability, left thigh scar, and lumbar spine disability. Because the February 2013 VA examiner did not provide a complete rationale for the conclusion reached, a new examination is necessary that adequately addresses whether the Veteran’s restless legs syndrome is related to his military service or secondary to his service-connected disabilities. See Barr, supra. The examiner must all address all pertinent evidence, including any relevant service and post-service treatment records, as well as the Veteran’s his lay statement concerning the onset and continuity of any pertinent symptoms. 3. Entitlement to an initial compensable rating for service-connected post-traumatic deformity of the right fifth metacarpal, and entitlement to an initial rating greater than 10 percent for service-connected degenerative changes of the right wrist. In a May 2009 rating decision, the AOJ awarded service connection for a post-traumatic deformity of the right fifth metacarpal, with an evaluation of 0 percent, and for degenerative changes of the right wrist, with an evaluation of 10 percent, both effective March 13, 2009. In a subsequent rating decision, the AOJ changed the effective date of the award of service connection for the right fifth metacarpal deformity to December 7, 1965. The Veteran disagreed with the assigned initial ratings for both disabilities. On a VA examination in March 1966, it was noted that x-rays of the right hand showed good healing of the mid-shaft fracture of the fifth metacarpal. However, the examiner indicated that the Veteran had lost 50 percent of his grip in the right hand. At a May 2009 VA examination, it was noted that the Veteran had mild atrophy of the thenar and hypothenar muscles, and weakness of the right hand. Severe degenerative changes of the right thumb (first carpometacarpal joint) were also identified, along with the post-traumatic deformity of the fifth metacarpal. At a December 9, 2010 VA consultation, the Veteran continued to note difficulty with grip in the right hand. No atrophy of the upper extremities was identified. The examiner noted that “because of the decreased strength throughout the right arm, by his description chronic, he does have further difficulty with the hand not being fully in a position of function when attempting to grip, which, combined with the findings at the right thumb carpometacarpal joint . . . are decreasing strength in the right hand even further.” At an August 15, 2011 VA Consultation Report, a VA physician noted the Veteran’s continued complaints of pain when gripping in the hand, particularly pain going into his little and ring fingers. The physician identified no atrophy in the intrinsic muscles. The Veteran’s severe arthritis of the right thumb appeared to the physician to be the primary problem affecting function of the right hand. At a July 2015 VA examination, the Veteran’s right hand grip weakness was noted to be due to severe degenerative joint disease to the right wrist and the right thenar process wasting evident on examination. Throughout the appeal period, the Veteran has articulated a history of hand problems, to include sensitivity, tenderness, soreness, swelling, weakness, and instability. The Board believes that before the Veteran’s service-connected right fifth metacarpal deformity or right wrist arthritis can be rated, additional evidentiary development is necessary to clarify to what extent, if at all, the Veteran’s history of hand problems—to specifically include problems with grip—are symptoms of either service-connected disability. On remand, medical examinations should be scheduled to assess the history and severity of these conditions. 4. Entitlement to an initial rating in excess of 10 percent for service-connected right elbow disability is remanded. The Board finds that further remand is warranted to ensure an adequate record upon which to decide the Veteran’s claim for an initial rating in excess of 10 percent for his service-connected right elbow disability. The Veteran underwent a VA examination in May 2017 of his right elbow. The examiner noted that the Veteran’s report of occasional pain, as well as an inability to fully extend his right arm. The examiner then noted that the Veteran denied flare-ups, as well as any additional functional loss or functional impairment. The Veteran’s range of motion was as follows: flexion to 120 degrees; extension to five degrees; supination to 85 degrees; and pronation to 80 degrees. Subsequently, the examiner indicated that the Veteran had “some degree of ankylosis” at five degrees. The Board notes, however, that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Dorland’s Illustrated Medical Dictionary 94 (32th ed. 2012); see also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, NOTE (5) (defining ankylosis as fixation of a joint in a particular position). Given the contradictory nature of the findings of the May 2017 VA examination report, the Board finds that the Veteran should be afforded a new VA examination to determine the current nature and severity of his service-connected right elbow disability. Furthermore, in a decision issued after the May 2017 VA examination, the Court held that, when a veteran has a history of flare-ups and the examination does not occur when a flare-up is being experienced, the examiner must ascertain adequate information-such as frequency, duration, characteristics, severity, or functional loss-regarding the veteran’s flares by alternative means, in order to estimate the veteran’s functional loss due to flares based on all the evidence of record. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this regard, during the course of the appeal, the Veteran had reported increased symptomatology and functional impairment following repetitive use. For examiner, in July 2015, the Veteran stated that his right elbow was very sensitive, and that it caused tenderness, soreness, and weakness especially when picking up heavy objective or after using his elbow for more than 30 minutes. Thus, to ensure an adequate record upon which to decide the Veteran’s claim, and to ensure compliance with the Court’s holding in Sharp, supra, the Board finds that the Veteran should once again be scheduled for a new VA examination. See Barr, supra. 5. Entitlement to a rating in excess of 20 percent for service-connected left femur disability and entitlement to higher ratings for service-connected left knee disability are remanded. In May 2017, the Veteran underwent VA examinations of his left knee and left femur disabilities. The examination report which pertains to the Veteran’s left femur and hip notes that the Veteran experience pain at the extremes of movement and with prolonged walking; however, he stated that he could not tell which was more limiting—his left hip or his left knee. Subsequently, however, the examiner noted that the Veteran denied flare-ups or any functional loss of his left femur disability. Thereafter, the examiner stated that pain in the knee and hip with prolonged walking or standing significantly limited the Veteran’s functional ability. With regard to the May 2017 VA knee examination, the examiner noted that the Veteran denied flare-ups or any functional loss of his left knee disability. As to whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use, the examiner marked yes, indicating that the Veteran reported pain with prolonged walking; however, the examiner did not express his finding in terms of range of motion, because he was unable to tell if the Veteran’s left hip was causing the restriction on activity or if it was his left knee. Furthermore, the examiner noted that the Veteran did not have a history of lateral instability. Despite, the findings reported in the May 2017 VA examination, the Board notes that, throughout the appeal period, the Veteran has reported increased symptomatology after prolonged use of both his left femur and left knee. For example, in July 2015, the Veteran reported that he experienced a severe and prominent abnormal gait and a twisting of his left leg after walking for more than two city blocks or when he stood in one place for an extended period of time of near the end of the day. Additionally, the Veteran stated that his total knee replacement has exacerbated his abnormal gait, as well as the pain in his hip. The Veteran also stated that he tried exercising by going for a walk, but that he was unable to do so because of severe left knee pain. Similarly, in a July 2015 VA examination, although the examiner indicated that the Veteran denied flare-ups or any functional loss of his left knee disability, later in the examination report, the examiner noted that the Veteran was unable to do any prolonged standing and walking. As noted above, the Court has recently held that, in the case of a Veteran with a history of flare-ups, if the examination occurs when a flare-up is not being experienced, the examiner must ascertain adequate information-such as frequency, duration, characteristics, severity, or functional loss-regarding the Veteran’s flares by alternative means, in order to estimate the Veteran’s functional loss due to flares based on all the evidence of record. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Thus, to ensure an adequate record upon which to decide the Veteran’s claim, and to ensure compliance with the Court’s holding in Sharp, supra, the Board finds that the Veteran should once again be scheduled for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 6. Entitlement to an initial compensable rating for service-connected scars left knee is remanded. Finally, the Board finds that the Veteran’s claim for an initial compensable rating for service-connected scars left knee is intertwined with his claim for a higher rating for his service-connected left knee disability. As such, a remand of this issue is required. On remand, the AOJ should associate with the claims file any outstanding VA treatment records. See 38 U.S.C. 5103A (2012); 38 C.F.R. 3.159 (2017); Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, the Veteran should be given the opportunity to identify any outstanding evidence pertinent to the claims on appeal. The matters are REMANDED for the following action: 1. Obtain a complete copy of all VA treatment records dated since May 2018. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. The Veteran should be afforded a VA examination by a competent medical professional to determine whether there is a relationship between any currently-diagnosed left thumb disorder and/or left wrist disorder, to include degenerative arthritis of the carpometacarpal joint of the left thumb or avascular necrosis of the left wrist, and his military service. The claims file must be reviewed by the examiner, and the examiner should take a history from the Veteran as to the progression of his disability. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, to include the Veteran’s lay statements concerning the onset and continuity of any symptoms, the examiner should address the following: (a) Identify any currently-diagnosed left thumb disorder and/or left wrist disorder, to include degenerative arthritis of the carpometacarpal joint of the left thumb or avascular necrosis of the left wrist. (b) With regard to any diagnosed left thumb disorder and/or left wrist disorder, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset during, or is otherwise related to, his active duty service, to include his in-service motor vehicle accident. In offering any opinion, the examiner must consider the full record, to include the Veteran’s service and post-service treatment record, as well as the Veteran’s lay statements regarding the onset and continuity of symptoms, and the opinion should reflect such consideration. A clearly-stated rationale for any opinion offered should be provided. 4. The Veteran should be afforded a VA examination by a competent medical professional to determine whether there is a relationship between any currently-diagnosed restless legs syndrome and his military service, to include his in-service motor vehicle accident, or whether such is secondary to his service-connected disabilities. The claims file must be reviewed by the examiner, and the examiner should take a history from the Veteran as to the progression of his disability. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, to include the lay statements from the Veteran concerning the onset and continuity of symptomatology, the examiner should address the following questions: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s restless legs syndrome had its onset during, or is otherwise related to, his military service, to include his in-service motor vehicle accident? b) Regardless of the answers provided to the question above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s restless legs syndrome was caused or aggravated beyond its natural progression by his service-connected left femur disability, left knee disability, left thigh scar, and lumbar spine disability? In this regard, the Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. In offering any opinion, the examiner must consider the full record, to include the Veteran’s service and post-service treatment record, as well as the Veteran’s lay statements regarding the onset and continuity of symptoms, and the opinion should reflect such consideration. A clearly-stated rationale for any opinion offered should be provided. 5. Schedule the Veteran for VA examinations of the right wrist, right hand and right fingers and thumb to assess the severity of his service-connected right metacarpal deformity and right wrist disability. The entire record should be sent to, and reviewed by the VA examiner. The examiner should take a history from the Veteran as to the progression of his right hand, fingers and wrist symptoms. Upon review of the file, and examiner is asked to specifically identify whether any symptoms of the Veteran’s service-connected fifth metacarpal deformity or right wrist arthritis cause functional impairment of the hand. In particular, the examiner should identify whether the Veteran’s longstanding history of grip strength problems is attributable to the Veteran’s fifth metacarpal deformity, his right wrist arthritis, or to another disability. If muscle atrophy exists, this should be identified. Importantly, even if no current functional impairment of the hand exists, the examiner is asked to provide a retrospective opinion as to whether the Veteran’s prior complaints of hand impairment, to specifically include decreased grip strength, were attributable to the Veteran’s service-connected right fifth metacarpal deformity and/or right wrist arthritis. 6. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected right elbow disability, left femur disability, and left knee disability. The entire record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner must address each of the following inquiries: a) The examiner should describe all symptoms associated with the Veteran’s service-connected right elbow disability, left femur disability, and left knee disability. If such is not possible, an explanation should be provided as to why this is so. b) For the Veteran’s right elbow, left hip, and left knee, the examiner should test for pain in active motion, passive motion, weight-bearing, and nonweight-bearing. If such testing cannot be completed, an explanation should be provided as to why this is so. c) For the Veteran’s right elbow, left hip, and left knee, the examiner should ask the Veteran to report any range of motion loss during flare-ups or following repeated use. Even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to his history of flare-ups and ask him to describe the additional functional loss, if any, he suffers during flare-ups or following repeated use. For each joint where the examination does not occur during a flare-up, the examiner should estimate the functional loss, including loss of range of motion, due to flare-ups or following repeated use based on all the evidence of record including the Veteran’s lay statements. If the examiner cannot provide the above-requested opinion without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). d) For the Veteran’s right elbow, the examiner must specifically address whether the Veteran suffers from ankylosis of the joint (fixation of a joint in a particular position), and whether such is favorable, intermediate, or unfavorable. e) For the Veteran’s left knee, the examiner should address whether the Veteran has experienced chronic residuals consisting of severe painful motion or weakness since September 2014. The Veteran’s surgical scars should also be assessed. f) For the Veteran’s left femur disability, the examiner should address whether the Veteran’s femur results in a marked hip disability. A clearly-stated rationale for any opinion offered must be provided. 7. Thereafter, and after any further development deemed necessary, the issues on appeal should be readjudicated. If the benefits sought on appeal are not granted, the Veteran should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel