Citation Nr: 20059622 Decision Date: 09/10/20 Archive Date: 09/10/20 DOCKET NO. 10-11 022 DATE: September 10, 2020 ORDER Entitlement to a rating in excess of 20 percent for lumbar strain prior to November 2, 2010, in excess of 10 percent from November 2, 2010 through February 24, 2012 and in excess of 20 percent thereafter is denied. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee is denied. REMANDED Entitlement to service connection for a bilateral hip condition is remanded. FINDINGS OF FACT 1. The Veteran’s lumbar sprain is manifested by no more than limitation of forward flexion of 45 degrees, a combined range of motion of 115 degrees and muscle spasms and/or guarding severe enough to cause an abnormal gait and/or abnormal spinal contour. 2. The Veteran’s degenerative joint disease of the right knee is manifested by no more than a limitation of flexion of 60 degrees with pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent prior to November 2, 2010, in excess of 10 percent from November 2, 2010 through February 24, 2012 and in excess of 20 percent thereafter for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5242-5237. 2. The criteria for a rating in excess of 10 percent for degenerative joint disease of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1983 to February 1987 and March 1996 to September 1996 and in the United States Air Force from October 1992 to February 1993. In November 2015 and April 2018, the Veteran testified at Board hearings. The transcripts are of record. This is a panel decision as testimony was taken by two judges on the same issues. Increased Rating 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. §§ 3.321(a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a “staged” rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Entitlement to a rating in excess of 20 percent for lumbar strain prior to November 2, 2010, in excess of 10 percent from November 2, 2010 through February 24, 2012 and in excess of 20 percent thereafter In August 2009, the Veteran filed a claim for service connection for the lumbar spine and a December 2009 rating decision granted service connection with a 20 percent rating. The Veteran filed a timely notice of disagreement and a December 2011 rating action reduced his rating to 10 percent and a statement of the case was issued. The Veteran filed a Form 9 contending his symptoms are most consistent with a 40 percent rating. The Veteran's lumbar strain is currently rated under 38 C.F.R. §§ 4.71a, DC 5242-5237. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5242 applies to degenerative arthritis. DC 5237 applies to lumbosacral strain. Both DCs permit rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5 In November 2009, the Veteran attended a VA examination for his lumbar spine condition. He reported a dull ache that is moderate but constant with pain down the legs and flare-ups described as severe that occur due to bending or playing with his kids that happens weekly. The examiner noted an abnormal gait but no spinal curvature abnormalities and no incapacitating episodes. Examination revealed no spasms, atrophy or weakness but the Veteran had guarding, pain with motion and tenderness, and used a back brace for support. Range of motion testing revealed flexion to 60 degrees and left and right lateral flexion and left and right lateral rotation to 15 degrees. Functionally, the examiner noted the Veteran has decreased mobility and pain that effects daily activities. The Veteran underwent another VA examination in November 2010 and reported difficulty with lifting, twisting, bending and stooping. Physical examination revealed no stiffness, weakness, spasms, guarding, tenderness or pain with motion. The examiner reported that the Veteran had lumbar flattening, but a normal gait. Range of motion testing revealed flexion to 70 degrees, extension to 23 degrees, left lateral flexion to 15 degrees, left lateral rotation to 40 degrees, right lateral flexion to 20 degrees, and right lateral rotation to 40 degrees. The Veteran attended a VA examination in February 2013 and reported difficulty with many household chores due to back pain and flare-ups described as pain with different movements. Range of motion testing revealed forward flexion to 75 degrees with pain at 50 degrees, extension to 15 degrees with no pain, and right and left lateral flexion and rotation to 20 degrees with pain beginning at 10 degrees. Repetitive use testing did not result in additional loss of motion but there was functional loss due to less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing and/or weight-bearing. Examination revealed tenderness and guarding or muscle spasms resulting in an abnormal gait. There was reduced muscle strength of four out of five for hip flexion and ankle dorsiflexion but no muscle atrophy and normal deep tendon reflexes. The sensory examination revealed decreased sensation in the feet and toes, and the straight leg raise test was positive bilaterally. The examiner found no neurological abnormalities related to the spine condition but noted intervertebral disc syndrome (IVDS) with no incapacitating episodes. Imaging studies were interpreted as revealing mild lumbar disc protrusions with possible nerve root impingement. Functionally, the examiner concluded that the Veteran has difficulty with prolonged sitting, standing, walking, twisting, bending, kneeling, and squatting, lifting and carrying. In March 2014, the Veteran attended another VA examination and reported difficulty with household chores and flare-ups which occur in the morning and the end of the day that cause stiffness and pain. Range of motion testing revealed forward flexion to 80 degrees with pain at 45 degrees, extension to 20 degrees with pain at 10 degrees, right lateral flexion to 20 degrees with pain at 15 degrees, left lateral flexion and right and left lateral rotation to 20 degrees with pain. Repetitive use testing did not result in additional loss of motion but there was functional loss due to less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, interference with sitting, standing and/or weight bearing, and lack of endurance. Examination revealed mild tenderness and muscle spasms and guarding resulting in abnormal gait. Testing revealed muscle strength of four out of five, no muscle atrophy, normal deep tendon reflexes, and decreased sensation in the feet and toes. The examiner found no neurological abnormalities related to the spine condition but reported intervertebral disc syndrome (IVDS) with no incapacitating episodes. Functionally, the examiner concluded that the Veteran has difficulty with prolonged sitting, standing, walking, twisting, bending, kneeling, and squatting, lifting and carrying. The Veteran underwent another evaluation in July 2014. Range of motion testing revealed forward flexion to 70 degrees with pain at 30 degrees, extension to 20 degrees with pain, right and left lateral flexion and right lateral rotation to 20 degrees with pain and left lateral rotation to 20 degrees with pain at 15 degrees. The Veteran did not undergo repetitive use testing citing to too much pain. The examiner found functional loss due to less movement than normal, weakened movement, excess fatigability, deformity and scoliosis. Examination revealed tenderness, guarding and/or muscle spasms resulting in abnormal gait and spinal contour, reduced muscle strength of four out of five for ankle dorsiflexion, absent deep tendon reflexes in the right ankle and normal results from the sensory examination. The straight leg raise test was negative and the examiner concluded that the Veteran did not have IVDS. Functionally, the examiner concluded that the Veteran has difficulty with activities of daily living, weakness and pain inhibiting all activities making it difficult to stand, walk, drive or descend stairs. At the April 2017 VA examination the Veteran reported a constant dull ache in the center mid and low back with pain down both legs. He stated that he has flare-ups that cause pain that extends to the feet and causes difficulty straightening up all the way. Range of motion testing revealed forward flexion to 60 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 10 degrees with pain noted on examination. There was evidence of pain on weight-bearing, and tenderness. The Veteran had additional loss with repetitive use testing with forward flexion reduced to 45 degrees and extension reduced to 10 degrees. Examination revealed no guarding or muscle spasms, reduced muscle strength of four out of five, no muscle atrophy, hypoactive reflexes in the ankles, and normal sensations. The Veteran’s straight leg raise test was positive on the right. The examiner found no neurological abnormalities related to the spine condition but noted IVDS with no incapacitating episodes. Imaging results revealed minimal degenerative changes. Functionally, the examiner concluded that the Veteran has difficulty with physical demanding tasks, prolonged walking and standing due to pain. The Veteran attended another examination in August 2019 and reported difficulty with occupational and ordinary activities. He described flare-ups that are mild to moderate, which occur two to three times a week and last from 10 minutes up to an hour that are precipitated by repetitive motions. Range of motion testing revealed forward flexion to 60 degrees, extension and right and left lateral flexion to 10 degrees, and right and left lateral rotation to 15 degrees with pain. There was pain on weight-bearing but no tenderness or pain on palpation. The Veteran was unable to tolerate repetitive use testing due to pain, so it was not completed. The examiner found pain, weakness, fatigue and lack of endurance contributed to functional loss but was unable to describe in terms of range of motion. The examiner explained that after review of the testimony, medical records, available medical knowledge and expertise, and all the facts, there were too many contributing factors that needed to be taken into consideration; thus, it was not possible to evaluate without speculation. The examination revealed guarding or muscle spasm not resulting in abnormal gait or spinal contour and reduced muscle strength of at most, three out of five. There was no muscle atrophy and no ankylosis but hypoactive deep tendon reflexes for the right knee and ankle and decreased sensation on the right side with a positive straight leg raise on the right. The examiner found IVDS with episodes of bed rest having a total duration of at least one week but less than two weeks during the past 12 months. The examiner noted that these episodes were reported by the Veteran and he did not seek medical attention so there is no documentation provided to support these incidences. The Veteran reported occasional use of a cane and functional limitations resulting in difficulty picking up objects from the floor or bending or twisting to reach, difficulty with walking or sitting or standing for any length of time and difficulty climbing stairs after repeated use or during flare ups. The claims file includes clinical treatment records; however, they do not contain detailed measurements of the Veteran's range of motion for his lumbar spine. The records do reveal consistent complaints of low back pain and emergency room visits for back pain in 2015 and 2016. The record also contains Social Security Administration (SSA) records. While SSA records are not controlling for VA determinations, they may be pertinent to VA claims. Collier v. Derwinski, 1 Vet. App. 412 (1991); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Within the SSA records is a low back pain questionnaire from March 2014 where the Veteran disclosed severe pain that comes and goes and pain with personal care, lifting, walking, sitting, standing, and sleeping as well as physical therapy notes from that same month reporting limitations in range of motion. When making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). At the hearing, the Veteran testified that he has difficulty with bending and twisting and has to rest due to pain but no pain medications. He also described decreased range of motion that affects daily activities with pain and tightness. Period from November 2, 2010 to February 24, 2013 For the period on appeal from November 2, 2010 through February 24, 2013 the Veteran is assigned a rating of 10 percent for forward flexion limited to 70 degrees. For the next higher rating of 20 percent the evidence must establish forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Veteran’s November 2010 VA examination revealed range of motion with forward flexion to 70 degrees with no guarding, muscle spasms, or tenderness and no pain on motion. As the Veteran’s forward flexion during the period at issue is, at most, 70 degrees, his symptoms are most consistent with the criteria contemplated by a 10 percent rating for limitation of flexion of the spine greater than 60 degrees but not greater than 85 degrees. Therefore, a rating in excess of 10 percent is not warranted for the period from November 2, 2010 through February 24, 2013. Prior to November 2, 2010 and as of February 25, 2013 In order to warrant the next higher rating of 40 percent for the periods prior to November 2, 2010 and after February 24, 2013 the evidence must establish forward flexion limited to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. The evidence of record reveals that, at most, the Veteran has limitation of forward flexion to 45 degrees and guarding and/or muscle spasms resulting in abnormal gait and spinal contour, which is consistent with the criteria contemplated by a 20 percent rating. The Board considered whether a higher disability rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. The evidence establishes that the Veteran experiences pain and limitation of motion that causes difficulties with activities such as lifting, bending, and prolonged standing and walking; however, the objective medical evidence reveals, at most, limitation of forward flexion to 45 degrees during repetitive use testing at the April 2017 VA examination. The Board notes that the Veteran was unable to complete repetitive use testing at the July 2014 and August 2019 VA examination due to pain; however, while pain causes functional limitations the evidence does not establish that pain, or other factors, cause functional loss more closely approximating favorable ankylosis or limitation of motion to 30 degrees or less. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes as the evidence establishes a diagnosis of IVDS. The September 2019 VA examiner reported that the Veteran has IVDS with episodes of bed rest of at least one week but less than two during the past 12 months but noted that he does not seek medical attention and there is no documentation to support these incidences. VA regulation provides that an incapacitating episode only applies to a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, DC 5243. As the evidence does not contain bedrest and treatment prescribed by a physician, a higher rating is not warranted for IVDS. Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for lumbar strain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee The Veteran contends that he is entitled to a rating of at least 30 percent for his degenerative joint disease of the right knee. The Veteran’s knee condition is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran attended a VA examination in February 2013 and reported flare-ups described as constant throbbing pain and triggered by activities such as bending, kneeling and squatting. Range of motion testing revealed flexion to 100 degrees with painful motion at 60 degrees and no limitations or pain with extension. Repetitive use testing did not result in additional limitations of motion, but the Veteran had functional loss due to less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing and weight-bearing. Physical examination revealed tenderness and/or pain on palpation, reduced strength of four out of five for flexion, no joint instability and no evidence of recurrent patellar subluxation or dislocation. The examiner noted a meniscus tear with frequent episodes of joint pain and effusion. Imaging results revealed arthritis. Functionally, the examiner concluded that the Veteran has difficulty with prolonged standing, walking, bending, kneeling and squatting. In July 2014 the Veteran attended a VA examination and reported no flare ups. Range of motion testing revealed flexion to 110 degrees with pain at 45 degrees and no limitations in extension. Repetitive use testing did not result in any additional loss of motion, but there was functional loss due to less movement than normal, weakened movement, excess fatigability, instability of station, disturbance of locomotion, and requires a cane for hills and stairs. Physical examination revealed tenderness and/or pain on palpation, normal muscle strength, no joint instability and no evidence of recurrent patellar subluxation or dislocation. The examiner noted a meniscal tear with residuals of pain and instability but no episodes of locking, pain or effusion. The Veteran underwent a VA examination in April 2017 and reported weakness, swelling and throbbing pain. He denied instability or use of a cane but reported occasional use of a knee brace. He reported flare-ups described as difficulty with stairs, kneeling, twisting or dancing. Range of motion testing revealed flexion to 120 degrees and extension from 120 to zero with no pain on motion and no additional loss of motion with repetitive use testing. There was no pain on weight-bearing but localized tenderness and/or pain on palpation at the medical and lateral knee joint and crepitus. Physical examination revealed reduced muscle strength of four out of five, no muscle atrophy, and no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion and no joint instability. Functionally, the examiner concluded that the Veteran has difficulty with kneeling, squatting or stairs. In August 2019, the Veteran attended a VA examination and reported current symptoms of swelling, pain, stiffness and difficulty with occupational functioning and ordinary activities due severe tenderness and pain. The Veteran stated that he has flare-ups described as moderate, painful and precipitated by activities of daily living that results in the inability to stop or bend or walk for extended periods of time. Range of motion testing revealed flexion to 60 degrees and extension from 60 to zero degrees with pain on flexion. There was no objective evidence of tenderness and/or pain on palpation or pain on weight-bearing but there was crepitus. The Veteran declined repetitive use testing due to pain. The examiner reported pain, fatigue, and weakness limits functional ability but was unable to measure due to the Veteran’s inability to perform repetitive use testing. The examiner reported that the examination was conducted during a flare-up concluded that pain, fatigue and weakness limits functional ability. Range of motion testing was not completed due to increased pain and the examiner was unable to describe in terms of range of motion without speculation. The examiner explained that after reviewing the Veteran’s testimony, medical records and considering available medical knowledge and expertise there are too many contributing factors that need to be taken into consideration. Physical examination revealed muscle strength of four out of five, no atrophy and no ankylosis. There is no history of recurrent subluxation, no lateral or joint instability and no recurrent effusion. The Veteran requires occasional use of a cane. Functionally, the examiner concluded that the Veteran is unable to walk or stand for extended periods of time. Review of the clinical records reveals complaints of pain and functional limitations but do not contain detailed measurements of range of motion. In June 2012, the Veteran reported pain and locking but had a normal gait with normal strength and tone. Conversely, in January 2013, he reported no locking of the knee but a six-month history of swelling; however, the examination revealed no swelling and full range of motion with some medical joint line tenderness. In August 2017, the Veteran’s knee was stable with good range of motion and no effusion but in September 2018 he described his knee pain as severe. The Board has considered the lay statements of record. At the hearings, the Veteran testified that he has weakness, pain and swelling in his knee. He indicated periods of instability but denied locking. In order to warrant the next higher rating of 20 percent under DC 5260, the evidence must establish limitation of flexion to 30 degrees. The evidence reveals flexion limited to, at most, 60 degrees, which is consistent with a non-compensable rating; however, the Veteran is currently rated at 10 percent for painful motion. The Board considered whether a higher rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. In this case, the VA examiners generally found that weakness, pain and fatigability limits functional ability; however, the evidence does not establish that pain, or other factors, cause functional loss more closely approximating limitation of flexion to 30 degrees or even 45 degrees, which is the criteria contemplated by the 10 percent rating. As such, a rating in excess of 10 percent is not warranted. Throughout the entire period at issue, the Board has considered whether separate compensable evaluations are warranted for the right knee under other applicable provisions of the Diagnostic Code. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). For the following reasons, the Veteran does not warrant a separate rating for his right knee condition. The Board notes that while the record contains reports concerning locking and instability of the knee, these reports are inconsistent as the Veteran also denied locking and joint stability testing consistently yielded normal results. As such, the Veteran’s reports of knee locking, and instability have been considered but due to the lack of frequency and inconsistency of the report’s ratings under D C5257 or DC 5258 are not warranted. Additionally, the medical evidence establishes that the Veteran has measurable range of motion in his right knee, thus ankylosis of the knee is not shown and an evaluation under DC 5256 is not warranted. The evidence does not establish limitation of motion of extension; thus, the Veteran is not entitled to a rating under DC 5261. Finally, the record does not reflect dislocated semilunar cartilage to warrant an evaluation under DC 5258, removal of semilunar cartilage to warrant an evaluation under DC 5259, or an impairment of the tibia and fibula or genu recurvatum to warrant an evaluation under DCs 5262 or 5263. See 38 C.F.R. § 4.71a. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for degenerative joint disease of the right knee. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hip condition The Board finds a remand is necessary as the opinion of records is inadequate for adjudication. The Veteran attended a VA examination for the hips and was diagnosed with bilateral osteoarthritis by x-ray and the physical examination revealed limited range of motion. The examiner opined that the Veteran’s hip condition is not related to service as there is nothing in the service treatment records to indicate a hip injury and the Veteran's history regarding his fall and injury is inconsistent and there are discrepancies between the medical records and hearing testimony. Regardless of the discrepancies, the examiner concluded that the posterior hip pain is actually a back condition not a hip condition and opined that the Veteran’s hip condition is less likely than not proximately due to or the result of his service-connected back condition because his claimed pain in the posterior hip is actually the back condition and not a separate condition. While the Veteran’s posterior hip pain maybe related to his back condition, the medical evidence of record contains x-ray imaging establishing bilateral osteoarthritis of the hips which is clearly a separate condition. While the examiner noted the mild degenerative changes, the opinion concluded that it is age related and not the cause of the Veteran’s symptoms. The Board finds this opinion inadequate for adjudication as the examiner did not provide an opinion as to whether osteoarthritis of the hips is proximately due to or aggravated by his service connected back and/or radiculopathy or provide an adequate rationale to support the conclusion that osteoarthritis is due to age and not his service-connected conditions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Once VA undertakes the effort to provide an examination, it must provide an adequate one). As such, a remand is necessary to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s osteoarthritis of the hips is related to his active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that osteoarthritis of the hips is proximately due to or the result of the Veteran’s service-connected back disorder? (c.) If the answer to (b) is negative, is it at least as likely as not that the osteoarthritis of the hips is aggravated (i.e., permanently or temporarily worsened) by the service-connected back disorder? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history due to his in-service injury with continued symptoms to the present. The examiner must specifically consider and discuss the lay statements of record. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.