Citation Nr: 21000493 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-31 274A DATE: January 5, 2021 ORDER Entitlement to service connection for a left wrist disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to rating in excess of 10 percent prior to October 15, 2013, for left and right hip degenerative joint disease (arthritis) is denied. Entitlement to rating in excess of 10 percent on and after October 15, 2013, for limitation of right hip extension is denied. Entitlement to a 10 percent rating, but not more from October 15, 2013 to September 11, 2015 for limitation of right hip flexion is granted. Entitlement to a 30 percent rating, but not more, on and after September 11, 2015 for limitation of right hip flexion is granted. Entitlement to a 20 percent rating, which is the maximum, from October 15, 2013 to September 11, 2015, for limitation of right hip abduction is granted. Entitlement to a rating in excess of 20 percent, on and after September 11, 2015 for limitation of right hip abduction is denied. Entitlement to 10 percent rating, but not more, from October 13, 2015 to January 6, 2020, for left hip degenerative joint disease is granted. Entitlement to a rating in excess of 10 percent on and after January 6, 2020 for limitation of left hip extension is denied. Entitlement to a compensable rating for limitation of left thumb degenerative joint disease is denied. Entitlement to a compensable rating prior to September 11, 2015 for cervical spine degenerative changes is denied. Entitlement to a rating in excess of 10 percent on and after September 11, 2015 for cervical spine degenerative changes is denied. REMANDED ISSUE Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) prior to March 6, 2018. INTRODUCTION The Veteran served on active duty from June 1991 to August 2012. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been associated with the claims file. In June 2019, the Board remanded the Veteran’s claims for additional development. After the issuance of a July 2020 supplemental statement of the case, the appeal has been remitted to the Board for further appellate review. In June 2019, Board remanded several service-connection claims. While in remand status, the RO issued a July 2020 rating decision granting service connection for each claimed disability. Because the benefit sought on appeal has been granted, further appellate evaluation is moot. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a left wrist disability at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence of record is against finding that the Veteran has had a right ankle disability at any time during or approximate to the pendency of the claim. 3. Prior to October 15, 2013, the evidence demonstrates the presence of left and right hip arthritis (confirmed by x-ray) that is not manifested by a limitation of motion. 4. The already assigned 10 percent rating on and after October 15, 2013, for limitation of right hip extension is the maximum schedular rating available. 5. From October 15, 2013 to September 11, 2015, the Veteran’s right hip flexion more nearly approximates a limitation to 45 degrees. 6. On and after September 11, 2015, the Veteran’s right hip flexion more nearly approximates a limitation to 20 degrees. 7. From October 13, 2015 to September 11, 2015, the Veteran’s right hip abduction more nearly approximates limitation of abduction, motion lost beyond 10 degrees. 8. The already assigned 20 percent rating on and after September 11, 2015, for limitation of right hip abduction is the maximum schedular rating available. 9. From October 13, 2015 to January 6, 2020, the Veteran’s left hip disability was manifested by degenerative arthritis and a noncompensable limitation of motion. 10. On and after January 6, 2020, the Veteran’s limitation of left hip extension has already been assigned the maximum 10 percent. 11. Throughout the pendency of this appeal, the symptoms associated with the Veteran’s left thumb degenerative joint disease do not meet or more nearly approximate meets or more nearly approximates limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, and does not involve 2 or more minor joint groups. 12. Prior to September 11, 2015, the Veteran’s cervical spine disability was manifested by degenerative disc disease, normal range of motion without pain, and no flare-ups. 13. On and after September 11, 2015, the Veteran’s cervical spine disability did not meet or more nearly approximate forward flexion greater than 15 degrees but not greater than 30 degrees; a combined range of motion of the cervical spine not greater than 170 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. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial rating in excess of 10 percent prior to October 15, 2013, for left and right hip degenerative joint disease (arthritis) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5010. 4. There is no legal basis for the assignment of a schedular disability rating in excess of 10 percent for limitation of right hip extension on and after October 15, 2013. 38 U.S.C. § 1155; 38 C.F.R. § 4.71A, Diagnostic Code 5251. 5. The criteria for a 10 percent rating, but not more, from October 15, 2013 to September 11, 2015, for limitation of right hip flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5252. 6. The criteria for a 30 percent rating, but not more, on and after September 11, 2015, for limitation of right hip flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5252. 7. The criteria for a 20 percent rating, but not more, from October 13, 2015 to September 11, 2015, for limitation of right hip abduction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5253. 8. There is no legal basis for the assignment of a schedular disability rating in excess of 20 percent for limitation of right hip abduction on and after September 11, 2015. 38 U.S.C. § 1155; 38 C.F.R. § 4.71A, Diagnostic Code 5253. 9. The criteria for a 10 percent rating, but not more, from October 13, 2015 to January 6, 2020, for left hip degenerative arthritis have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71A, Diagnostic Code 5003, 5010, 5251, 5252, 5253. 10. There is no legal basis for the assignment of a schedular disability rating in excess of 10 percent for limitation of left hip extension on and after January 6, 2020. 38 U.S.C. § 1155; 38 C.F.R. § 4.71A, Diagnostic Code 5251. 11. The criteria for a compensable rating for left thumb degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5228. 12. The criteria for a compensable rating prior to September 11, 2015, for cervical spine degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5242. 13. The criteria for a rating in excess of 10 percent, on and after September 11, 2015, for cervical spine degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminarily, in the June 2019 remand, the Board directed the RO to provide the Veteran with VA examinations. In January 2020, the Veteran underwent the requested VA examinations. After re-adjudicating the Veteran’s claims and issuing a July 2020 supplemental statement of the case, the appeal was returned to the Board. The Board finds that the RO substantially complied with the remand directives and, thus, a remand to ensure compliance is not warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). I. Left Wrist and Right Ankle The salient question presented by these claims is whether the evidence demonstrates current left wrist and right ankle disabilities. See Degmetich v. Brown, 104 F.3d 1328 (1997). Recently, the Federal Circuit held that “pain in the absence of a presently-diagnosed condition can cause functional impairment,” which may qualify as a “disability” for VA compensation purposes. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). The Federal Circuit in Saunders, however, cautioned against the notion that “a veteran could demonstrate service connection simply by asserting subjective pain” because, to establish that a disability is present, the veteran “will need to show that... pain reaches the level of a functional impairment of earning capacity.” Id. at 1367-68. “Functional impairment,” the Federal Circuit noted, is defined as the inability of the body or a constituent part of it “‘to function under the ordinary conditions of daily life including employment.’” Id. at 1363 (quoting 38 C.F.R. § 4.10). The Veteran’s service treatment records demonstrated that he complained about and received treatment for symptoms associated with left wrist and right ankle injuries. During the November 2018 Board hearing, the Veteran testified as to lay observable symptoms, such as pain. Pursuant to the Veteran’s claims, he was provided VA examinations in March 2012 and January 2020. During the examinations, the Veteran reported in-service injuries to his left wrist and right ankle. The March 2012 and January 2020 VA examiners reviewed the evidence of record and administered clinical testing. Neither examiner found a diagnosable left wrist or right ankle disability. As for pain resulting in functional limitation without a diagnosable disability, the January 2020 VA examiner was specifically requested to address this possibility. Ultimately, the examiner confirmed that there is no current diagnosable left wrist or right ankle condition. The examiner then opined as follows with respect to the Veteran’s left wrist: No pathology of the left wrist was identified on today’s exam[ination] to render a left wrist diagnosis. The [V]eteran report he does not have symptoms of a current left wrist condition. With respect to the Veteran’s right ankle, the examiner provided the following rationale: [The] Veteran reports he does not have pain or limitations from a right ankle condition. He has not received medical care for a right ankle condition since discharge and there is no currently diagnosed right ankle condition. While the final physical lists osteoarthritis multiple sites including the right ankle, current x[-]rays are normal and do not indicate a diagnosis of right ankle osteoarthritis. The evidence of record does not otherwise include a diagnosis of a left wrist or right ankle disability, nor does it demonstrate functional impairment of either joint due to pain. Saunders, 886 F.3d at 1368. Because a left wrist and right ankle disability have not been shown, the preponderance of the evidence is against these service connection claims, the benefit-of-the-doubt rule does not apply, and the claims of entitlement to service connection must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. It is the intention of the rating schedule to recognize any painful, unstable or malaligned joint, due to healed injury, by assigning at least the minimum compensable rating for that joint. 38 C.F.R. § 4.59. 38 C.F.R. § 4.59 provides for a minimum 10 percent rating for painful, unstable, or malaligned joints, including for residuals of injuries in non-arthritis contexts. Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). Moreover, with respect to all service-connected joint disorders, evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995) (holding that, to adequately portray the functional loss of musculoskeletal disabilities, a medical examination must “express an opinion on whether pain could significantly limit functional ability during flare-ups or when the [joint] is used repeatedly over a period of time”). However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 3 8 C.F.R. §§ 4.40, 4.45 (2016); Johnson v. Brown, 9 Vet. App. 7 (1996). A. Right and Left Hip Left and Right Hip Prior to October 15, 2013 In March 2012, the Veteran submitted pre-discharge claims of entitlement to service connection for left and right hip disabilities. Pursuant to these claims, the Veteran underwent an examination in March 2012. The examiner noted that the diagnoses as right hip degenerative joint disease, status post decompression, and left hip degenerative joint disease. The Veteran denied flare-ups. The examiner administered range of motion testing that revealed the following, bilaterally: flexion from zero to 125 degrees or more, with no objective evidence of painful motion; extension from zero to greater than 5 degrees, with no objective evidence of painful motion; abduction not lost beyond 10 degrees; adduction not lost enough to prevent the Veteran from crossing his legs; and rotation sufficient enough that the Veteran was able to “toe-out” more than 15 degrees. The Veteran was able to perform repeat range of motion testing with no loss of motion or increased functional loss. There was no pain or tenderness on palpation, bilaterally; muscle strength testing was normal, bilaterally; and no ankylosis, malunion or nonunion of the femur, flail hip joint, or leg-length discrepancy, bilaterally. The Veteran did not use an assistive device for ambulation. The examiner indicated that imaging revealed the presence of bilateral degenerative joint disease. In an October 2012 rating decision, the RO granted service connection for bilateral hip arthritis, assigning thereto a single 10 percent rating, effective September 1, 2012 (the day after the date of the Veteran’s service discharge) under Diagnostic Code 5003. According to the Rating Schedule, traumatic and degenerative arthritis are rated under Diagnostic Code 5003. 38 C.F.R. § 4.71A, Diagnostic Code 5003, 5010. When a diagnosis of arthritis (be it degenerative or traumatic) is confirmed by x-ray, the disability will be rated on limitation of motion. If, under the appropriate diagnostic code or codes, the limitation of motion associated with the disability results in a noncompensable rating, Diagnostic Code 5003 directs the rater to assign a single 10 percent rating for each major joint. If there is no limitation of motion, Diagnostic Code 5003 directs the rater, in relevant part, to assign a 10 percent rating for 2 or more major joints. Id. Based on the results of the March 2012 examination, and the other relevant evidence of record, including the Veteran’s assertions, the Veteran’s left and right hip disabilities were manifested by x-ray-confirmed arthritis, but no limitation of motion and no flare-ups. Given that each hip is deemed to be “major” joint, a single 10 percent rating is warranted. 38 C.F.R. §§ 4.45(f), 4.71A, Diagnostic Code 5003. The Board finds that the preponderance of the evidence is against finding that the Veteran’s left and right hip disabilities were manifested by symptoms that more nearly approximated a rating or ratings in excess of 10 percent prior to October 13, 2015, for left and right hip degenerative joint disease. Left and Right Hip Subsequent to October 13, 2015 The Veteran appealed the October 2012 rating decision, seeking increased rating(s) for his service-connected left and right hip disabilities. On October 15, 2013, the Veteran underwent a VA examination to evaluate the severity of left and right hip disabilities. The examiner indicated that the Veteran underwent surgery for avascular necrosis of his right hip. The Veteran reported that he experienced chronic hip pain, bilaterally, and attributed his left hip disability to compensating for his right hip disability. The Veteran denied flare-ups. With respect to the Veteran’s right hip, the examiner administered range of motion testing that revealed the following: flexion from zero to 50 degrees, with pain at 50 degrees; extension from zero to 5 degrees, with pain at 5 degrees; abduction not lost beyond 10 degrees; adduction lost enough to prevent the Veteran from crossing his legs; and rotation sufficient enough that the Veteran was able to “toe-out” more than 15 degrees. After repeated range of motion testing, the only change concerned extension, which the examiner indicated improved from zero to 5 degrees or greater. In terms of functional impairment, the examiner indicated that the Veteran’s right hip was manifested by less movement than normal, weakened movement, excess fatiguability, incoordination/impaired ability to execute skilled movement smoothly, pain on movement, disturbance of locomotion, and interfere with sitting, standing, and/or weight-bearing. There was no pain or tenderness on palpation. On muscle strength testing, the Veteran scored 4 out 5 on flexion, abduction, and extension, indicating “active movement against come resistance.” The Veteran’s right hip was not manifested by ankylosis, malunion or nonunion of the femur, flail hip joint, or leg-length discrepancy. For his right hip, the examiner indicated that the Veteran constantly used a cane. Imaging of the hip revealed the presence of traumatic or degenerative arthritis. With respect to the Veteran’s left hip, the examiner administered range of motion testing that revealed the following: flexion from zero to 85 degrees, with no objective evidence of painful motion; extension from zero to greater than 5 degrees, with no objective evidence of painful motion; abduction not lost beyond 10 degrees; adduction not lost enough to prevent the Veteran from crossing his legs; and rotation sufficient enough that the Veteran was able to “toe-out” more than 15 degrees. After repeat range of motion testing, no changes were observed. In terms of functional impairment, the examiner indicated that the Veteran’s left hip was manifested by less movement than normal and weakened movement. There was no pain or tenderness on palpation. On muscle strength testing, the Veteran scored 5 out 5 on flexion, abduction, and extension, indicating normal strength. The Veteran’s left hip was not manifested by ankylosis, malunion or nonunion of the femur, flail hip joint, or leg-length discrepancy. Imaging did not reveal the presence of left hip degenerative or traumatic arthritis. At the conclusion of the report, the examiner included a section on functional impairment, but did not distinguish between the Veteran’s right and left hips. As such, the Board will contemplate this assessment for both. The examiner found that the Veteran’s right and left hip disabilities would cause difficulties with labor that involved prolonged standing, walking, use of lower extremities for lifting, and squatting. On September 11, 2015, the Veteran underwent a VA examination to assess the severity of his right and left hip disabilities. With respect to his right hip, the examiner noted that the Veteran underwent in-service surgery (core decompression), with worsening pain since his active duty. The Veteran endorsed daily pain, with “severe” flare-ups two or three times per month, each lasting one or two days. With respect to functional impairment, the Veteran stated that walking is painful, and he requires a cane for ambulation. Range of motion tests were administered and revealed the following: flexion from zero to 30 degrees; extension from zero to 10 degrees; abduction from zero to 10 degrees; and adduction from zero to 10 degrees. Adduction was not so limited that the Veteran could not cross his legs. External and internal rotation were from zero to 10 degrees. The Veteran was able to repeat range of motion testing, but no additional functional impairment or reduced range of motion resulted. The examiner determined that the Veteran’s impaired range of motion contributed to functional loss in that movement of the right hip in any direction was painful. Pain was noted on weight bearing and there was objective evidence of tenderness or pain on palpation. The examiner determined that there were other factors contributing the Veteran’s right hip disability, namely less movement than normal due to “ankylosis, adhesions, etc.,” as well as instability of station, disturbance of locomotion, interference with sitting, and interference with standing. In this instance, ankylosis is included in a “catch-all” category and does not necessarily mean that ankylosis is present. Indeed, the range of motion testing revealed movement in all ranges, albeit impaired. Further, the examiner specifically confirmed that the Veteran’s right hip disability is not manifested by ankylosis later in the examination. Muscle strength testing was normal in all tested aspects, with no reduction in strength. There was no malunion or non-union of femur, flail hip joint, or leg-length discrepancy. The examiner reviewed the Veteran’s surgical history (one, occurring in 2004), and that the Veteran was offered a total hip replacement, which he said he was considering. The examiner noted that the Veteran constantly used a cane for ambulation. Imagining of the right hip revealed degenerative or traumatic arthritis, as well as avascular necrosis or the right femoral head with subchondral collapse. With respect to functional impact on the ability to perform occupational tasks, the examiner stated that the Veteran experienced pain on weight bearing, walks with a cane, and walks with an antalgic gait favoring his right hip. With respect to the left hip, range of motion testing revealed normal ranges in extension, abduction, adduction, and internal and external rotation. Repeat range of motion testing did not result in functional impairment or reduced range of motion. There was no pain during testing, no pain or tenderness on palpation, and no pain with weight bearing, but there was evidence of crepitus. The examiner determined that there were no additional contributing factors of disability. Muscle strength testing was normal in all tested aspects, with no reduction in strength. There was no ankylosis, no malunion or non-union of femur, no flail hip joint, and no leg-length discrepancy. Imaging of the left hip did not reveal degenerative or traumatic arthritis. In January 2020, the Veteran underwent another VA examination to evaluate the severity of his service-connected left and right hip disabilities. With respect to his right hip, he described “constant flare ups,” during which it is difficult for him to get up and walk. The Veteran described his right hip flare ups as “painful,” “hard to move the area, such as rolling over and getting up,” having a hard time stepping over things, “its like a throb.” He stated that each flare up lasted from a couple of days to a week, occurred twice per month, and characterized them “severe.” The Veteran reiterated that he was offered a right hip replacement, but that he was “not ready for the yet.” The Veteran demonstrated his range of motion during a flare up, which the examiner measured as follows: flexion from zero to 30 degrees, extension from zero to 5 degrees, abduction from zero to 10 degrees, and adduction and internal and external rotation were each “zero.” Functional impairment or functional loss, according to the Veteran, was an inability to run, avoidance of prolonged standing, avoiding heavy lifting, and pain with prolonged walking. The examiner then administered range of motion testing that revealed the following: flexion from zero to 90 degrees, extension from zero to 5 degrees, abduction from zero to 10 degrees, and adduction from zero to 10 degrees. The examiner determined that the Veteran’s adduction limited to the extent that he was unable to cross his legs. Both internal and external rotation were from zero to 20 degrees. Pain was observed in each testing range of motion and with weight bearing. The was no pain or tenderness on palpation or crepitus. The Veteran was able to perform repeat range of motion testing with no additional loss of function or range of motion. The examiner opined that the examination is medically consistent with the Veteran’s statements describing functional loss flare ups due to pain. The examiner reiterated the Veteran’s demonstrated range of motion during a flare up. Regarding additional contributing factors of disability, the examiner noted disturbance of locomotion and interference with standing. Specifically, standing for 5 to 10 minutes and walking more than 200 years caused increased pain. Muscle strength testing was normal in each tested aspect, with no reduction in muscle strength and no atrophy. The examiner found no ankylosis, malunion or non-union of the femur, flail hip joint, or leg-length discrepancy. With respect to his left hip, the Veteran reported increasing pain. He also stated that he experienced flare-ups, occurring every couple of months, and rating them as “moderate.” The Veteran reported that he experienced difficulty with ambulation, stepping over things, and rolling over in bed during a flare up. During a flare up, the Veteran demonstrated his range of motion, which the examiner measured as follows: flexion from zero to 50 degrees, extension from zero to 15 degrees, and abduction from zero to 40 degrees, with adduction, internal rotation, and external rotation each similar to non-flare up range of motion. Functional impairment or functional loss, according to the Veteran, was an inability to run, avoidance of prolonged standing, avoiding heavy lifting, and pain with prolonged walking. The examiner administered range of motion testing that revealed the following: flexion from zero to 90 degrees, extension from zero to 15 degrees, abduction from zero to 45 degrees, and adduction from zero to 25 degrees. The Veteran’s adduction was not so limited that it prevented him from crossing his legs. External rotation was from zero to 40 degrees and internal rotation was from zero to 30 degrees. Pain was observed in each testing range except internal rotation, and pain on weight bearing. There was no pain or tenderness on palpation and no crepitus. The Veteran was able to perform repeat range of motion testing with no additional loss of function or range of motion. The examiner opined that the examination is medically consistent with the Veteran’s statements describing functional loss flare ups due to pain. The examiner reiterated the Veteran’s demonstrated range of motion during a flare up. With respect to additional contributing factors or disability, the examiner noted only disturbance of locomotion. Specifically, walking more than a mile increased pain. Muscle strength testing was normal in each tested aspect, with no reduction in muscle strength and no atrophy. The examiner found no ankylosis, malunion or non-union of the femur, flail hip joint, or leg-length discrepancy. The examiner then reviewed the Veteran’s surgical history and noted that the Veteran regularly used a walking stick. Imaging revealed the presence of bilateral degenerative or traumatic arthritis. With respect to both hips, the examiner stated that the Veteran experienced pain during passive range of motion testing and in non-weight-bearing. The examiner stated that, because the opposing joint was also damaged, a comparison with an undamaged joint was not possible. Diagnostic Codes For limitation of extension of the thigh, where extension is limited to 5 degrees, a maximum 10 percent evaluation is assigned. 38 C.F.R. § 4.71a Diagnostic Code 5251. For limitation of flexion of the thigh, where flexion is limited to 45 degrees, a 10 percent evaluation is assigned; where flexion is limited to 30 degrees, a 20 percent evaluation is assigned; where flexion is limited to 20 degrees, a 30 percent evaluation is assigned; and where flexion is limited to 10 degrees, a 40 percent evaluation is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5252. For impairment of the thigh, a 10 percent rating is warranted for limitation of rotation resulting in an inability to toe out more than 15 degrees or limitation of adduction resulting in ability to cross legs. A 20 percent rating is warranted for abduction lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The Veteran does not assert, and the evidence of record does not otherwise support finding, that his left or right hip disability is manifested by ankylosis, flail joint, or femur impairment. Therefore, Diagnostic Code 5250, 5254, and 5255 are not for application herein. Right Hip Extension On and After October 15, 2013 The Veteran’s right hip limitation of extension has already been assigned a 10 percent rating on and after October 15, 2013. As this is the maximum available rating under Diagnostic Code 5251, further evaluation is not warranted. Right Hip Flexion From October 15, 2013 to September 11, 2015 From October 15, 2013 to September 11, 2015, the Veteran’s right hip flexion has been assigned a noncompensable rating. In order for a 10 percent rating to be warranted, the evidence must demonstrate or more nearly approximate a limitation of flexion to 45 degrees. The October 15, 2013 VA examiner determined that the Veteran’s right hip flexion was limited to 50 degrees. During the examination, the Veteran denied experiencing flare-ups, and repeat range of motion testing did not produce any additional limitation of flexion or functional impairment. With that said, however, muscle strength testing showed that the Veteran scored 4/5 on flexion. Coupled with the examiner’s determination as to the Veteran’s overall right hip functional impairment, the Board finds that the Veteran’s right hip disability more nearly approximates a limitation of flexion to 45 degrees. Consequently, the Board finds that a 10 percent rating, but not more, is warranted from October 15, 2013 to September 11, 2015. Right Hip Flexion On and After September 11, 2015 During this period, the Veteran’s right hip limitation of flexion has already been assigned a 20 percent rating. In order for a rating in excess of 20 percent to be warranted, the evidence of record must show, or more nearly approximate, limitation of flexion to 20 degrees. The September 11, 2015 VA examiner determined that the Veteran’s right hip flexion was limited to 30 degrees. Although the Veteran was able to repeat range of motion testing without additional limitation of flexion and without additional functional impairment, the Veteran reported to the examiner that he experienced “severe” flare-ups 2 or 3 times monthly. The September 11, 2015 examination occurred prior to changes in the law with respect to the adequacy of VA examinations concerning flare-ups. Consequently, the examiner did not ascertain or estimate the Veteran’s additional loss of motion or additional functional loss during a flare-up. During the January 2020 VA examination, the examiner determined that Veteran’s right hip flexion was limited to 90 degrees, but limited to 30 degrees during a flare-up. The Veteran demonstrated his range of motion during a flare-up, which the examiner accepted as medically consistent with the examination. Giving the Veteran the benefit of the doubt, and with consideration of the flare-ups and functional impairment associated with this disability, the Board finds that the Veteran’s right hip flexion more nearly approximates a limitation to 20 degrees on and after September 11, 2015. Consequently, the Board finds that a 30 percent rating, but not more, is warranted for right hip limitation of flexion on and after September 11, 2015. Right Hip Adduction From October 15, 2013 to September 11, 2015 A 10 percent rating has already been assigned under Diagnostic Code 5253 for impairment of right hip adduction. In order for the maximum 20 percent rating to be warranted, the evidence must show or more nearly approximate a limitation of abduction, motion lost beyond 10 degrees. During the October 15, 2013 VA examination, the Veteran specifically denied flare-ups. Range of motion testing revealed that the Veteran’s right hip abduction was not lost beyond 10 degrees and that there was no additional limitation of motion or additional functional loss after repeat testing. The examiner did not describe the extent of the Veteran’s motion in abduction beyond 10 degrees. With consideration of the strength testing score of 4/5 for abduction, the Veteran’s functional impairment, and his lay assertions, and giving the Veteran the benefit of the doubt, the Board finds that the Veteran’s right hip disability more nearly approximates a loss of abduction motion beyond 10 degrees from October 13, 2015 to September 11, 2015. Consequently, the Board finds that a 20 percent rating is warranted throughout this period. Right Hip Abduction On and After September 11, 2015 The Veteran’s right hip limitation of abduction has already been assigned a 20 percent rating on and after September 11, 2015. As this is the maximum schedular available rating under Diagnostic Code 5253, further evaluated in not warranted. Left Hip From October 15, 2013 to January 6, 2020 Preliminarily, the Board observes that, prior to October 15, 2013, the Veteran’s service-connected left hip degenerative joint disease was included in the 10 percent rating for bilateral hip degenerative joint disease under Diagnostic Code 5003 (discussed above). This is so because neither the right nor left hip disability was compensable under the applicable range of motion diagnostic codes prior to October 15, 2013. Indeed, neither hip was manifested by any limitation of motion. In the presence of no limitation of motion, as is the case here prior to October 15, 2013, Diagnostic Code 5003 requires two “major” joints that are noncompensable under applicable range of motion diagnostic codes in order for the 10 percent rating to be assigned. Starting on October 15, 2013, VA determined that the Veteran’s service-connected right hip disability was manifested by limitations of motion that were compensable under the applicable diagnostic code. See 38 C.F.R. §§ 4.71A, Diagnostic Code 5251, 5252, 5253. As such, the RO determined that the Veteran’s remaining left hip disability was considered only one “major” joint under Diagnostic Code 5003 and, thus, was noncompensable. See 38 C.F.R. § 4.31. However, pursuant to Diagnostic Code 5003, if arthritis is noncompensable under the applicable range of motion diagnostic codes, but results in limitation of motion, then a 10 percent rating is applicable for each major joint. As is demonstrated by the results of the October 13, 2015 VA examination, the Veteran’s left hip disability is manifested by limitation of flexion (from zero to 85 degrees), and the hip is a “major” joint. Consequently, the Board finds that a 10 percent rating is warranted from October 13, 2015 to January 6, 2020. The Board will now address whether a rating in excess 10 percent is warranted from October 13, 2015 to January 6, 2020 under the applicable range of motion diagnostic codes. From October 13, 2015 to January 6, 2020, the Veteran’s left hip ranges of motion were determined to be normal, except flexion on one occasion. The October 15, 2013 VA examiner determined that the Veteran’s left hip flexion was limited to 85 degrees, with no objective evidence of pain on motion. There was no additional limitation of motion and no additional functional loss after repeat testing. The Veteran denied flare-ups. Further, muscle strength testing was normal (5/5) for flexion. Even with consideration of the Veteran’s functional impairment and lay assertions, the Board finds that the preponderance of the evidence is against finding that the Veteran’s left hip disability was manifested by a compensable limitation of motion under any of the applicable diagnostic codes. 38 C.F.R. §§ 4.71A, Diagnostic Codes 5251, 5252, 5253. Consequently, a rating in excess of 10 percent is not warranted from October 13, 2015 to January 6, 2020. Left Hip On and After January 6, 2020 The Veteran’s left hip limitation of extension has already been assigned a 10 percent rating on and after January 6, 2010. This is the maximum available rating under Diagnostic Code 5251. As such, further consideration is moot. With respect to other limitations of left hip motion, the Board notes that the January 6, 2020 VA examiner found flexion from zero to 90 degrees, extension from zero to 15 degrees, abduction from zero to 45 degrees, and adduction from zero to 25 degrees. The Veteran’s adduction was not so limited that it prevented him from crossing his legs. External rotation was from zero to 40 degrees and internal rotation was from zero to 30 degrees. The examiner found that, during flare-ups, the Veteran’s flexion was from zero to 50 degrees, extension was from zero to 15 degrees, and abduction was from zero to 40 degrees, with adduction, internal rotation, and external rotation each similar to non-flare up range of motion. Consequently, even with consideration of the Veteran’s functional impairment, lay assertions, and flare-ups, the Board finds that the preponderance of the evidence is against finding that the Veteran’s left hip disability was manifested by a compensable limitation of flexion, adduction, abduction, or rotation on and after January 6, 2020. 38 C.F.R. §§ 4.71A, Diagnostic Codes 5252, 5253. Consequently, a separate compensable rating for the Veteran’s left hip disability is not warranted on and after January 6, 2020. B. Left Thumb Throughout the pendency of this appeal, the Veteran’s service-connected left thumb degenerative joint disease has been assigned a noncompensable rating under Diagnostic Code 5228, which concerns limitation of thumb motion. Diagnostic Code 5228 provides that a 10 percent rating is assigned for limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent rating is assigned for limitation of motion of the thumb with a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. The Veteran underwent VA examinations in March 2012, October 2013, September 2015, and January 2020, to ascertain the severity of his left thumb disability. The March 2012 VA examiner determined that the Veteran’s left thumb was normal in each tested aspect. During the October 2013 examination, the Veteran reported that he had a cyst removed from his left thumb, with no subsequent problems with mobility. As such, no evaluation of the thumb was administered. Similarly, the Veteran did not report any left thumb issues during the September 2015 or January 2020 examinations. During these examinations, the Veteran consistently reported symptoms pertaining to his left 4th (i.e., ring) finger. He denies any left thumb symptoms and elects to undergo elevation of his left 4th finger instead. Service connection has been denied for the Veteran’s left 4th finger disability. Regardless, any clinical findings obtained with respect to the Veteran’s left 4th finger are immaterial to evaluating the severity of his service-connected left thumb. The Board has referred to the RO a claim to reopen the issue of entitlement to service connection for left 4th finger disability. The preponderance of the evidence is against finding that the Veteran’s service-connected left thumb disability meets or more nearly approximates limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. As such, a compensable rating under Diagnostic Code 5228 is denied throughout the pendency of this appeal. The Board observes that the Veteran’s service-connected left thumb disability is diagnosed as degenerative joint disease. Consequently, Diagnostic Code 5003 is for application. As determined above, the Veteran does not claim, and the evidence does not otherwise demonstrate, that his left thumb disability is manifested by limitation of motion. Under Diagnostic Code 5003, arthritis with no limitation of motion will be assigned a 10 percent rating for 2 or more major joints or 2 or more minor joint groups. For purposes of arthritis, multiple involvements of the interphalangeal joints are considered a group of minor joints, ratable on a parity with major joints. 38 C.F.R. § 4.45(f). Although the Veteran originally claimed service connection for a “hand contusion,” the scope of service connection granted in the October 2012 rating decision was limited to left thumb degenerative joint disease. Further, service connection has been denied for left 4th finger disability. Even if the Board were to consider the Veteran’s service-connected left thumb disability to encompass multiple involvements of the interphalangeal joints (i.e., the distal interphalangeal joint, the proximal interphalangeal joint, and the carpometacarpal joint), this constitutes only one group of minor joints. A second group of minor joints is required under Diagnostic Code 5003 in order for the 10 percent rating to be assigned. Consequently, the Board finds that the preponderance of the evidence is against the Veteran’s claim and, thus, a compensable rating under Diagnostic Code 5003 is not warranted for any distinct period throughout the pendency of this appeal. The evidence of record does not support evaluating the Veteran’s disability under any other anatomically relevant diagnostic codes. See 38 C.F.R. § 4.71A, Diagnostic Codes 5216-5227, 5229-5230. C. Cervical Spine Under the General Rating Formula, a 10 percent rating is assigned when forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; a combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 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 evaluation is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; a combined range of motion of the cervical spine not greater than 170 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 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees of less, or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. Prior to September 11, 2015 In March 2012, the Veteran underwent a VA examination to ascertain the presence and severity of any cervical spine disability. Imaging revealed the presence of degenerative disc disease. The clinical evaluation, including range of motion testing, was entirely normal with no objective evidence of pain on motion and no intervertebral disc syndrome. Moreover, the Veteran denied flare-ups. In the October 2012 rating decision, the RO granted service connection for a cervical spine disability and assigned a noncompensable rating under Diagnostic Code 5242, which concerns degenerative arthritis of the spine. The evidence of record relevant to the period prior to September 11, 2015, including the Veteran’s assertions, does not meet or more nearly approximate forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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. Consequently, the Board finds that a compensable rating under General Rating Formula is not warranted. Because the diagnosis of the Veteran’s cervical spine disability is arthritis (degenerative disc disease), Diagnostic Code 5003 is applicable. When arthritis is noncompensable under the applicable range of motion diagnostic code(s), a 10 percent rating is for application if there is some limitation of motion. As determined by the March 2012 VA examination, the Veteran’s cervical spine disability was not productive of any limitation of motion and there was no objective evidence of pain on motion. See 38 C.F.R. § 4.59. When arthritis is not manifested by any limitation of motion, a 10 percent rating will be assigned with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. According to 38 C.F.R. § 4.45(f), the cervical spine is a group of minor joints. The evidence of record does not demonstrate the involvement of another group of minor joints. Consequently, a compensable rating is not warranted under Diagnostic Code 5003. 38 C.F.R. § 4.31. There are no other anatomically relevant diagnostic codes under which to evaluate the Veteran’s cervical spine disability prior to September 11, 2015. On and After September 11, 2015 The Veteran appealed the October 2012 rating decision, seeking a compensable rating for his cervical spine disability. On September 11, 2015, the Veteran underwent a VA examination to assess the severity of his cervical spine disability. During the examination, the Veteran reported “mild” flare-ups in the morning and “moderately-severe” flare-ups twice per year. The Veteran did not report functional loss or impairment. Range of motion testing was normal, with no objective evidence of pain on motion and no loss function or range of motion on repeat testing. There was no tenderness or pain on palpation, and no localized tenderness, guarding, or muscle spasm. Muscle strength and neurological testing were normal in all tested aspect. No ankylosis or intervertebral disc disease was present, but the diagnosis was “multi-level” degenerative disc disease. On January 6, 2020, the Veteran underwent another VA examination to assess the severity of his cervical spine disability. The Veteran stated that his neck “bothered him of time in the mornings.” The Veteran reported pain in the mid to lower portion of his neck. Regarding functional impairment, the Veteran said he avoided driving long distances due to “having to turn his neck side to side, which is painful.” Range of motion testing revealed the following: forward flexion from zero to 35 degrees, extension from zero to 20 degrees, right lateral flexion from zero to 20 degrees, left lateral flexion from zero to 25 degrees, right lateral rotation from zero to 50 degrees, and left lateral rotation from zero to 45 degrees. The Veteran was able to perform repeat testing with no loss of function or range of motion. Pain was noted on examination in each range of motion, on weight-bearing, in passive range of motion, and there was mild tenderness to palpation at the base of the Veteran’s cervical spine. The examiner found that pain significantly limited the Veteran’s functional ability with repeated use over time. There was no guarding or muscle spasm, strength and neurological testing was normal, and imaging confirmed the presence of degenerative disc disease, but no intervertebral disc syndrome. In a July 2020 rating decision, the RO granted a 10 percent rating for the Veteran’s cervical spine disability, effective September 11, 2015. It is unclear to the Board on what basis the 10 percent rating was assigned. The section of the rating decision that concerns the Veteran’s cervical spine erroneously discusses the Veteran’s hip disabilities. The Board will not disturb this grant. In order for a 20 percent rating to be warranted on and after September 11, 2015, the evidence must meet or more nearly approximate forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; a combined range of motion of the cervical spine not greater than 170 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 evidence during this period does not demonstrate the presence of any muscle spasm or guarding associated with the Veteran’s cervical spine disability. Further, the Veteran’s cervical spine forward flexion was, at worst, limited to 35 degrees, and his combined range of motion was, at worst, 195 degrees. Consequently, even with consideration of the Veteran’s assertions and his flare-ups, the Board finds that the evidence of record does not demonstrate that his cervical spine disability meets or more nearly approximates the criteria for a rating in excess of 10 percent. 38 C.F.R. §§ 4.7, 4.71A, Diagnostic Code 5242, The General Rating Formula. As such, the Veteran’s claim is denied. Because the evidence of record did not demonstrate that the Veteran’s cervical spine disability was manifested by intervertebral disc syndrome, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not for application, neither is consideration for any associated neurological abnormalities. 38 C.F.R. § 4.71A, Diagnostic Code 5243, Note (1).   There are no other anatomically relevant diagnostic codes under which to grant a rating in excess of 10 percent for the Veteran’s cervical spine disability on and after September 11, 2015. REASONS FOR REMAND Subsequent to the June 2019 Board remand, the RO issued a July 2020 rating decision wherein it granted entitlement to TDIU, effective March 6, 2018. TDIU is for application throughout the appeal and, thus, entitlement to TDIU prior to March 6, 2018, is still pending before VA. Herein, the Board has granted several increased ratings that affect the adjudication of the TDIU claim during the still pending period. The Board finds that a remand is warrant in order for the RO to implement the Board’s decision and re-adjudicate TDIU prior to March 6, 2018, in the first instance. The matters are REMANDED for the following action: Effectuation the Board’s decisions herein, then re-adjudicate the claim of entitlement to TDIU prior to March 6, 2018. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his attorney. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean G. Pflugner, Counsel 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.