Citation Nr: 21065641 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 06-26 856 DATE: October 26, 2021 ORDER Entitlement to a compensable rating for a right hip disability (abduction), prior to December 19, 2014, is denied. Entitlement to a rating in excess of 10 percent for a right hip disability (abduction), from December 19, 2014, is denied. Entitlement to a rating in excess of 10 percent for a right hip disability (flexion), prior to December 19, 2014, is denied. Entitlement to a compensable rating for a right hip disability (flexion), from December 19, 2014, is denied. Entitlement to a compensable rating for a right hip disability (extension) is denied. REMANDED Entitlement to an increased rating in excess of 10 percent for a left knee disability (extension), prior to January 13, 2012, is remanded. Entitlement to an increased rating in excess of 20 percent for a left knee disability (extension), from January 14, 2012, to October 20, 2016, is remanded. Entitlement to an increased rating in excess of 30 percent for a left knee disability (extension), from October 21, 2016, to April 14, 2019, is remanded. Entitlement to an increased rating in excess of 10 percent for a left knee disability (extension), from April 15, 2019, to May 2, 2019, is remanded. Entitlement to an increased rating in excess of 20 percent for a left knee disability (extension), from May 3, 2019, to June 19, 2019, is remanded. Entitlement to an increased rating in excess of 30 percent for a left knee disability (extension), from June 20, 2019, is remanded. Propriety of the reduction from 30 percent to 10 percent effective April 15, 2019, for a left knee disability (extension), is remanded. Entitlement to an increased rating in excess of 10 percent for a left knee disability (flexion), from December 11, 2018, is remanded. Entitlement to an increased rating in excess of 10 percent for a right knee disability (extension), prior to January 13, 2012, is remanded. Entitlement to an increased rating in excess of 20 percent for a right knee disability (extension), from January 14, 2012, to October 20, 2016, is remanded. Entitlement to an increased rating in excess of 30 percent for a right knee disability (extension), from October 21, 2016, to April 14, 2019, is remanded. Entitlement to an increased rating in excess of 10 percent for a right knee disability (extension), from April 15, 2019, to May 2, 2019, is remanded. Entitlement to an increased rating in excess of 20 percent for a right knee disability (extension), from May 3, 2019, to June 19, 2019, is remanded. Entitlement to an increased rating in excess of 30 percent for a right knee disability (extension), from June 20, 2019, is remanded. Propriety of the reduction from 30 percent to 10 percent effective April 15, 2019, for a right knee disability (extension), is remanded. Entitlement to an increased rating in excess of 10 percent for a right knee disability (flexion), from December 11, 2018, is remanded. Entitlement to an earlier effective date, prior to April 5, 2015, for assigned of a total disability rating for individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to December 19, 2014, the Veteran's impairment of the right hip manifested as painful motion, but with the ability to cross his legs. There was no evidence of ankylosis, flail joint, or impairment of the femur. 2. From December 19, 2014, the Veteran's impairment of the right hip manifested with painful motion and limitation of adduction with an inability to cross his legs. There was no showing of limitation of abduction of motion lost beyond 10 degrees, or evidence of ankylosis, flail joint, or impairment of the femur 3. During the entire appeal period, the Veteran's right hip disability manifested with painful motion and flexion to 70 degrees, but without ankylosis, flail joint, or impairment of the femur. 4. During the entire appeal period, the Veteran's limitation of extension of the right hip manifested with painful motion and extension to 10 degrees; but without ankylosis, flail joint, or impairment of the femur. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for a right hip disability (abduction), prior to December 19, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5253. 2. The criteria for a rating in excess of 10 percent for a right hip disability (abduction), from December 19, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5253. 3. The criteria for an initial rating in excess of 10 percent for a right hip disability (flexion), prior to December 19, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010-5252 4. The criteria for a compensable rating for a right hip disability (flexion), from December 19, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010-5252. 5. The criteria for an initial compensable rating for limitation of extension of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5251 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from April 1986 to March 1990. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases where the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is considered limited motion at the point that the pain actually sets in. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). 1. Entitlement to a compensable rating for a right hip disability (abduction), prior to December 19, 2014. 2. Entitlement to a rating in excess of 10 percent for a right hip disability (abduction), from December 19, 2014. 3. Entitlement to a rating in excess of 10 percent for a right hip disability (flexion), prior to December 19, 2014. 4. Entitlement to a compensable rating for a right hip disability (flexion), from December 19, 2014. 5. Entitlement to a compensable rating for a right hip disability (extension) By way of procedural history, service connection was granted for a right hip disability (flexion) and an initial 10 percent rating was assigned under 38. C.F.R. § 4.71a, DC 5010-5252. Subsequently, in a February 2016 rating decision, the RO awarded separate ratings for limitation of extension of the right hip (DC 5251) and for abduction of the right hip (DC 5253) - both rated as noncompensable, effective July 11, 2014. The rating decision also continued a 10 percent rating for right hip (flexion). Thereafter, in a November 2017 rating decision, the RO granted a higher 10 percent rating for impairment of the right hip (abduction), effective December 19, 2014; continued the noncompensable rating for limitation of extension of the right hip (DC 5251); and assigned a noncompensable rating to right hip flexion (now DC 5010-5252), effective December 19, 2014. In February 2019, the Board denied the Veteran's claims for increased rating noted herein based on the competent medical evidence of record. The Veteran appealed the Board's decision with respect to the denial of increased ratings for his service-connected right hip disability based on limitation of abduction, flexion, and extension to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 Memorandum Decision, the Court vacated the February 2019 decision, and remanded the appeal for further development consistent with the Memorandum Decision. In the September 2020 Memorandum Decision, the Court found that a remand was necessary because the Board relied on inadequate examinations reports. Specifically, the Court determined that a November 2017 VA examination report did not comply with the Court's holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The Court also found that a 2010 VA examination did not opine as to what extent of the Veteran's functional loss was due to pain. As such, consistent with the terms of the September 2020 Memorandum Decision, the Board remanded the claims in April 2021 so that the Veteran can be afforded a new VA examination to address the current nature and severity of his service-connected right hip disability. Such development has been substantially accomplished by the RO, and the issues related to the Veteran's right hip disability is ripe for appellate review. For the diagnostic code assigned to right hip degenerative joint disease (DJD), hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. According to DC 5010, traumatic arthritis (as substantiated by X-ray findings) should be rated as degenerative arthritis, which is found under DC 5003. Under DC 5003, where there is no limitation of motion of the specific joint or joints involved, a 10 percent rating is warranted with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating disabilities listed under DCs 5013 to 5024, inclusive. 38 C.F.R. § 4.71a. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate DCs, then DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. However, when there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate DCs, the compensable limitation of motion should be rated under the appropriate DCs for the specific joint or joints involved. Id. Regarding the right hip, separate ratings are available pursuant to DCs 5250 - 5255. Specifically, DC 5251 evaluates limitation of extension of the thigh; DC 5252 evaluates limitation of flexion of the thigh; and DC 5253 evaluates limitations of abduction, adduction, and rotation of the thigh. Normal hip flexion is to 125 degrees; normal hip abduction is to 45 degrees. 38 C.F.R. § 4.71, Plate II. A January 2009 private treatment record shows the Veteran reported stiff, achy pain in his right hip after long periods of sitting. He was unable to sit with right hip crossed due to pain. The clinician noted active range of motion in his right hip was decreased, but no findings were provided. In a September 2009 letter, the Veteran reported that it was very painful to sit with his right leg crossed. At a March 2010 VA examination, the Veteran reported pain, fatigue, and lack of endurance in his right hip. He reported walking 40 to 50 feet before feeling right hip pain. He denied flare-ups or incoordination. Range of motion testing showed flexion to 90 degrees, adduction to 40 degrees, abduction was to 70 degrees, and extension was to 70 degrees. There was no additional loss in range of motion, coordination, fatigue, endurance, or pain level, after repetitive use testing. A March 2010 VA X-ray report showed no acute bony, joint, or soft tissue abnormality. In July 2010, the Veteran reported to Dr. M. that he was unable to sit with his right leg crossed over, as it caused right hip pain. Range of motion on his right- side was decreased with pain, but the left-side was within normal limits. An October 2010 VA treatment record noted range of motion for the hip were within normal limits. A January 2012 record from Dr. M. showed right hip flexion to 90 degrees, abduction to 40 degrees with pain, and adduction to 35 degrees with pain. At a July 2014 VA contract examination, the range of motion testing showed right hip flexion to 120 degrees with pain, and extension to 20 degrees with pain. Abduction was not lost beyond 10 degrees; adduction was not limited such that the Veteran could not cross his legs; and rotation was not limited such that he could not toe-out more than 15 degrees. There was no ankylosis, malunion or nonunion of the femur, flail joint, or leg length. Private treatment records from the Holistic Chiropractic Services in 2014 shows the Veteran continued reporting that he was unable to stand or walk for long periods of time due to his back and bilateral hip pain. A December 19, 2014 visit and June 2015 records from Holistic Chiropractic Service show active range of motion testing was conducted. Right hip flexion was to 115 degrees with pain, extension to 15 degrees with pain, abduction to 30 degrees with pain, and adduction to 15 degrees with pain. There was no additional functional loss noted after repetitive-use testing. The clinician found that the Veteran was unable to cross his legs at the December 19, 2014 visit. The November 2017 rating decision awards were based on this visit. The subsequent June 2015 private record also showed that the Veteran was unable to cross his legs. At the November 2015 VA examination, the Veteran reported soreness and stiffness of his hips. He reported flare-ups. Range of motion testing showed right hip flexion to 90 degrees, extension to 30 degrees, abduction to 40 degrees and adduction to 20 degrees. There was no additional functional loss in range of motion after repetitive-use testing. No ankylosis was found. He was not limited to where he could not cross his legs. Records from Holistic Chiropractic Services in June 2016 and June 2017 reflect the Veteran reported that he was unable to stand or sit for long periods of time without an increase in hip and knee pain. Active range of motion showed right hip flexion to 115 degrees with pain, abduction to 30 degrees with pain, and adduction to 15 degrees with pain. There was no additional range of motion loss after repetitive-use testing. He was unable to cross his legs. The clinician opined that his walking distance is limited to 15 to 26 yards before he develops pain. He can stand for 15 minutes before needing to sit and sit for 20 minutes before needing to stand. At a November 2017 VA examination, the Veteran's right hip forward flexion was limited to 70 degrees, extension to 10 degrees, abduction to 25 degrees, and adduction to 10 degrees. He could not cross his legs. There was no additional function loss noted after repetitive-use testing. There was no ankylosis, malunion or nonunion of femur, flail joint, or leg length. There was evidence of pain on passive range of motion testing and when the joint is used in non-weightbearing. Subsequent private examination notes from May 2018, December 2018, and May 2019, from Holistic Chiropractic Services, all reveal the same results with regards to the Veteran's right hip; these reports noted range of motion testing for the right hip showed flexion was limited to 80 degrees, extension to 10 degrees, and abduction to 30 degrees, all with pain. Subjective reports from the Veteran noted flare-ups, generally, in association with his back disability, which was caused from prolonged use, to include sitting or standing for long periods of time. No further increased in limitation of movement, to include with the right hip were explicitly noted by the examiner nor the Veteran during these examinations. In May 2021, the Veteran submitted another private examination conducted at the Holistic Chiropractic Services. Here, the Veteran again complained of increased pain due to his back, knees, and hip disabilities, to include preventing him from accomplishing chores of daily living. The Veteran again, noted increased pain in his right hip from prolonged use to include siting for long periods of time. Upon physical examination, the Veteran's right hip range of motion was noted to be limited to 30 degrees of abduction, 75 degrees of flexion, and 10 degrees of extension. No notation with regards to this ability to cross his leg. In a July 2021 VA examination, the Veteran again reported that he experiences flare-ups of his right hip disability, to explicitly include after prolonged use such as siting, standing, or walking for long period of time. The Veteran noted sharp, but moderate pain, onset especially after weight bearing; such was relieved by use of pain medication such as ibuprofen, and also a TENs unit. Upon testing the Veteran's right hip disability was noted to be limited to 95 degrees of flexion, 25 degrees of extension, and 40 degrees of abduction. Physical examination revealed that the Veteran's adduction did not prevent the Veteran from crossing his legs, and weight bearing, and active/passive motion did caused pain. Repeat use testing revealed no addition loss of range of motion, however, the examiner estimates that over time, repeat use would reduce the Veteran's range of motion to 90 degrees of flexion, 15 degrees of extension, and 40 degrees of abduction; this further limited motion is also what the examiner estimated to result from flare-ups. Further analysis of the Veteran's condition reveals no additional conditions to include no muscle atrophy, no femur/flail hip joint impairment, or residuals from any note surgical procedures. The Veteran was noted to use a brace for ambulation and, occasionally, a cane. Overall functional impact was noted to be limitation in climbing, running, bending over, squatting, and standing for long period of time. Diagnostic analysis ultimately revealed a diagnosis of right hip degenerative joint disease of the right hip. Limitation of Extension As noted earlier, a compensable rating is warranted under this diagnostic code if the Veteran's right hip extension was limited to 5 degrees. See 38 C.F.R. § 4.71a. Here, a compensable rating under DC 5251 is not warranted as the record does not show that thigh extension is limited to 5 degrees at any point during the appeal period. Neither the VA examinations and nor the private treatment records and examinations reports have recorded the Veteran's his right hip extension to be worse than 10 degrees, at worst, during the entire appeals period. A close review of the VA and private treatment records, contemporaneous to the claims period, also reveals no additional objective evidence of the Veteran's right hip extension to meet the criteria for a compensable rating. Moreover, although the Veteran experiences pain on extension, there is no indication that his reported pain and functional limitation caused by his right hip disability further limits his extension to a level approximating the criteria for a 10 percent rating under DC 5251. 38 C.F.R. §§ 4.40, 4.45. Indeed, in his most recent VA examination, the examiner explicitly noted that even consideration both repeat motion over time, and flare-ups, that the Veteran's extension was only limited to 15 degrees; far short of the requisite 5 degrees required under the criteria for a compensable rating. Consequently, the Board must find that the preponderance of evidence remains against the finding that the Veteran's right hip disability (extension) has been limited to 5 degrees during the course of the claims period, and as such, the Veteran's claim for a right hip disability, with regards to limitation of extension, must be denied. Limitation of Flexion Under DC 5252, a compensable 10 percent rating is warranted if flexion is limited to 45 degrees; a higher 20 percent rating is warranted if flexion is limited to 30 degrees. However, prior to December 19, 2014, a higher 20 percent rating is not warranted as the record does not show that flexion was limited to 30 degrees. Here, a close review of the relevant objective range of motion evidence of record, to include the VA examination reports and private treatment records noted flexion was, at worst, limited to 90 degrees during the relevant time period. Reviews of both VA and private treatment records reveal no additional objective testing of the Veteran's right hip disability, that reveals evidence of a worse range of motion with regards to flexion during this time. Additionally, while the Veteran's has claimed pain in his right hip, examinations has revealed no additional function loss in range of motion after repetitive-use testing, and there were no other range of motion findings which showed further limitations of flexion. From December 19, 2014, a compensable (10 percent) rating is also not warranted as the record does not show that flexion is limited to 45 degrees. At worst, the VA examinations of record, to include in November 2017, December 2018, and July 2021, note the Veteran's flexion was limited only to 70 degrees, at worst. To this end, in his most recent VA examination, the July 2021 VA examiner explicitly noted consideration of flare-ups reported by the Veteran, but ultimately found that even considering flare-ups and repeat use over time, functional loss of the right hip would only be productive of flexion being limited to 90 degrees (a decrease of five degrees from normal motion tested during that examination). The Board finds that these objective results of limitation of flexion is reflected in the private examination reports submitted by the Veteran from his treating chiropractor during this period. With several of these examination reports noting objective testing for both the Veteran's hip, back, knees, and ankles, these reports reflect similar results as the contemporaneous VA examinations, to include subjective complaints of increasing pain, especially upon prolonged use such as sitting and standing, and decreased ability to accomplish daily chores. However, even in these reports the Veteran's right hip flexion was limited to, at worst, 75 degrees, with no additional function loss in range of motion noted after repetitive-use testing. In addition to these VA and private examination reports, there are no other range of motion findings during the period from December 19, 2014, which showed further limitations of flexion, to include in his extensive VA treatment records during either relevant period. In this regard, for each of these periods, the Board recognizes that the Veteran has continuously reported experiencing pain on movement, however, there is no indication that his reported pain and functional limitation caused by his right hip disability further limits his flexion to a level approximating the criteria for the higher rating criteria for either period. 38 C.F.R. §§ 4.40, 4.45. Therefore, the Board finds that the Veteran's right hip (flexion) disability warrants no more than the 10 percent evaluation assigned prior to December 19, 2014, and no more than the noncompensable rating assigned thereafter. Limitation of Abduction Under DC 5253 (abduction), a 10 percent rating is warranted for limitation of rotation of the affected leg (with an inability to "toe-out" more than 15 degrees) or limitation of adduction causing an inability to cross legs, and a 20 percent evaluation for limitation of abduction resulting in motion lost beyond 10 degrees. Prior to December 19, 2014, an initial compensable rating under DC 5253 is not warranted. There was no indication that the Veteran could not cross his legs until the December 19, 2014 private treatment record. The Board has considered the July 2010 private treatment record where the Veteran reported pain when sitting with his right leg crossed over, however, it was noted that the Veteran, nonetheless, was able to cross his legs, and subsequent VA and private treatment records in October 2010 and January 2012 did not repeat the same finding or show that he was unable to cross his legs. As such, the Board does not find that a single incident of reporting pain while crossing his legs to constitute a fulfillment of the criteria for a higher/compensable rating, especially in light of the surrounding evidence. The Veteran was afforded a VA examination in July 2014 to assess the nature and severity of his right hip disability. A review of this report, again, shows that adduction was not limited such that the Veteran could not cross his legs, and there was no evidence of that the Veteran's rotation was limited as to not be able to toe-out more than 15 degrees. Additionally, there was no indication of limitation of rotation of the affected leg noted in any VA or private treatment records prior to December 19, 2014. As such, the Board finds that the noncompensable rating was appropriately assigned prior to December 19, 2014. For the period from December 19, 2014, the Veteran's right hip disability has not been productive of limitation of abduction of the thigh with motion lost beyond 10 degrees. The available range of motion studies do not show right thigh abduction motion loss beyond 10 degrees during objective testing at any examinations of record during this relevant period. During this claims period, the Veteran was afforded VA examinations in November 2015, November 2017, and July 2021. A close review of these examination reveals that abduction was noted, at worst, at 25 degree, with no evidence any further decreases due to flare-ups and repeat motion. Other records during the same claims period, to explicitly include private examination reports from the Veteran's treating chiropractor also reflect abduction in excess of the criteria, with objective limitation of abduction, at worst, noted to be limited to 30 degrees. Therefore, as a higher 20 percent rating under DC 5253 requires a condition with loss of motion "beyond" 10 degrees, the Board must find that a rating in excess of 10 percent remains not warranted. In making this finding, the Board has considered the Veteran's complaints of experiencing pain on abduction and adduction; however, there is no indication that his reported pain and functional limitation caused by his right thigh disability further limits his abduction to a level approximating the maximum 20 percent rating. 38 C.F.R. §§ 4.40, 4.45; see also Mitchell, 25 Vet. App. at 38. Importantly, separate ratings for painful abduction, adduction, and/or rotation may not be assigned, as these are all evaluated under the same diagnostic code, DC 5253, and it is settled law that a single disability is not entitled to more than one disability rating within the same diagnostic code unless the regulation expressly provides otherwise. See Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010). Therefore, the Board finds that the Veteran's right hip limitation of rotation warrants no more than the 10 percent evaluation currently assigned under DC 5253, from December 19, 2014. Further, the Board has also considered the Veteran's condition during flare-ups, and any additional functional loss related to such. The Board notes that the Veteran's most recent VA examination in July 2021 reflects consideration of the Veteran's condition with regards to flare-up and repeat use over time and have explicitly found that no additional objective loss of range of motion, with regards to abduction or adduction, is found even considering flare-ups. In this regard, the examiner noted explicit consideration of the Veteran's subjective complaints of pain and symptoms. Accordingly, the preponderance of the evidence is against a finding of an initial compensable rating for limitation of extension of the right hip; for an initial rating in excess of 10 percent for right hip (abduction), prior to December 19, 2014, and a compensable rating thereafter; and for an initial compensable rating for impairment of the right hip, prior to December 19, 2014, and in excess of 10 percent thereafter. The Board has considered other diagnostic codes but found that they are not applicable here. The medical evidence of record reveals that he does not have ankylosis (DC 5250), flail joint of the hip (DC 5254), or impairment of the femur (DC 5255). Accordingly, a higher rating under these codes is not appropriate at any time during the appeal. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. There are no additional expressly raised or reasonably raised issues raised on the record. REASONS FOR REMAND 1. Entitlement to an increased rating in excess of 10 percent for a left knee disability (extension), prior to January 13, 2012 is remanded. 2. Entitlement to an increased rating in excess of 20 percent for a left knee disability (extension), from January 14, 2012, to October 20, 2016, is remanded. 3. Entitlement to an increased rating in excess of 30 percent for a left knee disability (extension), from October 21, 2016, to April 14, 2019, is remanded. 4. Entitlement to an increased rating in excess of 10 percent for a left knee disability (extension), from April 15, 2019, to May 2, 2019, is remanded. 5. Entitlement to an increased rating in excess of 20 percent for a left knee disability (extension), from May 3, 2019, to June 19, 2019, is remanded. 6. Entitlement to an increased rating in excess of 30 percent for a left knee disability (extension), from June 20, 2019, is remanded. 7. Propriety of the reduction from 30 percent to 10 percent effective April 15, 2019, for a left knee disability (extension), is remanded. 8. Entitlement to an increased rating in excess of 10 percent for a left knee disability (flexion), from December 11, 2018, is remanded. 9. Entitlement to an increased rating in excess of 10 percent for a right knee disability (extension), prior to January 13, 2012, is remanded. 10. Entitlement to an increased rating in excess of 20 percent for a right knee disability (extension), from January 14, 2012, to October 20, 2016, is remanded. 11. Entitlement to an increased rating in excess of 30 percent for a right knee disability (extension), from October 21, 2016, to April 14, 2019, is remanded. 12. Entitlement to an increased rating in excess of 10 percent for a right knee disability (extension), from April 15, 2019, to May 2, 2019, is remanded. 13. Entitlement to an increased rating in excess of 20 percent for a right knee disability (extension), from May 3, 2019, to June 19, 2019, is remanded. 14. Entitlement to an increased rating in excess of 30 percent for a right knee disability (extension), from June 20, 2019, is remanded. 15. Propriety of the reduction from 30 percent to 10 percent effective April 15, 2019, for a right knee disability (extension), is remanded. 16. Entitlement to an increased rating in excess of 10 percent for a right knee disability (flexion), from December 11, 2018, is remanded. The Board finds that with regards to both the Veteran's claims for increased rating for a right and left knee disabilities, the most recent VA examination afforded to the Veteran in July 2021 to be inadequate, and a remand is required. The Board notes that the VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.15(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Here, the Board notes that in accordance with the Board's last remand directive, the Veteran was afforded a VA examination in July 2021 addressing the Veteran's left and right knee disability. The Board, in its directives, required the examiner to explicitly and directly address functional loss due to flare-ups; this included providing, when possible, objective range of motion measurements with regards to functional loss during flare-ups. The Board notes, however, that a close review of the July 2021 VA examination reveals internal inconsistencies with specific regards to flare-ups. Specifically, in the initial section noting flare-ups, the examiner only noted and described symptoms regarding flare-ups regarding the right knee, however, when noting estimates for loss of range of motion or functional loss due to flare-ups, the examiner noted that the right knee experienced no flare-ups and noted no additional changes in functional loss due to such. The Board finds that such inconsistencies render the examination inadequate, as it fails to properly speak to any functional loss or potential loss of range of motion related to flare-ups reported by the Veteran. As such is an essential element in which was explicitly requested in the last remand directive, the Board must find that remand is again necessary to clarify the examination report. Therefore, the Board finds that, as the July 2021 VA examination is found to be inadequate, a remand is necessary for the VA to fulfil its duty to the Veteran. 17. Entitlement to an earlier effective date, prior to April 5, 2015, for assigned of a TDIU is remanded. Additionally, with regard to the claim for a TDIU, the Board finds that that claim is inextricable intertwined with those other conditions on remand, as those potential treatment records may yield additional information regarding such conditions. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, the claims for a TDIU must also be remanded. The matters are REMANDED for the following action: 1. Provide the claims file to the same VA examiner that conducted the July 2021 VA examination for an addendum/corrective opinion regarding the Veteran's bilateral knee disability; if the same examiner is not available schedule the Veteran for with an appropriate VA medical professional to determine the current nature and severity of his service-connected bilateral knee disability. The entire record must be made available to and be reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his service-connected knee disability. The examiner must address each of the following: (a) The examiner should describe all symptoms associated with the Veteran's service-connected bilateral knee disabilities since August 19, 2005; (b) The examiner should conduct range of motion testing (expressed in degrees) in active motion, passive motion, weight-bearing, and non weight-bearing. If pain is noted on range-of-motion testing, the examiner must specify at what point the Veteran's loss of range of motion was due to pain and at what point the evidence of pain ended; (c) The examiner should ask the Veteran to report any range of motion loss during flare-ups or following repeated use since August 19, 2005. The Veteran should be asked to identify: (1) the frequency of flare-ups; (2) the duration of flare-ups; (3) any precipitating factors; and (4) any alleviating factors. Even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to flare ups and ask him to describe the additional functional loss include loss of range of motion, if any, he suffers during flare-ups or following repeated use; (d) If the examination does not occur during a flare-up, based upon the evidence of record, and the information elicited on examination, to include the Veteran's lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that during flare-ups or following repeated use since August 19, 2005, (1) flexion has been limited to 30 degrees; and/ or (2) extension has been limited to 15 degrees. If flexion has been limited to less than 30 degrees and/or extension has been limited to less than15 degrees, please estimate the additional degree of motion loss during flare-ups or following repetitive use since August 19, 2005. 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, and duration of 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). All examination findings/testing results, along with a complete, clearly stated rationale for any opinion offered, must be provided. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ziheng Zhu, 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.