Citation Nr: 21068695 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-16 793 DATE: November 12, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for right hip strain with impairment of thigh is remanded. Entitlement to an initial rating in excess of 10 percent for left hip strain with impairment of thigh is remanded. Entitlement to an initial compensable disability rating for right hip strain with limitation of extension of thigh is remanded. Entitlement to an initial compensable disability rating for left hip strain with limitation of extension of thigh is remanded. Entitlement to a compensable disability rating for left hip strain with a femoral neck stress fracture is remanded. Entitlement to a compensable disability rating for right hip strain with a femoral neck stress fracture is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2010 to February 2011 and from May 2011 to September 2011. These matters are before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In October 2018 and April 2021, the Board remanded the Veteran's claims for further development. The record reflects that the Veteran's service-connected disabilities may have prevented him from working during the appeal period. See April 2018 Board hearing. Because a TDIU rating is inherent in any claim for an increased rating when raised by the appellant or by the record, see Rice v. Shinseki, 22 Vet. App. 447 (2009), it has been added as an issue. 1. Entitlement to an initial rating in excess of 10 percent for right hip strain with impairment of thigh is remanded. 2. Entitlement to an initial rating in excess of 10 percent for left hip strain with impairment of thigh is remanded. 3. Entitlement to an initial compensable disability rating for right hip strain with limitation of extension of thigh is remanded. 4. Entitlement to an initial compensable disability rating for left hip strain with limitation of extension of thigh is remanded. 5. Entitlement to a compensable disability rating for left hip strain with a femoral neck stress fracture is remanded. 6. Entitlement to a compensable disability rating for right hip strain with a femoral neck stress fracture is remanded. Despite the additional and regrettable delay, a further remand is needed in order to obtain an additional VA examination. A careful review if the record indicates that the Veteran's service-connected disabilities have a significant impairment on numerous muscle groups surrounding his pelvis, hips, and thighs. To date, the Veteran has not been afforded a pelvic girdle and thigh VA examination. The Board finds this additional examination necessary in order to completely evaluate the Veteran's total disability picture and could result in a higher disability evaluation under Diagnostic Codes 5313 through 5318. 38 C.F.R. § 4.55(b). Information specific to these diagnostic codes has not been obtained; thus, a remand is required for an additional VA examination. 7. Entitlement to a TDIU is remanded. The Veteran should be provided the opportunity to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, and provide any additional evidence relating to his inability to work during the appeal period. Additionally, the matter of entitlement to TDIU is inextricably intertwined with the Veteran's other remanded issues. Finally, the Veteran currently does not meet the schedular requirements to be entitled to TDIU. See 38 C.F.R. § 4.16(a). Thus, the Board will refer the matter to the Director, Compensation Service, for extraschedular consideration of TDIU (in the event he does not meet the schedular rating upon readjudication at the AOJ). See 38 C.F.R. § 4.16(b). Accordingly, entitlement to TDIU must be remanded as well. The matters are REMANDED for the following action: 1. The AOJ should provide the Veteran appropriate notice of VA's duties to notify and assist regarding how to substantiate a claim for entitlement to TDIU, to include providing him a VA Form 21-8940. The Veteran should assist in the matter by providing the requested information. 2. After the development in the first directive is completed, the AOJ should arrange for an examination of the Veteran to assess the current severity of his service-connected right and left hip disabilities. The examiner must review the entire record (including this remand) in conjunction with the examination and note such review was conducted. The examiner should provide a full description of the disability and report all signs and symptoms associated with the Veteran's disability. (a.) Specifically, the AOJ should schedule the Veteran for any and all examinations relating to the pelvic girdle, hip, and thigh. Diagnostic Codes 5250 to 5255 and 5313 to 5318. The examiner must report all signs and symptoms necessary for rating the Veteran's right and left hip disabilities under the applicable rating criteria. In particular, the examiner should provide the range of motion of the hips, in degrees. In so doing, the examiner should test the Veteran's range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, if possible. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she must clearly explain in the report why the testing is not required or cannot be completed. The presence of objective evidence of pain, premature or excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. The examiner shall inquire as to periods of flare-up and note the frequency and duration of any such flare-ups. Any additional impairment on use or in connection with flare-ups should be described in terms of the degree of additional functional impairment - including additional range of motion loss. The examiner should specifically describe the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she must clearly explain in the report why the testing is not required or cannot be completed. In assessing the current nature and severity of the Veteran's right and left hip disabilities, the examiner also is asked to address the functional impact of this disability in terms of the Veteran's ability to meet the demands of a substantially gainful job, whether sedentary or physical, including giving some indication of when this has occurred during the period of appeal under review. It is imperative the examiner discuss the underlying rationale for all opinions, regardless of whether favorable or unfavorable to the claims, preferably citing to specific evidence in the file supporting conclusions including examination findings and/or accepted medical authority. (Continued on the next page) 3. IF, after readjudication of the Veteran's disabilities, the Veteran does not meet the schedular TDIU requirements, then the AOJ should refer this case to the Director, Compensation Service, for extraschedular consideration of TDIU pursuant to 38 C.F.R. § 4.16(b). David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Williams, Associate 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.