Citation Nr: 21008454 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 10-46 144 DATE: February 17, 2021 ORDER For the period prior to January 15, 2016, entitlement to a compensable disability rating prior to January 30, 2012 and in excess of 20 percent thereafter for service-connected rheumatoid arthritis is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right ankle rheumatoid arthritis is denied. Entitlement to a disability rating in excess of 10 percent for service-connected left ankle rheumatoid arthritis is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right hip rheumatoid arthritis is denied. Entitlement to a disability rating in excess of 10 percent for service-connected left hip rheumatoid arthritis is denied. FINDINGS OF FACT 1. Prior to January 30, 2012, the service-connected rheumatoid arthritis has not been manifested by 1 or 2 exacerbations a year in a well-established diagnosis; from January 30, 2012, rheumatoid arthritis has not been manifested by incapacitating exacerbations occurring three or more times a year; at no time prior to January 15, 2016 is the Veteran shown to have or compensable limitation of motion of either ankle, shoulder, knee, and/or lumbosacral spine related to rheumatoid arthritis residuals. 2. Throughout the period on appeal, the Veteran’s right ankle rheumatoid arthritis is manifested by no more than moderate limited motion of the ankle. 3. Throughout the period on appeal, the Veteran’s left ankle rheumatoid arthritis is manifested by no more than moderate limited motion of the ankle. 4. Throughout the appeal period, the Veteran’s right hip rheumatoid arthritis is manifested by no more than painful or limited motion, but with extension of the hip or thigh to more than 5 degrees, flexion to more than 45 degrees, abduction to beyond 10 degrees, adduction with ability to cross the legs, and rotation with ability to toe-out more than 15 degrees; with no ankylosis, flail joint of the hip, or impairment of the femur. 5. Throughout the appeal period, the Veteran’s left hip rheumatoid arthritis is manifested by no more than painful or limited motion, but with extension of the hip or thigh to more than 5 degrees, flexion to more than 45 degrees, abduction to beyond 10 degrees, adduction with ability to cross the legs, and rotation with ability to toe-out more than 15 degrees; with no ankylosis, flail joint of the hip, or impairment of the femur. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating prior to January 30, 2012 and in excess of 20 percent thereafter for service-connected rheumatoid arthritis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5002. 2. The criteria for a disability rating in excess of 10 percent for right ankle rheumatoid arthritis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 3. The criteria for a disability rating in excess of 10 percent for left ankle rheumatoid arthritis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 4. The criteria for a disability rating in excess of 10 percent for right hip rheumatoid arthritis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 5. The criteria for a disability rating in excess of 10 percent for left hip rheumatoid arthritis have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1969 to April 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This case was most recently before the Board in January 2018 when it was remanded for additional development. It has returned for adjudication. Increased Ratings A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 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 rating 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Regarding the Veteran’s musculoskeletal disabilities, VA examiners consistently found no additional loss upon repetitive testing of each of the joints. They have not given an estimate of additional loss during flare-ups, or they stated that no opinion could be provided without mere speculation because there is no basis for making such a determination without directly observing function during a flare-up. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the Veteran has generally denied flare-ups or impact other than increased pain. There is no argument or indication that his pain or other factors during flare-ups results in additional loss of motion over that outlined below for each condition. Furthermore, the guidance on how to evaluate flare-ups has not been particularly clear. As a consequence, it is determined that the holding in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), will be expanded and flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated. The statements in this case do not show that flare-ups additionally limited function in a quantifiable way, or that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. Multiple VA examiners attempted to elicit this information from the Veteran, and he primarily reported increased pain with prolonged standing or walking but no additional impact. Notably, pain alone is not sufficient to constitute limitation of motion. 1. Prior to January 15, 2016, entitlement to a compensable disability rating prior to January 30, 2012 and in excess of 20 percent thereafter for service-connected rheumatoid arthritis By way of history, service connection for rheumatoid arthritis was granted in a January 2006 rating decision. Thereafter, in a March 2016 rating decision, compensation for rheumatoid arthritis was discontinued in favor of separate compensable evaluations of the affected joints, effective January 15, 2016. The Veteran asserts that he is entitled to an increased disability rating for his service-connected rheumatoid arthritis for the period prior to January 15, 2016. During the appeal period, the Veteran’s service-connected rheumatoid arthritis is rated noncompensably prior to January 30, 2012 and 20 percent disabling thereafter pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5002. Under this diagnostic code, rheumatoid arthritis as an active process with 1 or 2 exacerbations per year in a well-established diagnosis warrants a 20 percent disability rating. A 40 percent disability rating is assigned when there are symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent disability rating is assigned when there is less than total incapacitation as defined in the 100 percent disability rating, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year, or a lesser number over prolonged periods. A 100 percent disability rating is warranted for totally incapacitating constitutional manifestations associated with active joint involvement. The provisions of Diagnostic Code 5002 also provide that chronic residuals of rheumatoid arthritis, such as limitation of motion or ankylosis, favorable or unfavorable, are rated under the appropriate Diagnostic Codes for the specific joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5002. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the respective diagnostic code provisions, a 10 percent disability rating is to be assigned for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis; the higher rating will be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5002, Note. During an October 2006 VA examination, the Veteran reported pain and stiffness in his joints. The examiner found no evidence of rheumatoid arthritis on examination or upon review of the Veteran’s treatment records. Rather, the examiner indicated there are no residuals associated with the Veteran’s rheumatoid arthritis. The Veteran submitted an August 2007 statement from his physician, Dr. J.E., indicating that the Veteran experiences pain and moderate decline in physical activities related to a history of rheumatoid arthritis, degenerative joint disease of the knees, and right adhesive capsulitis. Dr. J.E. indicated that the Veteran had a mildly elevated erythrocyte sedimentation rate, elevated C-reactive protein, and negative cyclic citrullinated peptide, rheumatoid factor, and antinuclear antibodies. Radiographs of the hands showed no evidence of inflammatory arthropathy. Knee films were consistent with osteoarthritis versus calcium pyrophosphate deposition. A VA joints examination report dated in April 2009 reflects a diagnosis of rheumatoid arthritis during the Veteran’s period of service. At that time, the Veteran reported pain in his elbows, knees, and shoulders without radiation. He stated that he could get flare-ups with any strenuous activity and he used a cane for ambulation. He denied any episodes of dislocation or subluxation. Range of motion testing revealed elbow extension to 0 degrees and flexion to 145 degrees. Forward elevation of the shoulders was 160 degrees, abduction to 140 degrees, internal rotation to 90 degrees, and external rotation to 30 degrees. Extension of the knees was to 0 degrees and flexion to 120 degrees. The Veteran had pain on all movements but the examiner noted that he stopped at the point where the pain began. Repetitive motion did not increase the loss of range of motion and there was no evidence of edema, instability, weakness, tenderness, or abnormal movement. The examiner indicated that inflammatory arthritis was not seen on the examination. In August 2010, a VA examiner opined that the Veteran’s knees and shoulders were not affected by rheumatoid arthritis. The rationale is that the Veteran has had a negative rheumatoid factor from April 2007, no evidence of erosive changes consistent with rheumatoid arthritis, and a normal erythrocyte sedimentation rate which is an indication for little inflammation of which rheumatoid is an inflammatory process. The Veteran also had a negative anti-CPP which is a more specific indicator for rheumatoid arthritis. Since these tests were negative, the examiner found that the Veteran’s bilateral knee and shoulder disabilities were not a residual of his rheumatoid arthritis. In a February 2011 statement, Dr. J.E. reiterated his August 2007 diagnostic findings. However, he found that it was at least as likely as not that the Veteran’s current symptoms could be a result of his rheumatoid arthritis. During a January 2012 VA examination, the Veteran reported pain in the lower extremities and back. He noted that he also had intermittent swelling in the joints of the hands. He did not require continuous use of medication for his arthritis and he had not lost any weight. The Veteran had pain in the knees that he stated began after 5 minutes of walking. There were no joint deformities attributable to his arthritis condition. The Veteran reported 4 non-incapacitating exacerbations per year where he was unable to walk more than 5 minutes. The Veteran denied incapacitating exacerbations and he did not have constitutional manifestations associated with active joint involvement which were totally incapacitating. The Veteran used a cane constantly for locomotion. Treatment records show ongoing complaints of pain in the Veteran’s back and lower extremities. The Veteran received regular corticosteroid injections in his right knee related to complaints of swelling and inflammation. However, there is no indication of incapacitation related to his complaints and no range of motion findings showing decreased functionality. Further, the Veteran had leg weakness that was attributed to peripheral vascular disease. The Board finds the Veteran’s comments and statements regarding his disability are consistent with the objective evidence contained in the treatment records. After a review of the above, the Board finds that the record does not contain competent and credible evidence of 1 or 2 exacerbations per year in a well-established diagnosis until January 30, 2012, the date of the VA examination. Prior to that time, there is no evidence, objective or subjective, of incapacitation. Beginning January 30, 2012, there is no evidence of symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. Indeed, there is no objective evidence of incapacitating episodes at any point during the appeal period. The Board has also considered whether there is competent and credible evidence of compensable limitation of motion in the Veteran’s reportedly affected joints, the shoulders, knees, or lumbosacral spine, to warrant an increased rating under the second part of Diagnostic Code 5002. With regard to the shoulders, favorable ankylosis of scapulohumeral articulation, with abduction to 60 degrees, and the ability to reach mouth and head warrants a 20 percent disability rating (minor shoulder) and 30 percent disability rating (major shoulder). 38 C.F.R. § 4.71a, Diagnostic Code 5200. Limitation of motion of the minor and major arm at shoulder level warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal range of motion of the shoulder is flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. See 38 C.F.R. § 4.71a, Plate I. With regard to the knees, ankylosis at a favorable angle in full extension or in slight flexion between zero degrees and 10 degrees warrants a 30 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5256. If flexion of the knee is limited to 45 degrees, a 10 percent disability rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5260. If extension of the knee is limited to 10 degrees, a 10 percent disability rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II. With regard to the lumbosacral spine, the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula), provides a 10 percent disability rating if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or a vertebral body fracture with loss of 50 percent or more of the height. On review of the evidence of record, there are no indications of compensatory limitations of motion of the Veteran’s joints at any time during the appeal period. Further, the Veteran’s noted weakness was attributed to a separately diagnosed, nonservice-connected disability. The Board has considered the provisions of 38 C.F.R. § 4.59, as well as the holdings in DeLuca v. Brown, 8 Vet. App. 202 (1995), Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017), to the extent that they are applicable. The Veteran reported back and knee pain but there is a lack of functional impairment shown throughout the treatment records related to anything other than weakness caused by peripheral vascular disease. Pain alone does not warrant a compensable disability rating. Functional impairment must be shown. The Board finds it particularly persuasive that the January 2012 VA examiner concluded that there was no additional loss of range of motion after repetitive-use testing of the knees and did not find that the spine was affected by arthritis. The Board has considered whether any other Diagnostic Codes related to disabilities of the joints would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In summary, the preponderance of the evidence is against finding a compensable disability rating is warranted prior to January 30, 2012 or a disability rating in excess of 20 percent is warranted thereafter for the Veteran’s service-connected rheumatoid arthritis. The appeal is denied. 2. Entitlement to a disability rating in excess of 10 percent for service connected right ankle rheumatoid arthritis 3. Entitlement to a disability rating in excess of 10 percent for service connected left ankle rheumatoid arthritis The Veteran contends that he is entitled to a 20 percent disability rating for each ankle. The Veteran’s ankles are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. As noted above, for chronic residuals of rheumatoid arthritis, limitation of motion and ankylosis are to be rated under appropriate diagnostic codes for the specific joints involved and that ratings for active process will not be combined with the residual ratings for limitation of motion or ankylosis. Rather, the evaluator should assign the higher rating. Beginning January 15, 2016, a higher rating is assigned when evaluating each individual joint. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Descriptive terms such as “moderate” and “marked” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Normal range of motion of the ankle is 20 degrees dorsiflexion and 45 degrees plantar flexion. 38 C.F.R. § 4.71a, Plate II. The Veteran was afforded a VA examination in January 2016. At that time, the Veteran noted that he has swelling, numbness, and sharp pain in his bilateral ankles that make it difficult to get around. He reported flares of numbness and sharp ankle pain 1 or 2 times a month lasting 1 week. The Veteran further stated that he has a hard time walking and standing related to his ankle pain. Range of motion testing of both ankles revealed dorsiflexion to 15 degrees and plantar flexion to 35 degrees. The examiner noted that there was pain on the examination but it did not result in a functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and no evidence of pain with weight bearing or crepitus. There was no loss of range of motion on repetition and the examiner stated that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use or with flare-ups. Muscle strength testing was normal bilaterally and there was no evidence of atrophy. There was no evidence of ankylosis, instability, or dislocation. The Veteran reported constant use of a walker for ambulation related to his back pain with lower extremity weakness. The examiner stated that January 2016 imaging studies did not reveal current degenerative or traumatic arthritis in either ankle. The examiner found that the Veteran’s ankle disabilities would not impact his ability to perform any type of occupational task. The Veteran was afforded an additional VA ankle examination in December 2016. At that time, the Veteran stated that his bilateral ankle pain had increased since the January 2016 examination. The Veteran reported flare-ups of the ankles daily lasting until he rests. He noted sharp pain with prolonged standing. The Veteran stated that he has weakness in his ankles and that he is unable to stand or walk long distances. Range of motion testing revealed dorsiflexion to 10 degrees bilaterally, right ankle plantar flexion to 25 degrees, and left ankle plantar flexion to 30 degrees. The examiner noted that there was pain on the examination but it did not result in a functional loss. There was objective evidence of mild tenderness to palpation of the joint on both ankles. However, there was no evidence of pain with weight bearing or crepitus. There was no loss of range of motion on repetition and the examiner stated that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. The examiner noted swelling in both ankles. Muscle strength testing was normal bilaterally and there was no evidence of atrophy. There was no evidence of ankylosis, instability, or dislocation. The Veteran reported constant use of a walker for ambulation related to conditions of his knees, hips, and ankles. The examiner stated that imaging studies did not reveal current degenerative or traumatic arthritis in either ankle. The examiner found that the Veteran’s ankle disabilities would impact his ability to lift, carry heavy loads, and stand or walk for extended periods. The Veteran was afforded another VA ankle examination in March 2018. At that time, the Veteran stated that his ankle condition has stayed the same. He reported stiffness and pain with walking and pain with any movement. He had throbbing pain but no tingling. The Veteran denied flare-ups of the ankle but stated he had problem with walking and balancing related to pain and stiffness. He also indicated that he had mobility issues. Range of motion testing revealed dorsiflexion to 20 degrees bilaterally and bilateral ankle plantar flexion to 45 degrees. The examiner noted that there was pain on the examination but it did not result in a functional loss. There was objective evidence of mild tenderness to palpation of the medial and lateral aspects of both ankles. While there was evidence of pain with weight bearing, there was no evidence of crepitus. There was no loss of range of motion on repetition and the examiner stated that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. Muscle strength testing was normal bilaterally and there was no evidence of atrophy. There was no evidence of ankylosis, instability, or dislocation. The Veteran reported regular use of a cane and walker for ambulation related to his balance issues. The examiner stated that March 2018 imaging studies did not reveal current degenerative or traumatic arthritis in either ankle. The examiner found that the Veteran’s ankle disabilities would not impact his ability to perform occupational tasks. The examiner noted that there was objective evidence of pain on passive range of motion testing of the bilateral ankles. There was no evidence of pain on non-weight-bearing testing of either ankle. After review of the above, the Board finds that the evidence does not support that the Veteran is entitled to higher ratings for his rheumatoid arthritis of the ankles. While pain during range of motion was noted during each examination and swelling was noted on 1 examination during the appeal period, his limitation is motion is most nearly approximated by a moderate impairment. Indeed, during the most recent examination, the Veteran was not found to have any loss of range of motion. The Veteran also regularly denied flare-ups of pain and attributed his need for assistive devices to multiple disabilities, only sometimes including his ankles. The Board finds it particularly persuasive that the Veteran was able to perform repetitive testing without additional loss in range of motion. The Board acknowledges the Veteran’s contentions that he is entitled to higher ratings due to pain. The Board finds that the Veteran is a lay person and is competent to report observable symptoms he experiences through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He, however, is not competent to identify a specific level of disability according to the appropriate diagnostic codes. The evaluation is based on the objective evidence offered by the VA examiners in the examination reports and is consistent with the findings in the Veteran’s treatment records. The Board has also considered whether ratings higher than 10 percent could be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.49. The 10 percent disability ratings are based on chronic residuals of the Veteran’s rheumatoid arthritis and pain on movement. The record shows no additional factors which would restrict motion to such an extent that the criteria for a 20 percent rating would be justified. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. For the foregoing reasons, the preponderance of the evidence is against awarding disability ratings higher than 10 percent for the rheumatoid arthritis in the Veteran’s ankles. In denying such ratings, the Board finds the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 4. Entitlement to a disability rating in excess of 10 percent for service connected right hip rheumatoid arthritis 5. Entitlement to a disability rating in excess of 10 percent for service connected left hip rheumatoid arthritis The Veteran asserts that higher ratings are warranted for his bilateral hip rheumatoid arthritis. The Veteran is assigned 10 percent ratings for each hip under 38 C.F.R. § 4.71a, Diagnostic Code 5252, for rheumatoid arthritis with limited flexion of the thigh. There are several diagnostic codes pertinent to rating a disability of the hips. Under Diagnostic Code 5251, limitation of extension of the thigh to 5 degrees is assigned a 10 percent disability rating. Under Diagnostic Code 5252, limited flexion of the thigh to 45 degrees is assigned a 10 percent rating. A 20 percent or higher rating requires flexion limited to no more than 30 degrees. Under Diagnostic Code 5253, impairment of the thigh is assigned a 10 percent rating for limitation of rotation where cannot toe-out more than 15 degrees of the affected leg or for limitation of adduction where cannot cross legs; or a 20 percent rating for limitation of abduction where motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a. The Veteran was afforded a VA examination in January 2016. At that time, the Veteran reported daily sharp pain lasting all day and render him unable to sleep on his sides. The Veteran denied flare-ups of the hip or thigh and denied having functional loss related to his hip disabilities. Range of motion testing of the right hip revealed flexion to 110 degrees, extension to 25 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 50 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was no evidence of pain with weight bearing, pain with palpation of the joint, or crepitus. Range of motion testing of the left hip revealed flexion to 100 degrees, extension to 30 degrees, abduction to 40 degrees, adduction to 25 degrees, external rotation to 45 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was no evidence of pain with weight bearing, pain with palpation of the joint, or crepitus. The Veteran was able to perform repetitive-use testing without additional loss of range of motion on either hip. The examiner found that pain, weakness, fatigability, and incoordination would not significantly limit functional ability with repeated use over a period of time for either hip. Muscle strength testing was normal bilaterally and there was no evidence of atrophy or ankylosis. There was no evidence of malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported constant use of a walker related to his back pain with lower extremity weakness. The examiner indicated that the Veteran’s hip disabilities would not impact his ability to perform any type of occupational tasks. The Veteran was afforded an additional VA examination in December 2016. At that time, the Veteran stated that his condition had worsened and he used ibuprofen and a topical cream for pain. The Veteran denied flare-ups of hip pain but noted that he has weakness and is unable to stand or walk for prolonged periods of time related to his hip disabilities. Range of motion testing of the right hip revealed flexion to 100 degrees, extension to 30 degrees, abduction to 35 degrees, adduction to 25 degrees, external rotation to 50 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was no evidence of pain with weight bearing, pain with palpation of the joint, or crepitus. Range of motion testing of the left hip revealed flexion to 100 degrees, extension to 30 degrees, abduction to 40 degrees, adduction to 25 degrees, external rotation to 50 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was no evidence of pain with weight bearing, pain with palpation of the joint, or crepitus. The Veteran was able to perform repetitive-use testing without additional loss of range of motion on either hip. The examiner found that pain, weakness, fatigability, and incoordination would not significantly limit functional ability with repeated use over a period of time for either hip. Muscle strength testing was normal bilaterally and there was no evidence of atrophy or ankylosis. There was no evidence of malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported constant use of a walker related to his knees, hips, and ankles. Imaging studies of the hips did not reveal degenerative or traumatic arthritis of either hip. The examiner indicated that the Veteran’s hip disabilities would impact his ability to left, carry heavy loads, and stand or walk for prolonged periods. The Veteran was afforded a final VA examination in March 2018. At that time, the Veteran reported that his symptoms were worse than his last examination. He noted that he is prone to falls due to balance and stability issues. He also indicated that walking and standing are difficult. He reported increased pain on days with a lot of movement and activity. The Veteran stated that he had flare-ups of hip pain that caused mobility issues and he reported that he generally had a loss of balance and problems with walking. Range of motion testing of the right hip revealed flexion to 100 degrees, extension to 20 degrees, abduction to 30 degrees, adduction to 20 degrees, external rotation to 40 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was evidence of pain with weight bearing and mild tenderness to palpation of the anterior aspect. There was also objective evidence of crepitus. Range of motion testing of the left hip revealed flexion to 100 degrees, extension to 20 degrees, abduction to 30 degrees, adduction to 25 degrees, external rotation to 35 degrees, and internal rotation to 30 degrees. He was able to cross his legs and the decreased range of motion was not found to contribute to a functional loss. Pain was noted on examination but it did not result in a functional loss. There was evidence of pain with weight bearing and mild tenderness to palpation of the anterior aspect. There was no evidence of crepitus. The Veteran was able to perform repetitive-use testing without additional loss of range of motion on either hip. The examiner found that pain, weakness, fatigability, and incoordination would not significantly limit functional ability with repeated use over a period of time for either hip. Muscle strength testing was normal bilaterally and there was no evidence of atrophy or ankylosis. There was no evidence of malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported regular use of a cane and walker related to balance issues. Imaging studies of the hips did not reveal degenerative or traumatic arthritis of either hip. The examiner indicated that the Veteran’s hip disabilities would not impact his ability to perform occupational tasks. There was objective evidence of pain on passive range of motion testing of both hips and no evidence of pain on non-weight bearing testing of either hip. After a review of the above, the Board finds that the Veteran retained extension to more than 5 degrees, flexion of both hips or thighs to more than 45 degrees, abduction to beyond 10 degrees, adduction with ability to cross the legs, and rotation with ability to toe-out more than 15 degrees. The evidence does not meet the criteria for a compensable rating for limitation of motion under diagnostic codes 5251 to 5253. There is also no ankylosis, flail joint of the hip, or impairment of the femur (fracture with nonunion, false joint, or malunion) of either hip to warrant a separate rating under Diagnostic Codes 5250, 5254, or 5255. 38 C.F.R. § 4.71a. Although the Veteran reported increased pain at times with flare-ups, no resulting additional functional loss was estimated. As explained above, the evidence elicited from the Veteran does not suggest a quantifiable additional loss, so no additional VA examination or opinion is needed. Pain alone does not warrant a separate or higher rating without resulting additional functional loss, and painful motion alone does not constitute limited motion for the purposes of rating under the codes pertaining to limitation of motion for a particular disability, as opposed to assigning a minimum rating. As the evidence reflects that the Veteran retained significant motion of his hips despite pain, it did not result in a greater degree of functional loss or limitation than noted above. Accordingly, because he has painful motion resulting in functional loss at times that is noncompensable under the applicable diagnostic codes for the involved joint, the Veteran has been assigned a 10 percent rating for his arthritis of each hip, which is a major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5002. Similarly, 38 C.F.R. § 4.59 provides for a minimum compensable rating for actually painful joints in conjunction with a diagnostic code based on limitation of motion. See Sowers v. McDonald, 27 Vet. App. 472, 479 (2016); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). (Continued on the next page)   For the foregoing reasons, the preponderance of the evidence is against awarding disability ratings higher than 10 percent for the rheumatoid arthritis in the Veteran’s hips. In denying such ratings, the Board finds the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Connor, 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.