Citation Nr: 21014327 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 13-23 526 DATE: March 11, 2021 ORDER A schedular rating of 20 percent for a left ankle disability is granted. A schedular rating in excess of 10 percent for a left hip disability is denied. A schedular rating in excess of 10 percent for a left knee disability is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, to include on an extraschedular basis, is remanded. FINDINGS OF FACT 1. The Veteran’s left ankle disability is characterized by marked limitation of motion. 2. The Veteran’s left hip disability is characterized by functional loss due to popping, painful motion, flexion of at least 124 degrees, and extension of greater than 5 degrees, without limitation of adduction such that motion is lost beyond 10 degrees, evidence of ankylosis, flail joint of the hip, or impairment of the femur. 3. The Veteran’s left knee disability is characterized by painful motion but is not characterized by objective evidence of flexion limited to 30 degrees or less or of less than full extension. CONCLUSIONS OF LAW 1. The criteria for a schedular rating of 20 percent for a left ankle disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5270-74. 2. The criteria for a schedular rating in excess of 10 percent for a left hip disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5250-55. 3. The criteria for a schedular rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-63. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2005 to March 2008. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision of the Department of Veterans Affairs (VA) regional office (RO) in Seattle, Washington. The Board remanded the Veteran’s claims in October 2015, December 2018, and, most recently, in October 2020 for additional evidentiary development. The October 2020 remand directives remand directives instructed that the Veteran be provided the opportunity to complete an authorization for or submit records from the Idaho Department of Labor: Disability Determinations Service Division concerning the claimed disabilities. A letter requesting authorization to obtain such records was sent to the Veteran at his documented mailing address that same month. The letter indicated that were a response not received within thirty days, a decision may be made on the Veteran’s claim. To date, no response has been received. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered because of or incident to military service. 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. 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. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA must determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a “staged rating.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, 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, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Left Ankle Disability The Veteran maintains entitlement to a disability rating in excess of 10 percent for his service-connected left ankle disability, currently rated under Diagnostic Code 5272-5024. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional Diagnostic Code to identify the basis for the rating. 38 C.F.R. § 4.27. The hyphenated code indicates that the Veteran’s disability is assessed under Diagnostic Code 5272, which governs ankylosis of the ankle, and Diagnostic Code 5024, which governs tenosynovitis and directs that the disability be evaluated based on limitation of motion of the affected part. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is important to note that changing the Diagnostic Code under which a particular disability is rated does not change the service-connected status of the disability itself; rather adjudicators always strive to rate a disability under the most appropriate Diagnostic Code and changing a Diagnostic Code may represent a progression or alteration in the functional impairment resulting from the disability or the Veteran’s inability to perform certain acts. Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011). Ankle disabilities are generally rated under Diagnostic Codes 5270 to 5274 of 38 C.F.R. § 4.71a. Under Diagnostic Code 5270, a 10 percent rating is warranted for moderate limitation of motion and a maximum 20 percent rating is warranted for marked limitation of motion. Normal range of motion in the ankle is 45 degrees plantar flexion and 20 degrees dorsiflexion. See 38 C.F.R. § 4.71a, Plate II. The words “moderate” and “marked” are not defined in the VA Schedule for Rating Disabilities. Furthermore, the use of terminology by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at an appropriate rating that would compensate the veteran for losses such as impairment in earning capacity and functional impairment. 38 C.F.R. §§ 4.2, 4.6. Diagnostic Codes 5270 and 5272 evaluates ankylosis, Diagnostic Code 5273 evaluates astragalus, and Diagnostic Code 5274 evaluates astragalectomy. The medical record does not document any of these conditions. Therefore, these Diagnostic Codes are not applicable and will not be discussed further. As the Veteran sought an increased disability rating in September 2010, the Board will review all relevant evidence from one year prior to that date. An October 2009 VA treatment record documents the Veteran’s complaints of left ankle pain. A January 2010 radiological study of the Veteran’s left ankle showed no fractures or subluxation. Ankle mortise was well aligned and well-maintained without degenerative changes; the report was unremarkable. February and March 2010 VA treatment records document the Veteran’s complaints of constant pain in the lateral-anterior ankle joint region, as well as complaints of pain at the achilles insertion. He stated that pain increased with/proportional to weightbearing after forty minutes or with standing greater than one to two hours. He denied any mid or distal foot pain. The Veteran denied the use of a brace, stated that he took Vicodin for pain, and had no history of joint injection. On physical examination, the Veteran’s gait was stiff, slow, and antalgic. The Veteran was able to perform heel/toe walking with some subjective left ankle pain. On inspection, there was trace left anterior-lateral joint swelling. There was no erythema, ecchymosis, deformity, or wounds. Tenderness to palpation was observed in the medial, lateral joint, medial malleolus, and achilles insertion of varying severity. Range of motion showed plantarflexion to 25 degrees and dorsiflexion to 15 degrees. There was no focal instability with the left ankle joint. Varus, valgus, and Lachman’s tests were negative. Ankle strength was normal with somewhat subjective poor effort. Thompson test was negative. Pulses were normal. The Veteran underwent a VA examination in October 2010. The Veteran reported that his left ankle disability had worsened, resulting in difficulty walking and standing due to pain and swelling. He denied use of ankle boots or ankle braces and had not had any injections or surgery. He used a cane, but this use was attributed to concerns about left knee instability. On physical examination, the Veteran’s left ankle was symmetrical with the opposite side with no appreciable swelling. There was no puffiness, redness, or any other overt signs. The Veteran was palpating over the ankle but could not give a consistent response as to whether he had point tenderness. For the most part it was medially and behind the lateral malleolus. No instability, crepitus, or popping with active motion were observed. There was no evidence of synovitis or effusion. The Veteran was able to generate good power of resistance resisting the examiner taking the ankle in either an inverted or an everted direction. The Veteran complained a little about some discomfort laterally when he everted from an inverted position against resistance. Circulation was normal. There were no palpable spurs around the ankle. Ankle motion was noted to be 42 degrees initially, and the fourth motion was 45 degrees. Dorsiflexion was 100 degrees on initial measurement and 98 degrees on the fourth measurement. In other words, the Veteran was 10 degrees above neutral initially with dorsiflexion and was 8 degrees above neutral in the fourth motion. Ankle inversion is to 25 degrees initially, and the fourth motion was 22 degrees. Ankle eversion is to 5 degrees initially and 6 degrees on the fourth motion. Imaging studies were normal. The Veteran’s left ankle films were normal. The examiner noted that there may have been an effusion bar or a correlation of the medial edge of the lateral calcaneocuboid joint. That was the only abnormality found on the foot or ankle films. The examiner concluded that the condition of the Veteran’s left ankle was that of a congenital bar that was seen on X-rays but was completely asymptomatic with the Veteran not localizing any symptoms to that area of the ankle. There were no other findings in the ankle at all, and the finding was otherwise that of no condition of the ankle. March 2011 VA treatment records document the Veteran’s continued complaints of left ankle pain with new symptoms of sharp pain along the medial left lower extremity from the knee to the ankle region to light touch (dysesthesias). On physical examination, the Veteran’s gait was stiff, slow, and antalgic. The Veteran was able to perform heel/toe walking with some subjective left ankle pain. On inspection, there was trace left anterior-lateral joint swelling. There was no erythema, ecchymosis, deformity, or wounds. Tenderness to palpation was observed in the medial, lateral joint, medial malleolus, and achilles insertion of varying severity. Range of motion showed plantar flexion to 25 degrees and dorsiflexion to 15 degrees. There was no focal instability with the left ankle joint. Varus, valgus, and Lachman’s tests were negative. Ankle strength was normal with subjectively poor effort. An MRI performed at the end of that month revealed fibrous talocalcaneal tarsal coalition, at the middle subtalar facet/sustentaculum talus. At an April 2011 physical therapy consultation, the Veteran reported worsening left ankle pain, specifically with weightbearing. He used a cane for ambulation. Left ankle flexion was to 12 degrees. Extension was to 40 degrees. Inversion was to 8 degrees with pain in the lateral ankle and the talocrural joint region. Eversion was to 12 degrees. The examiner noted chronic left ankle pain affecting the overall function of the left lower extremity. He also observed decreased ankle range of motion from the previous physical therapy evaluation. There was no apparent contribution to the Veteran’s lower extremity disability from the lumbar spine. At a VA appointment in May 2012, the Veteran’s left ankle demonstrated full range of motion and normal strength. It was diffusely tender to very light touch. The Veteran underwent a VA examination in January 2016. He reported chronic ankle pain, increased achilles tendon pain as well as lateral ankle pain with palpation. He stated that eversion of the ankle led to immediate pain. Concerning flare-ups, he stated that eversion, prolonged standing, walking, and weightbearing, walking on uneven ground, and certain footwear resulted in increased pain and swelling. On physical examination, range of motion was normal. Dorsiflexion was to 20 degrees and plantar flexion was to 45 degrees. Pain was noted on dorsiflexion. There was evidence of pain with weightbearing. The Veteran reported achilles pain with dorsiflexion, tenderness to the achilles tendon with palpation and weightbearing, and lateral ankle pain was noted with eversion of the ankle. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion after three repetitions. The Veteran was examined immediately after repeated use over time. Pain was noted to significantly limit the Veteran’s functional ability with repeated used over time. The examination was conducted during a flare-up and the examiner found that pain significantly limited functional ability during flares. He noted that the Veteran’s range of motion was unchanged with pain to the achilles tendon and lateral ankle increased with repetitive range of motion testing and with direct pressure and eversion, causing flare-up. The examiner observed that the Veteran’s left ankle condition caused disturbance of locomotion (the Veteran limped due to ankle pain) and interference with standing (prolonged walking and standing made pain worse). Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. Ankle instability or dislocation was not suspected. The Veteran did not have nor had he ever had “shin splints,” achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), nor had he ever had a talectomy (astragalectomy). The Veteran reported regular use of a walking stick; however, the examiner observed that he did not appear unsteady on his feet. The examiner recounted diagnostic testing results from October 2013 which did not document degenerative or traumatic arthritis and were grossly normal. The examiner noted that imaging from service had shown tarsal coalition which is what the Veteran was separated from service for. Concerning overall functional impact of the condition, the examiner noted that the Veteran should avoid occupations which required prolonged walking, standing, climbing, or carrying heavy loads. The Veteran was afforded a VA examination in February 2020. There, the Veteran described his current symptoms as constant “hammer hitting” ankle pain rated at 9 or 10/10. He stated that he used ice for swelling and Tylenol or Ibuprofen as needed. The Veteran indicated that he used a crutch for distance walking and a Cooper fit sleeve that helped a little. He stated that he had to be careful with his left ankle and could not run, go on walks with his family, or walk his dog. The Veteran described severe flare-ups of pain when walking more than .25 miles and swelling with walking or standing. On physical examination, range of motion was normal. Dorsiflexion was to 20 degrees and plantar flexion was to 45 degrees. Pain was observed on both dorsiflexion and plantar flexion. There was evidence of pain with weightbearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the left ankle that was diffuse and mild in severity. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repeated use over time or during a flare-up. However, the examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss under both conditions. Pain, weakness, fatigability, or incoordination did not significantly limit the Veteran’s functional ability with repeated use over time. However, pain did limit the Veteran’s functional ability during flares. This pain did not result in additional loss of range of motion. The examiner observed that the Veteran’s left ankle condition caused disturbance of locomotion and interference with standing. Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. Ankle instability or dislocation was not suspected. The Veteran did not have nor had he ever had “shin splints,” achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), nor had he ever had a talectomy (astragalectomy). The Veteran reported regular use of a walking stick and did not appear steady on his feet. The examiner recounted diagnostic testing results from October 2013 which did not document degenerative or traumatic arthritis and were grossly normal. Concerning overall functional impact of the condition, the examiner noted that it affected the prolonged ability to stand and walk. The Board now turns to whether a higher disability rating is warranted. Following a review of the relevant evidence of record, the Board finds that the maximum 20 percent disability is warranted for the Veteran’s left ankle disability under Diagnostic Code 5271, as limitation of motion in the left ankle is marked. While range of motion findings at the October 2010, January 2016, and February 2020 VA examinations were grossly normal, VA treatment records document loss in plantar flexion of up to 20 degrees due to pain. Further, objective evidence of pain which significantly limited functional ability, swelling, and tenderness to palpation in the medial, lateral joint, medial malleolus, and achilles insertion has been detailed in VA examination reports and treatment records throughout the appellate period, as has the Veteran’s unsteady gait and use of a walking stick to compensate for this unsteadiness. VA examiners have also consistently indicated that the Veteran’s left ankle disability causes significant disturbance of locomotion and interference with standing such that recommendations to avoid occupations requiring prolonged walking, standing, climbing, or carrying heavy loads were made. The Board therefore finds the evidence is sufficient to establish a disability picture more nearly approximating marked limitation of motion of the ankle. To meet the criteria for the next highest rating of 30 percent the evidence must demonstrate ankylosis of the ankle with plantar flexion between 30 and 40 degrees, or dorsiflexion between zero and 10 degrees. As previously discussed, the Veteran has never demonstrated or been diagnosed with ankylosis. The evidence indicates that the Veteran’s range of motion and functional limitation more closely resemble limitations represented by a 20 percent rating; therefore, the Board finds that a schedular rating of 20 percent, and no higher is warranted. Left Hip Disability The Veteran maintains entitlement to a disability rating in excess of 10 percent for his service-connected left hip disability, currently rated under Diagnostic Code 5251-5024. The hyphenated code indicates that the Veteran’s disability is assessed under Diagnostic Code 5271, which governs limitation of hip extension, and Diagnostic Code 5024, which governs tenosynovitis and directs that the disability be evaluated based on limitation of motion of the affected part. Hip disabilities are generally rated under Diagnostic Codes 5250 to 5255 of 38 C.F.R. § 4.71a. Under Diagnostic Code 5251, a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5252 provides evaluation of hip disabilities based on limitation of flexion. A 10 percent disability rating is warranted for limitation of flexion of the thigh to 45 degrees. A 20 percent rating is warranted for limitation of flexion of the thigh to 30 degrees. A 30 percent rating is warranted for limitation of flexion of the thigh to 20 degrees. A 40 percent rating is warranted for limitation of flexion of the thigh to 10 degrees. Diagnostic Code 5253 provides evaluation of hip disabilities based on impairment. A 10 percent disability rating is warranted for limitation of abduction of rotation of, cannot toe out more than 15 degrees of affected leg or limitation of adduction, cannot cross legs. A 20 percent rating is warranted for limitation of abduction, motion lost beyond 10 percent. Normal ranges of motion of the hip are for hip flexion from 0 degrees to 125 degrees and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Codes 5250 evaluates ankylosis, Diagnostic Code 5254 evaluates flail joint, and Diagnostic Code 5255 evaluates impairment of the femur. The medical record does not document any of these conditions. Therefore, these Diagnostic Codes are not applicable and will not be discussed further. As the Veteran sought an increased disability rating in September 2010, the Board will review all relevant evidence from one year prior to that date. October 2009 and March 2010 VA treatment record documents the Veteran’s complaints of left hip pain. He endorsed periodic physical therapy with stretch bands. In October 2010, the Veteran underwent a VA examination. The Veteran reported that his hip popped in and out when getting out of a chair or out of bed and that it also grinds. He stated that this occurred daily, as did knifelike pain primarily in the front of his hip. He indicated that he had no treatment for it. He denied aching pains or giving way and stated that he had no pain in his hip at rest. On physical examination, there was minor tenderness over the rectus muscle belly but the muscle itself was working great. There was no weakness. The Veteran had good power of holding the hip flexed to 45 degrees against a downward force, but it caused some minor discomfort in the tendon. The Veteran was held down on the bed and asked to flex the hip and this caused minor discomfort over the same tendon. There was no significant tenderness over the greater trochanter of the hip at all, and the Veteran had normal 45 degrees of external rotation of the hip initially and 45 degrees on repetitive testing. Internal rotation was to 20 degrees initially and to 25 degrees on the fourth motion. Hip flexion was to 125 degrees initially and the fourth motion was to 124 degrees. Hip extension was to 30 degree initially and the fourth motion was to 28 degrees. Abduction was to 32 degrees initially and the fourth motion was to 34 degrees. There was no popping around the hip and hip muscles (around the abductors). The gluteus medius and minimus were all normal. The Veteran was diagnosed with mild tendonitis over the front of the hip with X-rays being normal and no other findings to suggest any other hip condition. At an April 2011 VA physical therapy consultation that was primarily for the Veteran’s service-connected left hip disability, the Veteran reported ongoing hip popping. A May 2012 VA primary care note documents both hips as nontender and full internal and external rotation in both hips without pain. No pain was observed with abduction or adduction of the hips and they both were normal strength. Imaging studies were performed in October 2013. Bilateral sacroiliac joint appeared normal. There was no acute fracture or dislocation at the level of the pelvis. The left hip showed minor sclerosis in the left acetabulum and the proximal aspect of the left femur showed signs of acute fracture. No osteophytes were observed. The examiner concluded that it was an unremarkable study of the pelvis and both hips. The Veteran underwent a VA examination in January 2016. There, he reported that his hip audibly popped in and out frequently. He also reported pain in his hip flexor and stated that physical therapy made the pain worse. The Veteran described flare-ups of pain that occurred with prolonged sitting or walking uphill. On physical examination, range of motion was normal. Flexion was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Pain was noted on adduction and internal rotation. The Veteran experienced pain with weightbearing. The examiner noted left groin tenderness with palpation. There was also objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. The Veteran was also examined immediately after repetitive use over time. Increased pain was seen following repetitive use over time; however, there was no change in the Veteran’s range of motion. The Veteran was not examined during a flare-up. The examiner found that the results of the examination were neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during flares. He was also unable to say whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability during flares, as the Veteran was not having a flare-up at the time of the examination, thus, the examiner could not objectively assess such functional loss. Additional contributing factors to the Veteran’s disability included disturbance of locomotion and interference with sitting and standing. Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. The Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran endorsed the regular use of a walking stick. The examiner recounted diagnostic testing results from October 2013 which were unremarkable and compared them to imaging studies taken for the January 2016 examination. Bone mineralization was normal. Joint spaces were maintained. There were no periarticular hypertrophic changes evident. There was no fracture or other significant bone or joint abnormality. The study showed normal radiographic appearance of the pelvis and bilateral hips. Concerning functional impact, the Veteran was directed to avoid activities which aggravated hip pain. The Veteran was afforded another VA examination in February 2020. He described constant left hip pain rated at 7/10. He described it as a swelling sensation. He used Ibuprofen and Tylenol for treatment and stretched in order to reposition his hip. The Veteran indicated that he had to walk carefully and slowly. He reported flare-ups of severe, excruciating pain that lasted between 10 and 15 seconds. These flares were precipitated by standing up to walk after prolonged sitting. They were alleviated by stretching to get the hip to pop back into place. On physical examination, range of motion was normal. Flexion was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees and was not limited such that the Veteran could not cross his legs. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Pain was noted on all ranges of motion and with non-weightbearing and weightbearing. There was objective evidence of mild localized tenderness or pain on palpation of the joint or the associated soft tissue laterally due to hip sprain. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. The Veteran was not examined immediately following repetitive use over time; however, the examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination were not found to significantly limit the Veteran’s functional ability with repeated use over a period of time. The Veteran was not examined during a flare-up; however, the examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. Pain was found to significantly limit the Veteran’s functional ability during flares. The examiner was able to describe this limitation in terms of range of motion. Flexion was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees and was not limited such that the Veteran could not cross his legs. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Additional contributing factors to the Veteran’s disability included disturbance of locomotion and interference with sitting and standing. Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. The Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran endorsed the regular use of a walking stick and the examiner observed that he did not appear steady on his feet. The examiner recounted the imaging studies from October 2013 and January 2016. He also noted that hip X-rays performed in February 2020 revealed no significant arthritis present. Concerning limitation of functional ability, the examiner noted that the Veteran’s left hip disability affected the prolonged ability to sit, stand, and walk. After a review of the relevant evidence of record, the Board finds that the current 10 percent disability rating for the Veteran’s left hip disability is appropriate. The evidence demonstrates that the Veteran experiences popping, painful motion of the left hip. As an initial matter, the Board finds that the Veteran is in receipt of the maximum schedular rating allowable for his service-connected left hip disability based on limitation of extension. No higher rating is possible as a matter of law. Thus, further discussion regarding limitation of extension is not warranted. The Board now turns to whether a separate or higher rating is warranted based on limitation of flexion. The medical record reflects that, at worst, the Veteran’s right hip flexion was limited to 124 degrees, as documented on repetitive motion at the October 2010 VA examination. It was otherwise normal, including with consideration of functional loss during flare-ups. While the record shows that the Veteran has experienced ongoing pain, there is no probative evidence to support a finding that his range of motion was limited beyond the objective findings contained in VA treatment records and examination reports. Therefore, a separate, higher rating is not warranted for the Veteran’s left hip disability based on limitation of flexion. Next, the Board assesses whether a separate or higher rating is warranted based on impairment of the Veteran’s left thigh. The probative medical evidence of record does not reflect that the Veteran was unable to toe out more than 15 degrees or was unable to cross his legs as contemplated by a 10 percent rating under Diagnostic Code 5253. Therefore, a separate, higher rating is not warranted for the Veteran’s left hip disability based on impairment of the left thigh. The Board has considered the possibility of awarding higher ratings under 38 C.F.R. §§ 4.40 and 4.45 and declines to do so. There is no indication in the medical evidence of record summarized above that symptoms such as pain have resulted in additional functional loss or limitation of motion that would meet or approximate the criteria for higher evaluations. There were no findings of additional limitations of motion due to pain during initial range of motion testing that meet or approximate the criteria for higher rating under the General Rating Formula. As such, higher ratings are unwarranted under DeLuca, 8 Vet. App. 202, 204-07. In sum, the Board has considered the entire record, including the Veteran’s reported symptomatology and the objective clinical evidence. For the reasons set forth above, the assignment of a disability rating in excess of 10 percent for the Veteran’s left hip disability is denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee Disability The Veteran maintains entitlement to a disability rating in excess of 10 percent for his service-connected left knee disability, currently rated under Diagnostic Code 5260-5024. The hyphenated code indicates that the Veteran’s disability is assessed under Diagnostic Code 5260, which governs limitation of knee flexion, and Diagnostic Code 5024, which governs tenosynovitis and directs that the disability be evaluated based on limitation of motion of the affected part. Knee disabilities are generally rated under Diagnostic Codes 5256 to 5263 of 38 C.F.R. § 4.71a. Diagnostic Code 5260 addresses limitation of flexion of the knee. A noncompensable rating is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion is limited to 45 degrees. A 20 percent rating is assigned for flexion is limited to 30 degrees. A 30 percent rating is assigned for flexion is limited to 15 degrees. Diagnostic Code 5261 addresses limitation of extension of the knee. A noncompensable rating is assigned for extension is limited to 5 degrees. A 10 percent rating is assigned for extension is limited to 10 degrees. A 20 percent rating is assigned for extension is limited to 15 degrees. A 30 percent rating is assigned for extension is limited to 20 degrees. A 40 percent rating is assigned for extension is limited to 30 degrees. A 50 percent rating is assigned for extension is limited to 45 degrees. The Board notes that the criteria under Diagnostic Codes 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71. Diagnostic Codes 5256 evaluates ankylosis, Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability, Diagnostic Codes 5258 and 5259 evaluates semilunar cartilage conditions, Diagnostic Code 5262 evaluates impairment of the tibia and fibula, and Diagnostic Code evaluates genu recurvatum. The medical record does not document any of these conditions. Therefore, these Diagnostic Codes are not applicable and will not be discussed further. As the Veteran sought an increased disability rating in September 2010, the Board will review all relevant evidence from one year prior to that date. In October 2010, the Veteran underwent a VA examination. The Veteran reported that his knee popped, felt rubbery, and swelled. He denied aspirations. He stated that walking on uneven surfaces caused knee pain rated as 6/10. He denied the use of any knee support or brace and did not have one prescribed. He also denied that stairs caused any problems with his knee. On physical examination, the Veteran’s left knee was totally symmetrical-appearing with muscles above and below totally normal with no atrophy at all. The Veteran had no varus or valgus deformity of the left knee. He had minimal tenderness over the patellar tendon. He had no crepitus on motion or effusion. There was no instability in either direction. There were no palpable osteophytes around the knee. He was able to generate 5/5 power of extension against resistance with complaints about a little discomfort over the patellar tendon. He was able to lock the knee in full extension against a downward force with no pain. The range of motion in the knee was 0 extension initially and on the fourth motion. Flexion was 125 degrees initially and 126 degrees on the fourth motion. The Veteran was diagnosed with very mild patellar tendonitis that was not functionally limiting and minimally symptomatic. A March 2011 VA treatment record documents that the Veteran’s left leg from the knee to the ankle was very sensitive to light touch. A May 2012 primary care note again documents that the Veteran’s left leg from the knee to the ankle was very sensitive to light touch. There was normal strength in the lower extremities. Straight leg raising test was negative. Sacroiliac joint loading test was negative. The Veteran underwent a VA examination in January 2016. There, the Veteran reported daily knee pain. He denied the use of medication for this condition. He stated that he experienced flare-ups of increased pain and stiffness walking stairs, up and down hills, and getting up from seated positions. On physical examination, flexion of the left knee was to 140 degrees and extension was to 0 degrees. Pain was noted on extension and with weightbearing. The examiner noted tenderness directly over the patellar tendon with pressure and with extension of the knee. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least repetitions without additional loss of range of motion. The Veteran was examined immediately after repetitive use over time. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability following repeated use over a period of time with resorting to mere speculation. He noted that although the Veteran’s range of motion and pain was unchanged after repetitive use testing, the Veteran reported that his pain would increase with prolonged repetitive use. The examination was not performed during a flare-up. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability during flare-ups without resorting to mere speculation. He noted that he could not objectively assess this, as the Veteran was not having a flare-up at the time of the examination. Additional contributing factors to the Veteran’s disability included interference with standing. Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. There was no history of recurrent subluxation or lateral instability. Joint stability tests were normal. The Veteran did not have nor had he had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. He had not undergone joint replacement or other surgical procedures for his left knee. The Veteran endorsed the use of a walking stick for his ankle pain. Imaging studies were performed and did not reveal degenerative or traumatic arthritis. Bone mineralization was normal. Joint spaces were maintained. No fracture or other significant bone or joint abnormality was evident. The Veteran was afforded another VA examination in February 2020. The Veteran described flare-ups of left knee pain that occurred a few times a day, especially with walking and standing for long periods of time. When sitting down, the knee would pop, resulting in excruciating pain. Cold weather and barometric changes of pressure increased the stiffness and pain in his knee. He reported that the knee made his left side cramp because he was always leaning to the right and walking with a limp. He also described intense side cramping after wiping bowel movements. The Veteran stated that he avoided stairs. The flares were alleviated by Ibuprofen and Tylenol. On physical examination, flexion of the left knee was to 140 degrees and extension was to 0 degrees. Pain was noted on both flexion and extension and with weightbearing and non-weightbearing. There was objective evidence of mild, diffuse localized tenderness or pain on palpation of the joint or associated soft tissue. There was also objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least repetitions without additional loss of range of motion. The Veteran was not examined immediately after repetitive use over time. The examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination were not found to significantly limit the Veteran’s functional ability with repeated use over a period of time. The examination was not performed during a flare-up. The examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare-up. Pain was found to significantly limit the Veteran’s functional ability during a flare-up. However, the examiner found no reduction in range of motion during flares. Additional contributing factors to the Veteran’s disability included disturbance of locomotion and interference with standing. Muscle strength testing yielded normal results; there was no reduction in muscle strength, nor did the Veteran have muscle atrophy. He did not have ankylosis. There was no history of recurrent subluxation or lateral instability. Joint stability tests were normal. The Veteran did not have nor had he had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. He had not undergone joint replacement or other surgical procedures for his left knee. The Veteran endorsed the use of a walking stick for his hip sprain and ankle tendonitis. The examiner recounted the imaging results from January 2016. Concerning limitation of functional ability, the examiner noted that the Veteran’s left knee disability affected the prolonged ability to stand and walk. The Board finds that a disability rating in excess of 10 percent for the Veteran’s service-connected left knee disability is not warranted. The Veteran has not met the minimum criteria for a higher, 20 percent rating based on limitation of flexion at any time during the appellate period. Under Diagnostic Code 5260, a 20 percent rating is warranted where flexion is limited to 30 degrees and higher ratings are awardable based on additional loss. Here, flexion of the Veteran’s left knee has not been limited at all, in all examinations it has been to 140 degrees. As there is no medical evidence of record demonstrating limitation of flexion to 30 degrees, a higher, 20 percent disability rating left knee limitation of flexion is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Further, the Board finds that a rating based on limitation of extension is not warranted. Throughout the period on appeal, the evidence does not suggest that the Veteran’s right knee extension is disabled at all, as she has been able to fully extend her knee at all VA examinations. As there is no medical evidence of record demonstrating limitation of extension, a separate rating for right knee limitation of extension is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board has considered functional impairment due to the Veteran’s service-connected left knee disability and acknowledges the subjective complaints of pain made throughout the course of the Veteran’s claim, as well as the objective evidence of pain on movement. While the Veteran experiences pain, the Board finds that the 10 percent evaluation assigned for the left knee adequately portrays any functional impairment, pain, and weakness that the Veteran experienced as a result of use of his left knee. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Therefore, higher evaluations for the left knee disability based on functional loss are not warranted for the period on appeal. See DeLuca, 8 Vet. App. at 204-06. In summary, the preponderance of the against weighs against the Veteran’s claim for a disability rating in excess of 10 percent for his service-connected left knee disability. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The issue of entitlement to a TDIU is remanded for referral to the VA Director of the Compensation Service for adjudication of TDIU eligibility in accordance with 38 C.F.R. § 4.16(b). In this case, the Veteran contends that he has been unemployable due to his service-connected left ankle, left hip, and left knee. The Veteran has reported that he last worked in 2012, has a high school education and some college experience, and has past relevant work experience in sales. During the period on appeal, the Veteran was in receipt of service connection for a left ankle disability, now rated as 20 percent disabling, a left hip disability, rated as 10 percent disabling, a left knee disability, rated as 10 percent disabling, tinnitus, rated as 10 percent disabling, a scar on the right abdomen, rated as 10 percent disabling, tinea unguium of the right foot, rated as 10 percent disabling, tinea unguium of the left foot, rated as 0 percent disabling, and a scar on the left thigh, rated as 0 percent disabling. Although the Veteran’s combined disability rating is now 60 percent, the preliminary schedular rating requirements for a TDIU are not met. There is evidence of record suggesting that the service-connected musculoskeletal disabilities may have rendered the Veteran unemployable during the period at issue. VA examiners consistently noted that the Veteran’s service-connected ankle, hip, and knee disabilities may adversely impact his ability to work due to limitations on prolonged sitting, walking, and standing. Because the Veteran’s past work experience involved prolonged periods of sitting, as well as some walking and standing, the symptoms and functional impairment caused by the Veteran’s service-connected left ankle, left hip, and left knee disabilities may have significantly impacted his ability to secure or maintain substantially gainful employment during the appellate period. As the threshold percentage requirements for the award of a TDIU under the provisions of 38 C.F.R. § 4.16(a) are not met at any time during the TDIU rating period on appeal, the issue of entitlement to a TDIU should be remanded for referral to the VA Director of the Compensation Service for adjudication of TDIU eligibility in accordance with 38 C.F.R. § 4.16(b). The matters are REMANDED for the following action: (Continued on the next page)   Refer the case to the VA Director of the Compensation Service for adjudication of entitlement to a TDIU (see 38 C.F.R. § 4.16(b)). Timothy Berryman Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berryman, 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.