Citation Nr: 21015034 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-19 899 DATE: March 16, 2021 ORDER Service connection for a right hip disorder is denied. A rating in excess of 10 percent prior to August 12, 2019, and a compensable rating thereafter for limitation of flexion of the left hip is denied. The separate rating for limitation of abduction of the left hip, evaluated as 20 percent disabling as of August 12, 2019, is proper; the appeal is denied. The separate rating for limitation of extension of the left hip, evaluated as noncompensably disabling as of August 12, 2019, is proper; the appeal is denied. FINDINGS OF FACT 1. A right hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, arthritis did not manifest to a compensable degree within one year discharge from active duty, and such is not caused or aggravated by a service-connected disability. 2. Prior to August 12, 2019, the Veteran’s left hip disability was manifested by flexion limited to, at most, 85 degrees, extension greater than 5 degrees, abduction not lost beyond 10 degrees, adduction not limited such that he could not cross his legs, and rotation not limited such that he could not toe-out more than 15 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups, without ankylosis, flail joint, or impairment of the femur. 3. Since August 12, 2019, the Veteran’s left hip disability is manifested by abduction limited to 5 degrees, flexion limited to, at most, 60 degrees, and extension limited to, at most, 15 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups, without ankylosis, flail joint, or impairment of the femur. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for a rating in excess of 10 percent prior to August 12, 2019, and a compensable rating thereafter for limitation of flexion of the left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5010-5252. 3. The separate rating for limitation of abduction of the left hip, evaluated as 20 percent disabling as of August 12, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5253. 4. The separate rating for limitation of extension of the left hip, evaluated as noncompensably disabling as of August 12, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5251. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from November 1976 to May 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, as relevant, the Board remanded the issue of entitlement to an increased rating for the Veteran’s left hip disability. While on remand, a June 2020 rating decision assigned separate ratings for limitation of abduction of the left hip, evaluated as 20 percent disabling as of August 12, 2019; and limitation of extension of the left hip, evaluated as noncompensably disabling as of August 12, 2019. While the Veteran expressed his disagreement as to the propriety of the initially assigned ratings in July 2020, the Board finds that such issues are part and parcel of the Veteran’s claim for an increased rating for his left hip disability. Therefore, the Board has assumed jurisdiction over such matters, and they are included on the title page of this decision. Further, the June 2020 rating decision reduced the Veteran’s 10 percent rating for his limitation of extension of the left hip to noncompensable as of August 12, 2019. Thus, such claim has been recharacterized as shown to reflect that a staged rating is in effect. Fenderson v. West, 12 Vet. App. 119 (1999). Subsequent to the issuance of the July 2020 statement of the case, the Veteran, through his representative, submitted additional evidence for consideration in his appeal. 38 U.S.C. § 7105(e)(1). Further, while additional VA treatment records were also subsequently associated with the record, such are duplicative or irrelevant to the instant claims. 38 C.F.R. § 20.1304(c). Thus, there is no prejudice to the Veteran in the Board proceeding with a decision at this time. Service Connection 1. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected left hip disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran asserts he has a current right hip disorder related to his military service. In the alternative, he contends that such disorder is secondary to his service-connected left hip disorder. Service treatment records (STRs) are silent for any complaints, treatment, or diagnosis referable to a right hip disorder. Following his discharge from service in May 1979, the first indication of a right hip disorder was noted in November 2009. Specifically, such VA treatment record reflects the Veteran’s report of right hip pain. Thereafter, a June 2011 VA treatment record indicates that an X-ray showed degenerative changes in both hips. Concerning a nexus, on VA examination in October 2011, the Veteran reported that he had a gradual onset of pain in his left hip in approximately 2008; and that since such time, he experienced right hip pain. In this regard, the examiner noted a diagnosis of right hip pain and opined that such was less likely than not proximately due to or the result of the Veteran’s service-connected left hip disorder. As rationale for the opinion, the examiner reported that the Veteran had minimal arthritis in his left hip, and it would not be expected to cause arthritis or any other problem in his right hip. Thereafter, a VA examiner provided an additional unfavorable nexus opinion following examination of the Veteran in August 2019. In this regard, she noted a diagnosis of right hip osteoarthritis, and, following a review of the record and medical literature, she opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, the examiner reported that the Veteran’s STRs contained no injuries which occurred to cause a right hip disorder, and no complaints for any right hip pain during his miliary service. The examiner further reported that the Veteran’s separation examination reflected no abnormalities in either hip. She concluded that, due to no complaints for any right hip pain and no in-service injury, the Veteran’s right hip disorder would not be related to his military service. The August 2019 VA examiner also determined that the Veteran’s right hip disorder was less likely than not proximately due to or the result of his service-connected left hip disorder. As rationale for the opinion, the examiner reported that it had been shown that the pain in one joint did not cause pain or abnormalities in the contralateral joint. Based on the medical literature, the examiner explained that osteoarthritis was a common disorder with prevalence increasing with age; and that such was a complex interplay between mechanical, cellular, and biomechanical factors leading to end-stage pathology. Here, the examiner noted that multiple risk factors had been linked to osteoarthritis, to include age, gender, genetics, joint injury, anatomical factors, obesity, and lifestyle. Additionally, she observed that the Veteran had no complaints for any right hip pain documented in his medical records until his July 2009 VA examination. The examiner noted that the Veteran’s October 2011 VA examination report indicated that he had developed left hip pain in 2008; and that his right hip pain had developed and became a constant pain. She explained that, according to medical literature, lay people and many doctors believed that pain or disability in one leg could stress the other one and produce symptoms in it; and that it was often claimed that an injury causing disability of one leg initiated or aggravated a disabling disorder in the opposite normal or previously asymptomatic lower extremity. The examiner further explained that it may be reasoned that the injury to one leg caused the patient to favor it or limp, and that this in turn unduly stressed the normal leg because it has had to bear more weight; which caused or accelerated arthritis in one of its joints (usually the knee). However, the August 2019 VA examiner reported that the mechanics of limping were poorly documented in orthopaedic literature, and there was no clear scientific basis for the aforementioned reasoning. Here, the examiner noted that few references had been found to the effect of the limp on the other leg; and that the evidence available indicated that an injury in one extremity rarely caused a major problem in the opposite or uninjured extremity except when damage to the leg resulted in a major displacement of the center of gravity of the body while walking, significant shortening of the injured limb and the abnormal gait pattern had been present for an extended period of time. Specifically, the examiner indicated that, due to the Veteran having increasing age, obesity, and a very active occupational work setting prior to the development of his right hip osteoarthritis, such factors should be considered in the causative factors for the diagnosis of right hip osteoarthritis. Additionally, the examiner noted that the Veteran’s gait had been normal throughout the years, and he had been using a scooter for mobility since at least June 2017; and that a December 2015 treatment record reflected that he had a steady gait with the use of a walker. The examiner concluded that, due to the findings of no abnormal gait for a prolonged period of time and the risk factors for the development of osteoarthritis, the Veteran’s right hip osteoarthritis would not be due to his service-connected left hip osteoarthritis. She indicated that there was no medical evidence that the Veteran’s right hip disorder was due to, the result of, or permanently aggravated by his service-connected left hip disorder. Upon review, the Board finds the competent evidence does not demonstrate that a current right hip disorder is related to the Veteran’s military service or secondary to a service-connected disability. Here, the October 2011 and August 2019 VA examiners reviewed the evidence extensively and opined that the cause of the Veteran’s current right hip disorder was unrelated to any service incidents and/or his service-connected left hip disorder. In doing so, such examiners provided conclusive opinions with reasoned explanations, citing to both specific evidence of record and medical literature. Nieves v. Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion… must support its conclusion with an analysis that the Board can consider and weight against contrary opinions”). Thus, the Board affords the October 2011 and August 2019 VA examiners’ opinions significant probative value. In addition, the Board finds pertinent that there is no medical opinion to the contrary. Although the Veteran claims he has a current right hip disorder related to his military service and/or his service-connected left hip disorder, it is well established that a layperson without medical training is not qualified to render medical opinions regarding the etiology of certain disorders. See 38 C.F.R. § 3.159(a)(1). In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of a right hip disorder, or the interplay between such disorder and the service-connected left hip disorder, as such concern internal physical processes extending beyond immediately observable cause-and-effect relationships. See Jandreau, supra; Davidson, supra. Here, it is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer such opinions. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Therefore, the Board affords his statements as to the etiology of his current right hip disorder no probative weight. Moreover, consistent with the August 2019 VA examiner’s opinion, the Board finds the medical evidence does not demonstrate arthritis of the right hip manifested to a compensable degree within one year of the Veteran’s discharge from service. In pertinent part, the Veteran reported that his right hip symptomatology did not begin until approximately 2008; and the earliest noted onset of degenerative changes of the right hip was in 2011, more than 30 years following separation from service. Consequently, presumptive service connection for arthritis of the right hip, to include on the basis of a continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Based on the foregoing, the Board finds that a right hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. Additionally, arthritis of the right hip did not manifest within one year of discharge from active duty, and such disorder is not shown to be caused or aggravated by a service-connected disability. Consequently, service connection for a right hip disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a right hip disorder. As such, that doctrine is not applicable in the instant appeal; and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). 2. Entitlement to a rating in excess of 10 percent prior to August 12, 2019, and a compensable rating thereafter for limitation of flexion of the left hip. 3. Propriety of the separate rating for limitation of abduction of the left hip, evaluated as 20 percent disabling as of August 12, 2019. 4. Propriety of the separate rating for limitation of extension of the left hip, evaluated as noncompensably disabling as of August 12, 2019. The Veteran asserts that his left hip disability is more severe than as reflected by the currently assigned ratings during the appeal period. In this regard, a 10 percent rating prior to August 12, 2019, and a noncompensable rating thereafter is assigned for the Veteran’s left disability based on limitation of flexion under DC 5010-5252. As of August 12, 2019, a separate 20 percent rating is assigned for limitation of abduction under DC 5010-5253; and a separate noncompensable rating is assigned for limitation of extension under 5010-5251. Here, the Board will review the entirety of the evidence with consideration of higher and/or additional separate ratings for the Veteran’s service-connected left hip disability. Hyphenated DCs 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. In the instant case, DCs 5010-5252, 5010-5253, and 5010-5251 indicate traumatic arthritis rated under DC 5010 as the service-connected disabilities and the residual symptoms of limited motion of the hip are rated under DCs 5252, 5253, and 5251. Under DC 5251, addresses limitation of extension of the thigh, and provides a maximum 10 percent rating where extension is limited to five degrees. Under DC 5252 addresses limitation of flexion of the thigh, and provides a 10 percent rating is assigned for flexion limited to 45 degrees, and a 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is provided for flexion limited to 20 degrees, and a 40 percent rating is provided for flexion limited to 10 degrees. DC 5253 addresses impairment of the thigh, and provides a 10 percent rating for limitation of rotation when one cannot toe-out more than 15 degrees, or limitation of adduction when one cannot cross legs. A 20 percent rating is assigned for limitation of abduction with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a. At an October 2011 VA examination, the Veteran was diagnosed with osteoarthritis of the left hip. At such time, he reported constant hip pain and denied flare-ups. Upon range of motion (ROM) testing, the Veteran exhibited left hip flexion of 85 degrees with objective evidence of painful motion at 85 degrees, as well as extension greater than 5 degrees with objective evidence of painful motion at greater than 5 degrees. Abduction was not lost beyond 10 degrees; adduction was not limited such that the Veteran could not cross his legs; and rotation was not limited such that the Veteran could not toe-out more than 15 degrees. The Veteran did not have additional limitation in ROM following repetitive use testing. Additionally, the examiner noted that the Veteran had functional loss and/or functional impairment of the hip, to include less movement than normal and pain on movement. There was no localized tenderness or pain to palpation for joints or soft tissue of either hip. Muscle strength was normal, and there was no ankylosis. The Veteran did have malunion or nonunion of femur, flail hip joint, or leg length discrepancy; and he has not undergone any surgical procedures. He regularly used a cane and occasionally used a walker for his back and bilateral hip pain. The examiner reported that the Veteran’s left hip disorder impacted his ability to work in that he had pain with prolonged standing and walking. At an August 2019 VA examination, the Veteran was diagnosed with osteoarthritis of the left hip. At such time, he reported that his hip pain had been present in both hips for approximately 10/15 years with worsening pain in the previous seven years. He stated the pain was constant and sharp, and that he experienced spikes where his left hip went out and caused him to fall. The Veteran further reported limitations with standing, walking, sitting, bending, and squatting; and lifting was limited to approximately 10lbs. He denied flare-ups. Upon ROM testing, the Veteran exhibited left hip flexion of 60 degrees, and extension of 15 degrees. Abduction and adduction were each at 5 degrees; and adduction was limited such that the Veteran could not cross his legs. The Veteran had external rotation of 20 degrees and internal rotation of 10 degrees. The ROM itself contributed to functional loss with limited sitting, standing, and walking. Pain was noted on examination on all ranges of motion and caused functional loss. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue; specifically, there was tenderness to palpation anteriorly and posteriorly. There was no objective evidence of crepitus; and no additional limitation in ROM following repetitive use testing. Additionally, the examiner indicated that pain, fatigue, and lack of endurance significantly limited functional ability with repeated use over a period of time; however, there was no additional limitation in ROM. Additional factors contributing to disability included instability of motion, disturbance of locomotion, and interference with standing, as well as limited sitting, standing, and walking. Muscle strength was normal, and there was no muscle atrophy or ankylosis. The Veteran did have malunion or nonunion of femur, flail hip joint, or leg length discrepancy; and he has not undergone any surgical procedures. He was noted to regularly use a cane, a walker, and a scooter. The examiner reported that the Veteran’s left hip disorder impacted his ability to perform occupational tasks in that he was limited in sitting, standing, and walking. With respect to Correia, supra, the examiner noted that passive ROM would be the same as active ROM in this case; and that there was evidence of pain on passive ROM testing, and when the joint was used in non-weight bearing. In addition to the aforementioned VA examinations, treatment records (to include Dr. M.H.’s September 2020 private letter) and lay statements concerning the nature and severity of the Veteran’s left hip are on file and have been fully considered. In this regard, the Board notes that such include findings consistent with those noted at the aforementioned VA examinations. Prior to August 12, 2019 In order to assign a rating in excess of 10 percent prior to August 12, 2019, based on limitation of flexion, the evidence must demonstrate flexion limited to 30 degrees. Here, the evidence of record reflects limitation of left hip flexion to, at most, 85 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups. Further, the Veteran is in receipt of the minimal compensable rating due to the provisions of DC 5010 for painful limitation of motion due to arthritis that is not otherwise compensable. Therefore, a rating in excess of 10 percent prior to August 12, 2019, under DC 5010-5252 is not warranted. Furthermore, the Board observes that the AOJ granted separate ratings for limitation of abduction and extension, effective August 12, 2019, the date of the most recent VA examination. In a June 2020 rating decision, the AOJ found the August 12, 2019, VA examination report is the first to demonstrate worsening of the Veteran’s left hip disorder, to include significant impairment of the thigh and extension of the thigh limited beyond 5 degrees. Upon review, the Board finds the assigned, 20 percent and noncompensable ratings for the left hip disability based on limitation of abduction and extension, respectively, are proper (as discussed further below); as well as the effective dates for the award of such. Prior to August 12, 2019, the medical evidence does not reflect compensable impairment of the thigh, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Here, the evidence demonstrates that the Veteran’s abduction was not lost beyond 10 degrees, adduction was not limited such that he could not cross his legs, and rotation was not limited such that he could not toe-out more than 15 degrees. Furthermore, the Veteran was not shown to have compensable limitation of extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Here, the evidence reflects that the Veteran’s extension was greater than 5 degrees. Notably, the October 2011 VA examination report indicates that the Veteran did not have additional limitation in ROM following repetitive use testing. Thus, prior to August 12, 2019, the Board finds that, to assign separate ratings for painful motion would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14, 4.59; Esteban, supra. Since August 12, 2019 Since August 12, 2019, the Board observes that the noncompensable limitation of motion that was previously addressed under DC 5010-5252 is now addressed under DC 5010-5253 (which will be discussed further below). In this regard, unless it can be shown that a separate rating is warranted for compensable limitation of flexion and/or extension, a separate rating would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14, 4.59; Esteban, supra. As noted above, compensable ratings for limitation of extension and flexion are provided for extension limited to five degrees and flexion limited to 45 degrees. The evidence of record demonstrates that extension was limited to, at most, 15 degrees while flexion was limited to, at most, 60 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups. As a result, the Board finds that, since August 12, 2019, compensable ratings are not warranted under DCs 5251 and 5252 based on extension limited to five degrees or flexion limited to 45 degrees. Further, since August 12, 2019, the evidence of record demonstrates limitation of abduction to 5 degrees, which is the basis of the Veteran’s current 20 percent rating under DC 5010-5253. However, 20 percent is the highest rating available under such DC; therefore, a higher rating is not possible, and no further discussion is required. Other Considerations The Board finds the October 2011 and August 2019 VA examinations, which considered the Veteran’s lay statements and completed all testing indicated by DeLuca, supra, and Mitchell, supra, particularly probative. See Nieves-Rodriguez, supra. In this regard, the Board notes the Veteran did not endorse flare-ups at either examination; both the October 2011 and August 2019 VA examiners considered the possibility of additional loss of limitation of motion due to pain and/or after three repetitions, but found none; and the August 2019 VA examination fully complied with Correia, supra. Additionally, the Board has considered whether additional separate ratings may be assigned for the Veteran’s service-connected left hip disability. However, the medical evidence does not reflect ankylosis, flail joint, or impairment of the femur at any time during the appeal period. 38 C.F.R. § 4.71a, DCs 5250, 5254, 5255. Therefore, a rating in excess of 10 percent for the Veteran’s left hip disability due to limitation of flexion is not warranted, and the separate 20 percent and noncompensable ratings assigned as of August 12, 2019, for limitation of abduction and extension, respectively, were proper. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the instant claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected left hip disability; however, the Board finds that his symptomatology has been stable throughout the appeal periods. Therefore, assigning additional staged ratings for such disability is not warranted. Therefore, the Board finds that higher or separate ratings for the Veteran’s left hip disability is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, such doctrine is not applicable in the instant appeal and his increased rating claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. K.STANTON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dawn A. Leung, 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.