Citation Nr: 21025359 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 14-14 440 DATE: April 27, 2021 ORDER Entitlement to an initial 10 percent evaluation, but not greater, for right hip strain, based on limitation of extension, prior to January 6, 2017 is granted, subject to regulations governing the payment of monetary awards. Entitlement to a 10 percent evaluation, but not greater, for right hip strain, based on limitation of extension, from December 5, 2018 is granted, subject to regulations governing the payment of monetary awards. Entitlement to an evaluation in excess of 10 percent for right hip strain, based on limitation of extension, from January 6, 2017 to December 4, 2018 is denied. Entitlement to an initial 10 percent evaluation, but not greater, for left thigh limitation of extension prior to January 6, 2017 is granted, subject to regulations governing the payment of monetary awards. Entitlement to a 10 percent evaluation, but not greater, for left thigh limitation of extension from December 5, 2018 is granted, subject to regulations governing the payment of monetary awards. Entitlement to an evaluation in excess of 10 percent for left thigh limitation of extension from January 6, 2017 to December 4, 2018 is denied. Entitlement to an initial compensable evaluation for right thigh limitation of flexion is denied. Entitlement to an initial compensable evaluation for left thigh limitation of flexion is denied. Entitlement to an initial evaluation in excess of 10 percent for impairment of the right thigh prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018 is denied. Entitlement to an initial evaluation in excess of 10 percent for left hip strain, based on impairment of the thigh, prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018 is denied. REMANDED Entitlement to an initial evaluation in excess of 20 percent for left knee sprain with meniscal tear is remanded. FINDINGS OF FACT 1. Prior to January 6, 2017, the Veteran’s right hip strain (based on limitation of extension) and left thigh limitation of extension has been manifested by additional functional loss due to painful motion. 2. From December 5, 2018, the Veteran’s right hip strain (based on limitation of extension) and left thigh limitation of extension has been manifested by additional functional loss due to painful motion. 3. From January 6, 2017 to December 4, 2018, the Veteran’s right hip strain (based on limitation of extension) and left thigh limitation of extension is rated as 10 percent disabling, which is the maximum schedular rating permitted for limitation of extension of the thigh. 4. The Veteran’s right thigh limitation of flexion and left thigh limitation of flexion is manifested by flexion at worst from 0 to 65 degrees, even with consideration of pain and functional loss. 5. Prior to January 6, 2017, the Veteran’s impairment of the right thigh and left hip strain (based on impairment of thigh) is not manifested by abduction that is limited such that motion is lost beyond 10 degrees. 6. From January 6, 2017 to December 4, 2018, impairment of the right thigh and left hip strain (based on impairment of thigh) is not manifested by rotation that is limited such that the Veteran cannot toe-out more than 15 degrees of the affected leg or adduction is limited such that the Veteran cannot cross legs. 7. From December 5, 2018, impairment of the right thigh and left hip strain (based on impairment of thigh) are rated as 20 percent disabling, which is the maximum schedular rating permitted for impairment of the thigh. CONCLUSIONS OF LAW 1. Prior to January 6, 2017, the criteria for a 10 percent rating for right hip strain (based on limitation of extension) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5251 (2020). 2. From December 5, 2018, the criteria for a 10 percent rating for right hip strain (based on limitation of extension) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5251 (2020). 3. From January 6, 2017 to December 4, 2018, the criteria for a rating in excess of 10 percent for right hip strain (based on limitation of extension) are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251 (2020). 4. Prior to January 6, 2017, the criteria for a 10 percent rating for left thigh limitation of extension are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5251 (2020). 5. From December 5, 2018, the criteria for a 10 percent rating for left thigh limitation of extension are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5251 (2020). 6. From January 6, 2017 to December 4, 2018, the criteria for a rating in excess of 10 percent for left thigh limitation of extension are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251 (2020). 7. The criteria for an initial compensable evaluation for right thigh limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252 (2020). 8. The criteria for an initial compensable evaluation for left thigh limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252 (2020). 9. The criteria for an initial evaluation in excess of 10 percent for impairment of the right thigh prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5253 (2020). 10. The criteria for an initial evaluation in excess of 10 percent for left hip strain (based on impairment of the thigh) prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5253 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to August 1995. This matter is before the Board of Veterans’ Appeals (Board) on appeal from September 2014 and July 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2017, a hearing was held before the undersigned. A transcript of the hearing is of record. The case was previously before the Board in January 2018, April 2020, and October 2020 when it was remanded for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If 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 required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to disability compensation has already been established and an increase in the assigned rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Turning to the evidence of record, VA treatment records from April 2015 note a recent visit to the ER with hip pain but there were no significant findings on x-ray. There was full flexion and extension of the hips in all planes; no clicking or clunking heard or felt; and no joint swelling, tenderness, or obvious joint deformity. The Veteran underwent a VA hip and thigh examination in July 2015. The Veteran complained of symptoms of pain, stiffness, and decreased range of motion on both sides. The Veteran reported that flare-ups impacted the function of the hip and thigh, stating that increased pain and stiffness caused him to stop what he was doing and sit. Flare-ups were daily, moderate in severity, and lasting one to two hours. Regarding functional loss or functional impairment, the Veteran stated that he cannot bend with ease and it was difficult to cross his legs and ambulate long distances. Range of motion testing in the right hip showed flexion from 0 to 115 degrees, extension/hyperextension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 15 degrees, external rotation from 0 to 45 degrees, and internal rotation from 0 to 25 degrees. Adduction was limited such that the Veteran could not cross his legs. Range of motion caused a decrease in ambulation. Pain was noted on exam and caused functional loss. There was objective evidence of pain on palpation over the superior iliac crest which was moderate. There was no evidence of pain with weight bearing or crepitus. In the left hip, range of motion testing showed flexion from 0 to 105 degrees, extension/hyperextension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 15 degrees, external rotation from 0 to 45 degrees, and internal rotation from 0 to 30 degrees. Adduction was limited such that the Veteran could not cross his legs. Range of motion caused a decrease in ambulation. Pain was noted on exam and caused functional loss. There was objective evidence of pain on palpation over the superior iliac crest which was moderate to severe. There was no evidence of pain with weight bearing or crepitus. The Veteran was able to perform repetitive use testing in the right hip with three repetitions, with no change in range of motion. In the left hip, he was able to perform repetitive use testing, and additional loss of function or range of motion after three repetitions was flexion from 0 to 100 degrees, extension/hyperextension from 0 to 15 degrees, abduction from 0 to 25 degrees, adduction from 0 to 10 degrees, external rotation from 0 to 40 degrees, and internal rotation from 0 to 35 degrees. Factors that caused functional loss were pain, fatigue, weakness, lack of endurance, and incoordination. Pain and weakness significantly limited functional ability during flare-ups or when the joint was used repeatedly over a period of time. Additional contributing factors of disability on both sides were weakened movement, instability of station, disturbance of locomotion, and interference with standing. There was no reduction in muscle strength and no muscle atrophy. There was no ankylosis. The Veteran used a brace and pillow for his hip strain. The Veteran’s bilateral hip strain interfered with getting in and out of his truck and loading and unloading his truck. The Veteran underwent another VA hip and thigh examination in January 2017. The Veteran complained of worsening pain with standing and sitting and limited range of motion. The Veteran reported that flare-ups impacted the function of the hip and thigh, stating that he would get burning sensations with prolonged walking, standing, and climbing. Regarding functional loss or functional impairment, the Veteran stated that he had trouble climbing and standing for a long time. Range of motion testing in the right hip showed flexion from 0 to 75 degrees, extension from 0 to 20 degrees, abduction from 0 to 45 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 60 degrees, and internal rotation from 0 to 40 degrees. Adduction was not limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam in flexion, extension, and adduction and caused functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing or crepitus. In the left hip, range of motion testing showed flexion from 0 to 75 degrees, extension from 0 to 20 degrees, abduction from 0 to 45 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 60 degrees, and internal rotation from 0 to 40 degrees. Adduction was not limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam in flexion and extension and caused functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing or crepitus. The Veteran was not able to perform repetitive use testing in both hips because he had significant pain on initial range of motion testing. There were no additional contributing factors of disability on both sides. There was reduction in muscle strength in both hips but no muscle atrophy. There was no ankylosis. The Veteran was functionally impaired from job duties as a truck driver in that he had difficulty climbing in and out of his truck cab. During his June 2017 Board hearing, the Veteran indicated he had a burning sensation, lack of endurance, and fatigue in the hips and thighs. He would have to stop and take a break while working. He would have a burning sensation and weakness a lot at night. At work he would have to sit down at points and sometimes have to lie down in the bed in his truck for 15 minutes for relief. The Veteran’s wife stated that she would have to massage him and would witness him limping and having to stop for rest. The Veteran could lift his foot about a foot and could not extend his leg to cross over. He had pain in his hip when trying to cross his legs. During a December 2018 VA muscle injuries examination, it was noted that the Veteran had a non-penetrating muscle injury, with pain, stiffness, soreness, and tightness. The Veteran had an injury to a muscle group of the thigh, the muscle groups affected were Group XIII posterior thigh/hamstring muscles and Group XIV anterior thigh muscles. The signs and symptoms include consistent weakness, as the Veteran could not climb up on the trailer of his truck because of weaker thighs and hips, and consistent fatigue-pain, as the Veteran complained of lack of endurance and constant pain. Muscle strength testing was normal and there was no muscle atrophy. The Veteran stated that his hips and thighs affected lifting, standing, and walking. Prolonged sitting was also affected. He was on leave of absence from his job. The Veteran underwent a VA hip and thigh examination in December 2018. The Veteran complained of bilateral burning hip pain and soreness, burning, and pain in the thighs. The Veteran reported that flare-ups made it hard to walk or do anything. He had flare-ups every couple of weeks lasting a couple days. Regarding functional loss or functional impairment, the Veteran stated that he had trouble climbing and standing for a long time. Range of motion testing in the right hip showed flexion from 0 to 65 degrees, extension from 0 to 20 degrees, abduction from 0 to 25 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 30 degrees, and internal rotation from 0 to 20 degrees. Adduction was limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam on rest/non-movement. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing or crepitus. In the left hip, range of motion testing showed flexion from 0 to 65 degrees, extension from 0 to 20 degrees, abduction from 0 to 25 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 30 degrees, and internal rotation from 0 to 20 degrees. Adduction was limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam on rest/non-movement. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing or crepitus. The Veteran was not able to perform repetitive use testing in both hips because of fear of pain. The examiner was unable to say whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or when the joint is used repeatedly over a period of time without mere speculation. The examiner stated that there was no conceptual or empirical basis for making such a determination without directly observing function under these circumstances. There were no additional contributing factors of disability on both sides. Muscle strength testing was normal in both hips and there was no muscle atrophy. There was no ankylosis. The Veteran stated that his hips and thighs affected lifting, standing, and walking. Prolonged sitting was also affected. He was on leave of absence from his job. In June 2020, an addendum opinion was obtained which addressed the results of the December 2018 VA hip and thigh examination regarding repeated use over time and flare-ups. The examiner indicated that pain, weakness, fatigability, or incoordination did significantly limit functional ability with repeated use over time and with flare-ups. Factors that caused the functional loss were pain. However, after review of the evidence and given the examiner’s clinical knowledge and medical expertise, there remained no basis to offer additional losses of function or motion. In an August 2020 letter, the Veteran stated that he was in constant pain in all areas and experienced limited range of motion with joint instability. He could only handle 40 percent of his workload and was experiencing other health conditions because of lack of mobility, such as weight gain, high blood sugar, and high blood pressure. The Veteran underwent a VA hip and thigh examination in November 2020. The Veteran complained of sharp pain with 8/10 intensity. Pain intensified with prolonged sitting and mobility was heavily impacted. The Veteran reported that flare-ups made him unable to bear weight or move. Flare-ups occurred once a week and lasted 1 to 2 days. Pain intensified to 10/10 and he was unable to drive during a flare-up. Regarding functional loss or functional impairment, the Veteran stated that he was unable to walk or exercise and limited the level of physical activity. Range of motion testing in the right hip showed flexion from 0 to 100 degrees, extension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 50 degrees, and internal rotation from 0 to 30 degrees. Adduction was not limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam but did not result in functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing but no evidence of crepitus. In the left hip, range of motion testing showed flexion from 0 to 100 degrees, extension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 50 degrees, and internal rotation from 0 to 30 degrees. Adduction was not limited such that the Veteran could not cross his legs. Range of motion did not contribute to functional loss. Pain was noted on exam but did not result in functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing but no evidence of crepitus. The Veteran was able to perform repetitive use testing in both hips and there was no additional loss of function or range of motion. The examiner indicated that pain, weakness, fatigability, or incoordination significantly limited functional ability during repeated use over time and during flare-ups. Factors causing functional loss during repeated use over time was pain. With regard to repeated use over time and flare-ups, in terms of range of motion, for both hips, flexion would be from 0 to 100 degrees, extension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 20 degrees, external rotation from 0 to 50 degrees, and internal rotation from 0 to 30 degrees. Adduction would not be limited such that the Veteran could not cross his legs. There were no additional contributing factors of disability on both sides. Muscle strength testing was normal in both hips and no muscle atrophy. There was no ankylosis. Regarding functional impact, the Veteran had pain with climbing up into his truck and also with driving during a flare-up. There was objective evidence of pain in both hips while used in non-weight bearing. Right Hip Strain, Right Thigh Limitation of Flexion, Impairment of the Right Thigh, Left Hip Strain, Left Thigh Limitation of Flexion, Left Thigh Limitation of Extension The Veteran is seeking an initial compensable rating for his service-connected right hip strain, based on limitation of extension, prior to January 6, 2017 and from December 5, 2018, and a rating in excess of 10 percent from January 6, 2017 to December 4, 2018. The Veteran is also seeking an initial compensable evaluation for right thigh limitation of flexion. He is also seeking an initial evaluation in excess of 10 percent for impairment of the right thigh prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018. Additionally, the Veteran is seeking an initial evaluation in excess of 10 percent for his service-connected left hip strain, based on impairment of the thigh, prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and an evaluation in excess of 20 percent from December 5, 2018. The Veteran is also seeking an initial compensable evaluation for left thigh limitation of flexion and an initial compensable evaluation for left thigh limitation of extension prior to January 6, 2017 and from December 5, 2018, and in excess of 10 percent from January 6, 2017 to December 4, 2018. The Veteran’s right hip strain and left thigh limitation of extension are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5251, for limitation of extension of the thigh. Under Diagnostic Code 5251, a maximum 10 percent rating is warranted for extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. The Veteran’s right thigh limitation of flexion and left thigh limitation of flexion are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5252. A rating of 10 percent is assigned when the Veteran’s flexion is limited to 45 degrees, and a rating of 20 percent is assigned when Veteran’s flexion is limited to 30 degrees. A rating of 30 percent is assigned when the Veteran’s flexion is limited to 20 degrees, and a rating of 40 percent is assigned when the Veteran’s flexion is limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. The Veteran’s impairment of the right thigh and left hip strain are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5253. A rating of 10 percent is assigned when the Veteran’s rotation is limited such that the Veteran cannot toe-out more than 15 degrees of the affected leg or adduction is limited such that the Veteran cannot cross legs. A disability rating of 20 percent is assigned when the Veteran’s abduction is limited such that motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, these Diagnostic Codes were not changed.   Right Hip Strain and Left Thigh Limitation of Extension For the period prior to January 6, 2017 and from December 5, 2018, the Veteran’s right hip strain and left thigh limitation of extension exhibited extension at worst from 0 to 20 degrees, and there was no evidence of extension limited to 5 degrees required for at least a compensable rating during these periods of time. However, during these periods, the July 2015 VA examiner found that there was pain that caused functional loss on both sides and the November 2020 VA examiner found that for both sides, pain, weakness, fatigability, or incoordination significantly limited functional ability during repeated use over time and during flare-ups and that pain was the factor causing functional loss. There was also objective evidence of pain in both hips while used in non-weight bearing. Given that the VA examiners noted there was additional functional loss due to painful motion for the period prior to January 6, 2017 and from December 5, 2018, the minimum compensable rating under Diagnostic Code 5251, in this case a 10 percent rating, is warranted for right hip strain and left thigh limitation of extension. 38 C.F.R. § 4.59. For the period from January 6, 2017 to December 4, 2018, as the Veteran is in receipt of the highest schedular rating for his right hip strain for limitation of extension of the thigh due to painful motion of the hip, there is no basis to award a higher rating. Right Thigh and Left Thigh Limitation of Flexion Regarding the Veteran’s right thigh limitation of flexion, during the period on appeal, the Veteran exhibited flexion from 0 to 115 degrees, from 0 to 75 degrees, from 0 to 65 degrees, and from 0 to 100 degrees. There was no evidence of flexion limited to 45 degrees, even with consideration of pain and functional loss, required for at least a compensable rating during the appeal period. Because the Veteran is already receiving compensable ratings for right hip extension due to painful motion, the Board finds that awarding him a compensable rating due to painful flexion would violate the rule against pyramiding. See 38 C.F.R. § 4.14. Regarding the Veteran’s left thigh limitation of flexion, during the period on appeal, the Veteran exhibited flexion from 0 to 105 degrees, from 0 to 75 degrees, from 0 to 65 degrees, and from 0 to 100 degrees. There was no evidence of flexion limited to 45 degrees, even with consideration of pain and functional loss required for at least a compensable rating during the appeal period. Because the Veteran is already receiving compensable ratings for left hip extension due to painful motion, the Board finds that awarding him a compensable rating due to painful flexion would violate the rule against pyramiding. See 38 C.F.R. § 4.14. Impairment of the Right Thigh and Left Hip Strain Regarding the Veteran’s impairment of the right thigh and left hip strain, for the period prior to January 6, 2017, a rating in excess of 10 percent is not warranted as there is no evidence that abduction is limited such that motion is lost beyond 10 degrees. Although the July 2015 VA examiner found that adduction was limited such that the Veteran could not cross his legs, the findings showed abduction from 0 to 30 degrees on both sides. During this period, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation would not result in symptoms more nearly approximating abduction lost beyond 10 degrees. For the period from January 6, 2017 to December 4, 2018, a compensable rating is not warranted as the evidence does not show that the Veteran’s rotation is limited such that the Veteran cannot toe-out more than 15 degrees of the affected leg or adduction is limited such that the Veteran cannot cross legs. The VA examiners found on both sides, external rotation no worse than 0 to 30 degrees and internal rotation from 0 to 20 degrees, and adduction was not limited such that the Veteran could not cross his legs. Because the Veteran is already receiving compensable ratings for left and right hip extension due to painful motion, the Board finds that awarding him a compensable rating due to painful rotation or adduction from January 6, 2017 to December 4, 2018 would violate the rule against pyramiding. See 38 C.F.R. § 4.14. For the period from December 5, 2018, as the Veteran is in receipt of the highest schedular rating under Diagnostic Code 5253 for both impairment of the right thigh and left hip strain, there is no basis to award a higher rating.   Other Considerations The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). As to a higher rating for any of the right hip and left hip disorders under Diagnostic Codes 5254 and 5255, the claims file does not contain a diagnosis of a flail joint, impairment of the femur with malunion, impairment of the femur with nonunion, a fracture of surgical neck with false joint, and/or a fracture of shaft or anatomical neck with nonunion and loose of motion (spiral or oblique fracture). Consequently, the Board finds that higher ratings are not warranted for any of the Veteran’s service-connected right and left hip and thigh disorders under Diagnostic Code 5254 and Diagnostic Code 5255 at any time during the pendency of the appeal. In conclusion, the Board finds that the balance of the evidence supports an initial 10 percent evaluation for right hip strain and left thigh limitation of extension prior to January 6, 2017 and from December 5, 2018. However, the preponderance of the evidence is against a rating in excess of 10 percent from January 6, 2017 to December 4, 2018 for right hip strain, an initial compensable evaluation for right thigh limitation of flexion, an initial evaluation in excess of 10 percent for impairment of the right thigh prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, and in excess of 20 percent from December 5, 2018. The preponderance of the evidence is also against a rating in excess of 10 percent from January 6, 2017 to December 4, 2018 for left thigh limitation of extension, an initial evaluation in excess of 10 percent for left hip strain prior to January 6, 2017, a compensable evaluation from January 6, 2017 to December 4, 2018, an evaluation in excess of 20 percent from December 5, 2018, and an initial compensable evaluation for left thigh limitation of flexion. 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, 4.7. REASONS FOR REMAND Left Knee Sprain with Meniscal Tear The Veteran is seeking an initial evaluation in excess of 20 percent for left knee sprain with meniscal tear, which is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5258, a maximum 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. As directed in the October 2020 Board remand, the Veteran was afforded a VA examination in November 2020. When describing flare-ups, the examiner noted the Veteran’s statements that his left knee gives out at times. However, the examiner did not discuss the Veteran’s statements and indicated no history of recurrent subluxation, lateral instability, and recurrent effusion. The examiner also found no joint instability. A separate rating may be warranted for recurrent subluxation or instability under Diagnostic Code 5257. Also, prior to February 7, 2021, objective medical evidence was not required to establish lateral knee instability under Diagnostic Code 5257. English v. Wilkie, 30 Vet. App. 347, 349 (2018). In addition, portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021. While Diagnostic Code 5258 was not changed, Diagnostic Code 5257 now provides for ratings based on sprain or ligament tear causing persistent instability. An August 2014 VA knee examiner found instability of station, and that there was slight anterior instability in the left knee. A January 2017 VA examiner found instability of station but no joint instability, and a December 2018 VA examiner also found instability of station. The Veteran has also indicated that he has joint instability. As the examiner did not address the Veteran’s complaints of knee instability, the Board therefore finds that a remand is necessary for a new VA examination to clarify whether the Veteran has left knee instability, and if so, the severity of such instability. Also, updated VA treatment records should be obtained.  The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from October 2020 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left knee sprain with meniscal tear. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must clearly determine whether the Veteran has instability of the left knee, and if so, the severity of such instability. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general   medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bonnie Yoon, 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.