Citation Nr: 21026767 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 12-11 930 DATE: May 3, 2021 ORDER A rating higher than 10 percent for a right hip disability prior to March 29, 2010 is denied. A 50 percent rating, but no higher, for a right hip disability from May 1, 2011 to May 16, 2018 is granted. A rating higher than 50 percent for a right hip disability from May 17, 2018 is denied. A rating higher than 10 percent for a left hip disability prior to June 13, 2019 is denied. REMANDED A rating higher than 30 percent for a left hip disability from August 1, 2020 is remanded. A rating higher than 10 percent for a right knee disability is remanded. A compensable rating for right knee and right hip scars is remanded. A rating higher than 10 percent for a low back disability is remanded. A total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to March 29, 2010, the Veteran's right hip disability caused painful motion, but it did not limit flexion to 30 degrees or limit abduction with motion lost beyond 10 degrees. 2. From May 1, 2011 to May 16, 2018, the Veteran experienced moderately severe residuals of weakness, pain, or limitation of motion following right hip replacement surgery. 3. Since May 17, 2018, the Veteran has continued to experience no more than moderately severe residuals of right hip replacement surgery. 4. Prior to June 13, 2019, the Veteran's left hip disability caused painful motion, but it did not limit flexion to 30 degrees or limit abduction with motion lost beyond 10 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for a right hip disability prior to March 29, 2010 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251-5253. 2. The criteria for a 50 percent rating, but no higher, for a right hip disability from May 1, 2011 to May 16, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054. 3. The criteria for a rating higher than 50 percent for a right hip disability from May 17, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054. 4. The criteria for a rating higher than 10 percent for a left hip disability prior to June 13, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5054. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1986 to August 1990 and from September 2001 to October 2002. This case returns to the Board of Veterans' Appeals (Board) after a remand to the agency of original jurisdiction (AOJ) in February 2018. Increased Ratings for Right and Left Hip Disabilities The Veteran seeks increased ratings for service-connected right and left hip disabilities. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. VA must evaluate all of the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. Where there is a question as to which of two evaluations shall be applied, a higher rating 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. Any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Right Hip Disability prior to March 29, 2010 The Veteran's right hip disability is rated based on painful motion for the period on appeal prior to March 29, 2010. After careful review, the Board finds that a rating higher than 10 percent is not warranted for this period. In general, hip disabilities are rated based on limitation of motion 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. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. Id. Under Diagnostic Code 5253, a 10 percent rating is warranted for limitation of rotation such that the Veteran cannot "toe-out" more than 15 degrees. A 10 percent rating is also warranted for limitation of adduction such that the Veteran cannot cross legs. A maximum 20 percent rating is warranted for limitation of abduction with motion lost beyond 10 degrees. Id. When evaluating musculoskeletal disabilities based on limitation of motion, VA must consider functional loss caused by pain or other factors that could occur during flare-ups or after repeated use which may not be reflected on range-of-motion testing. 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.45, VA must also consider 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). Under 38 C.F.R. § 4.59, painful motion associated with joint or periarticular pathology warrants at least the minimum compensable rating for the affected joint. Mitchell, 25 Vet. App. at 36; see also Burton v. Shinseki, 25 Vet. App. 1 (2011). VA examiners assessed the Veteran's hip disability in March 2007 and December 2009. These examinations are the most probative evidence in the record for the period prior to March 29, 2010. They do not support a rating higher than 10 percent. In March 2007, the Veteran rated his chronic right hip pain as "8/10" on a good day and "9/10" on a bad day. He also reported swelling and stiffness, but denied any other symptoms. He identified no alleviating factors for his hip pain. He reported difficulty walking for more than 100 feet, sitting for more than 45 minutes, and standing for more than five minutes due to bilateral hip and right knee pain. He also stated that he was unable to perform his duties as a federal police officer, which involved wearing about 35 pounds of gear, squatting, kneeling, and running. The Veteran's flexion was from 0 to 110 degrees, with pain on motion beginning at 90 degrees. Extension was from 0 to 30 degrees, without pain. Abduction was from 0 to 45 degrees, without pain. Adduction was from 0 to 20 degrees, without pain. External rotation was from 0 to 40 degrees, with pain at the endpoint, and internal rotation was from 0 to 10 degrees, with pain at the endpoint. X-rays revealed degenerative joint disease in both hips. At the December 2009 examination, the Veteran reported that he was able to stand for 15 to 30 minutes and walk one quarter of a mile. He denied using any assistive devices. Right hip flexion was from 0 to 125 degrees; extension was from 0 to 25 degrees; abduction was from 0 to 45 degrees. He could cross his right leg over the left, but he could not toe-out more than 15 degrees. There was objective evidence of pain with active motion and repetitive motion. There were no additional limitations after three repetitions. There was no evidence of ankylosis of the hip joint. The 2009 examiner noted right hip crepitus on examination. The Board finds no evidence, lay or medical, in the claims file that contradicts the examiners' findings, or otherwise supports an increased rating under any appropriate hip diagnostic code for this period. Medical records show numerous complaints of pain due to bilateral hip arthritis and associated disabilities, including service-connected myofascial pain syndrome in the buttocks. Physician statements reflect that the Veteran had difficulty with job duties involving long periods of standing, walking, bending, stooping, and crawling. However, the evidence does not show that the right hip disability limited flexion to 30 degrees or limited abduction with motion lost beyond 10 degrees prior to March 29, 2010. In sum, the preponderance of evidence is against assigning a rating higher than 10 percent for this period. As such, the benefit-of-the-doubt rule is not applicable in this instance. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). An increased rating prior to March 29, 2010 is denied. Right Hip Disability from May 1, 2011 to May 16, 2018 The Veteran received a 100 percent rating for one year following total right hip joint replacement surgery in March 2010, as provided by Diagnostic Code 5054. 38 C.F.R. § 4.71a. The AOJ then assigned a 30 percent rating for residuals from May 1, 2011 to May 16, 2018. The Board finds that the record supports a 50 percent rating, but no higher, for this period. Under Diagnostic Code 5054, a minimum 30 percent rating is assigned following the temporary 100-percent rating period for prosthetic replacement of the head of the femur or the acetabulum. A 50 percent rating is assigned for moderately severe residuals of weakness, pain, or limitation of motion. A 70 percent rating is assigned for markedly severe residual weakness, pain, or limitation of motion. A maximum 90 percent rating is assigned for painful motion or weakness requiring the use of crutches. 38 C.F.R. § 4.71a. The terms "moderately" and "markedly" are not defined in the VA regulations. The Board therefore relies on the ordinary, dictionary definitions of those terms. According to Merriam-Webster, "moderate" means "tending toward the mean or average amount or dimension," while "marked" means "having a distinctive or emphasized character." See www.merriam-webster.com/dictionary/. Rather than applying a mechanical formula, the Board must evaluate all of the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. The Board notes that VA recently amended certain diagnostic codes, including Diagnostic Code 5054, "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). These amendments went into effect on February 7, 2021. Id. Therefore, the changes to Diagnostic Code 5054 do not affect the rating criteria for the May 1, 2011-May 16, 2018 period. See 38 U.S.C. § 5110(g). During a February 2012 VA examination, the Veteran complained of ongoing soreness and pain after his hip surgery. He reported that his hips bothered him all day long. He did not report any flare-ups. He did not use any assistive devices. Right hip flexion was to 120 degrees, extension was greater than 5 degrees, and abduction was not lost beyond 10 degrees. He could cross his legs and toe-out more than 15 degrees. There was no objective evidence of painful motion. There was no additional limitation in range of motion after repetitive use testing. Muscle strength was normal ("5/5") on flexion, abduction, and extension. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. Imaging revealed right hip arthroplasty in satisfactory alignment. VA treatment records reflect that the Veteran received physical therapy for bilateral hip and low back pain in 2015. During a March 2015 session, he complained of "crippling" hip pain that made him feel like he was "hit by a Mack truck." A July 2015 treatment report notes tenderness to palpation of the biceps femoris at the joint line and over the right greater trochanter; the Veteran also reported pain with resisted abduction of the right hip. A November 2015 treatment report notes complaints of hip flexor pain and bursitis on the right hip. The Veteran testified at a hearing before the AOJ in February 2016. He reported that the hip replacement "helped for the acute pain that [he] was having," but then he developed bursitis due to overcompensation of his left hip, knees, and feet. At a March 2016 VA examination, the Veteran stated that the hip replacement had significantly helped his right hip pain, and that it was less painful than his left hip. He reported difficulty at work; with prolonged sitting, standing, and walking; and doing routine daily activities due to both hips. He denied any flare-ups. He reported constant use of a cane for assistance with walking, transfer, and steadiness. Right hip range of motion was from 0 to 125 degrees on flexion, 0 to 20 degrees on extension, 0 to 40 degrees on abduction, 0 to 25 degrees on adduction, 0 to 60 on external rotation, and 0 to 30 degrees on internal rotation, with pain in all directions. There was no additional loss of function or range of motion after three repetitions. There was moderate pain to palpation over the lateral hip. Muscle strength was normal on flexion, extension, and abduction; there was no muscle atrophy. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. The 2016 examiner noted that the right leg was longer than the left by 1.2 cm, causing altered biomechanics of the lower extremities. The examiner also noted an inflamed bursa on the right hip, and indicated that the Veteran's right hip replacement residuals included left hip bursitis, pain, and decreased range of motion. The examiner reviewed imaging from April 2014, which revealed stable postoperative changes of the right hip, and May 2015, which showed the hip in anatomic alignment and intact hardware. At an October 2017 hearing before the undersigned Veterans Law Judge, the Veteran testified that he had chronic right hip pain and limitation of movement. He also reported difficulty standing, kneeling, walking, sitting for a period of time, and lifting due to his hips. According to the Veteran, he thought the right hip replacement at had "[come] loose because [he] was having extreme pain in it." A VA physical therapist then reportedly explained to him that he had developed bursitis in the right hip. Resolving any reasonable doubt in his favor, the Board finds that the Veteran experienced moderately severe post-operative residuals prior to May 17, 2018. Gilbert, 1 Vet. App. at 53. Although neither the 2012 examiner nor the 2016 examiner characterized his residuals as "moderately severe," there is sufficient medical and lay evidence to support this finding. As discussed above, medical records for this period show complaints of "crippling" hip pain, and note moderate pain or tenderness to palpation. The 2016 examiner confirmed that the Veteran had an inflamed bursa on the right hip. At hearing, the Veteran described his pain as chronic and "extreme" following the hip replacement. His competent, credible lay statements regarding the severity of his hip pain are especially probative. The Veteran's right hip pain prior to May 17, 2018 is reasonably characterized as "moderately" severe under the ordinary, dictionary definition of the term. The record does not show that his symptoms were "markedly" severe. The 2012 and 2016 examination range of motion measurements were mostly within normal limits and would not warrant a rating above 10 percent for limitation of motion under any of the hip diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5251-5253. Likewise, the Veteran consistently demonstrated normal muscle strength on flexion, extension, and abduction. By his own account, the hip replacement "significantly helped" his right hip pain, and his left hip pain was worse than the right throughout this period. Accordingly, a 50 percent rating, but no higher, is granted prior to May 17, 2018. Right Hip Disability from May 17, 2018 On remand, the AOJ increased the Veteran's right hip rating to 50 percent rating for moderately severe residuals, effective May 17, 2018. See July 2019 rating decision. The Board finds that a rating higher than 50 percent is not warranted for the current period. As noted above, amendments to Diagnostic Code 5054 went into effect on February 7, 2021. 85 Fed. Reg. at 76463. The amended diagnostic code reduces the 100-percent convalescent period following implantation of a prosthesis from one year to four months, and adds "resurfacing" to the rating criteria. Id. These changes do not affect the rating criteria applicable here. 38 U.S.C. § 5110(g). The Veteran received VA examinations in May 2018 and September 2019. These examinations are the most probative evidence of record for the current period. During the May 2018 examination, the Veteran reported a dull throbbing pain around his right lateral trochanteric area. He stated that he was unable to run due to pain and loss of range of motion. He denied having any flare-ups and denied the use of any assistive devices. Right hip flexion was from 0 to 100 degrees, extension was from 0 to 25 degrees, abduction was from 0 to 40 degrees, adduction was from 0 to 25 degrees, external rotation was from 0 to 55 degrees, and internal rotation was from 0 to 30 degrees, with pain in all directions. There was no additional loss of function or range of motion after three repetitions. There was localized tenderness of the trochanteric area and hip joint. Muscle strength was normal on flexion, extension, and abduction. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. The 2018 examiner indicated that the Veteran had moderately severe post-operative residuals of weakness, pain, or limitation of motion. At the September 2019 examination, the Veteran reported that his pain, soreness, weakness, and stiffness has increased over the past 18 months. As with previous examinations, he reported difficulty walking, sitting, and standing for prolonged periods. He again denied having any flare-ups and denied the use of any assistive devices. Right hip flexion was from 0 to 90 degrees, extension was from 0 to 30 degrees, abduction was from 0 to 40 degrees, adduction was from 0 to 20 degrees, external rotation was from 0 to 60 degrees, and internal rotation was from 0 to 40 degrees. There was pain on flexion, extension, abduction, and adduction. The 2019 examiner estimated an additional 5-degree loss in flexion, extension, external rotation, and internal rotation due to pain with repeated use over a period of time. Muscle strength was again normal on flexion, extension, and abduction. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. Like the previous examiner, the 2019 found that the Veteran had moderately severe residuals of weakness, pain, or limitation of motion. Both VA examiners characterized the Veteran's right hip replacement residuals as "moderately" severe. This characterization is reasonably supported by the clinical findings above, as well as the Veteran's lay statements. The Board finds no evidence in the Veteran's medical records or elsewhere in the claims file suggesting that his right hip symptoms for the current period more nearly approximate the criteria for a 70 percent rating (i.e., "markedly" severe residuals) or higher. In sum, the preponderance of evidence is against finding that the Veteran has had markedly severe residual weakness, pain, or limitation of motion since May 17, 2018. Rather, he has continued to experience moderately severe residuals during the current period. There is no reasonable doubt to resolve in his favor in this instance. Gilbert, 1 Vet. App. at 53. A rating higher than 50 percent is denied. Left Hip Disability prior to June 13, 2019 The Veteran is in receipt of the minimum compensable rating10 percentfor his left hip disability prior to June 13, 2019. After careful review, the Board finds that an increased rating is not warranted for this period. VA examiners assessed the left hip in March 2007, December 2009, February 2012, and May 2018. These examinations are the most probative evidence of record. They do not support a rating higher than 10 percent. At the March 2007 examination, the Veteran rated his chronic left hip pain as "4/10" on a good day and "6/10" on a bad day. He reported swelling and stiffness as well, but denied any other symptoms. He identified no alleviating factors. As discussed above, he reported difficulty walking for more than 100 feet, sitting for more than 45 minutes, and standing for more than five minutes due to bilateral hip and right knee pain. He was reportedly unable to perform his duties as a federal police officer, including wearing about 35 pounds of gear, squatting, kneeling, and running. Left hip flexion was from 0 to 110 degrees, with pain on motion beginning at 90 degrees. Extension was from 0 to 30 degrees, without pain. Abduction was from 0 to 45 degrees, without pain. Adduction was from 0 to 20 degrees, without pain. External rotation was from 0 to 40 degrees, with pain at the endpoint, and internal rotation was from 0 to 10 degrees, with pain at the endpoint. Pain was greater on the right side than the left on range of motion testing. In December 2009, the Veteran reported that he was able to stand for 15 to 30 minutes and walk one quarter of a mile. He denied using any assistive devices. Left hip flexion was from 0 to 100 degrees; extension was from 0 to 15 degrees; abduction was from 0 to 30 degrees. He could cross his left leg over the right and he could toe-out more than 15 degrees. There was objective evidence of pain with active motion and repetitive motion. There were no additional limitations after three repetitions. There was no left hip crepitus on examination. There was no evidence of ankylosis of the hip joint. In February 2012, the Veteran reported that his hips bothered him all day long. He did not report any flare-ups. He did not use any assistive devices. Left hip flexion was to 120 degrees, extension was greater than 5 degrees, and abduction was not lost beyond 10 degrees. There was objective evidence of painful motion on extension, beginning at greater than 5 degrees. He could cross his legs and toe-out more than 15 degrees. There was no objective evidence of painful motion There was no additional limitation in range of motion after repetitive use testing. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. Imaging revealed mild degenerative changes in the left hip. In March 2016, the Veteran reported noticing an increase in left hip pain over the years. His symptoms reportedly mimicked the pre-replacement right hip symptoms. He stated that a left hip replacement had been recommended, but he was trying to hold off because he was only 49. He reported difficulty at work; with prolonged sitting, standing, and walking; and doing routine daily activities due to both hips. He denied any flare-ups. He reported constant use of a cane for assistance with walking, transfer, and steadiness. Left hip range of motion was from 0 to 125 degrees on flexion, 0 to 20 degrees on extension, 0 to 40 degrees on abduction, 0 to 25 degrees on adduction, 0 to 50 on external rotation, and 0 to 30 degrees on internal rotation, with pain in all directions. There was no additional loss of function or range of motion after three repetitions. There was moderate pain to palpation over the lateral hip. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. The 2016 examiner reviewed imaging from April 2014, which revealed moderate degenerative changes in the left hip, and May 2015, which showed moderate osteoarthritis. During the May 2018 examination, the Veteran again stated that his left hip pain had worsened, noting that it was worse than the right hip. He reported sharp left hip pain on movement, as well as a constant low level throbbing pain. He stated that he could not carry extra weight ("20 pounds maybe"), walk more than a couple hundred yards, or stand or sit for more than 20 minutes due to left hip pain. Left hip flexion was from 0 to 95 degrees, extension was from 0 to 20 degrees, abduction was from 0 to 35 degrees, adduction was from 0 to 15 degrees, external rotation was from 0 to 45 degrees, and internal rotation was from 0 to 10 degrees, with pain in all directions. There was no additional loss of function or range of motion after three repetitions. There was localized tenderness of the trochanteric area and hip joint. Muscle strength was normal on flexion, extension, and abduction. There was no evidence of ankylosis of the hip joint, malunion or nonunion of the femur, or flail hip joint. The examinations above do not show that the left hip disability limited flexion to 30 degrees or limited abduction with motion lost beyond 10 degrees prior to June 13, 2019. Contemporaneous medical records do not either. A November 2011 VA treatment record notes that range of motion was intact on the left hip, that the Veteran was able to lay down and sit up without problems, and that he walked with a non-antalgic gait. An October 2012 record notes mild pain on hip rotation, but does not provide specific measurements. The Veteran received physical therapy and steroid injections for left hip pain through VA in 2015. In September 2015, he demonstrated flexion to 100 degrees, full extension, abduction to 30 degrees, adduction to 15 degrees, internal rotation to 10 degrees, and external rotation to 30 degrees. There was mild tenderness to palpation over the left hip/greater trochanter. There was no swelling on examination. An August 2017 VA physical rehabilitation note indicates that the Veteran had painful left hip range of motion (especially internal rotation), but it does not include specific measurements. The Veteran rated his pain at "6-7/10" and noted that laying on the hip increased his pain. A radiograph performed around the same time revealed moderate degenerative changes. At an October 2017 VA orthopedic follow-up, the Veteran demonstrated left hip flexion from 0 to 90 degrees, with pain and stiffness at 90 degrees. There was also pain on internal and external rotation, but no tenderness to palpation over the greater trochanter. He reported constant "6/10" sharp, throbbing pain, with intermittent "10/10" "ice pick" stabbing pain in the anterior groin during activity. Ultimately, the preponderance of evidence is against finding that the Veteran's left hip disability limited flexion to 30 degrees or limited abduction with motion lost beyond 10 degrees prior to June 13, 2019. This is the case even when considering the Veteran's lay statements regarding functional loss and increased pain with activity. There is no evidence to support an increased rating under another applicable hip diagnostic code. The benefit-of-the-doubt rule is not applicable in this instance. Gilbert, 1 Vet. App. at 53. Accordingly, a rating higher than 10 percent prior to June 13, 2019 is denied. REASONS FOR REMAND Left Hip Disability from August 1, 2020 The Veteran received a 100 percent rating for one year following a total left hip joint replacement in June 2019, as provided by Diagnostic Code 5054. The AOJ then assigned the minimum 30 percent rating available under the diagnostic code, effective August 1, 2020. See September 2019 rating decision. The AOJ noted that although the September 2019 examination revealed moderately severe post-operative residuals, this examination occurred approximately two months after his surgery. Id. As the 2019 examiner indicated, the Veteran was still recovering from the procedure at that time. The Board finds insufficient medical evidence on file to determine the level of severity of the Veteran's left hip disability for the period since August 1, 2020. He has not received a hip examination during this current period. The most recent examination occurred while he was still recovering from a total hip replacement, which suggests that the 2019 examiner's findings may not accurately reflect his current level of disability. Remand for a new examination is therefore warranted. Right Knee Disability The Veteran seeks a rating higher than 10 percent for a service-connected right knee disability. Following the Board's remand, he received a new examination of the knee in May 2018. During the examination, he reported pain with repeated use, such as prolonged walking (especially downhill) and prolonged standing. He also reported that the "more active [the knee] is, the more inflamed it gets," so he limits himself in speed and distance while walking. The 2018 examiner was "unable to say without mere speculation" whether pain, weakness, fatiguability, or incoordination significantly limits functional ability with repeated use over a period of time. In support of this finding, the examiner indicated only that he "need[s] to examine after repeated use." The examiner provided no other explanation as to why he was unable to provide an opinion on functional ability with repeated use over time without resorting to speculation. The Board finds the examiner's conclusory determination inadequate. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (an examiner must clearly indicate precisely what facts cannot be determined that would allow for a more conclusive opinion); see also e.g. Sharp v. Shulkin, Vet. App. 26, 36 (2017) (an examiner must attempt to elicit all relevant information regarding the severity, frequency, duration, precipitating and alleviating factors, and the extent of functional impairment during flare-ups). Remand for a new examination is warranted. Right Knee and Right Hip Scars On remand, the AOJ assigned a separate noncompensable rating for scars associated with the Veteran's right knee and hip disabilities. See July 2019 rating decision. Since the Board is again remanding the right knee claim for development, the "inextricably intertwined" issue of a compensable rating for these scars is remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). The examiner should complete the appropriate disability benefits questionnaire for the Veteran's service-connected scars, as necessary. Low Back Disability The Veteran also seeks a rating higher than 10 percent for a low back disability. During a May 2018 examination, he reported that he could not lift weights of 20 pounds, bend over, or stand for five minutes due to back pain. The 2018 examiner was "unable to say without mere speculation" whether pain, weakness, fatiguability, or incoordination significantly limits functional ability with repeated use over a period of time. In support of this finding, the examiner indicated only that he "need[s] to examine after repeated use." The examiner provided no other explanation as to why he was unable to provide an opinion on functional ability with repeated use over time without resorting to speculation. The Board finds the examiner's conclusory determination inadequate. Jones, 23 Vet. App. at 390; see also e.g. Sharp, Vet. App. at 36 (2017). Remand for a new examination is warranted. TDIU The Board finds that the Veteran has raised the issue of unemployability in connection with his left hip increased rating claim. In a July 2019 statement, he requested a permanent and total disability rating due to his hip replacement, noting that he had been approved for medical retirement. He submitted supporting documentation from the U.S. Office of Personnel Management, which "found [him] to be disabled for [his] position as an Environmental Protection Specialist, due to osteoarthritis." The Board has jurisdiction to decide whether a TDIU is warranted. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). As noted above, the Board is remanding the left hip claim for the period since August 1, 2020. Since the TDIU issue is inextricably intertwined with this claim, remand is appropriate for the TDIU issue as well. Harris, 1 Vet. App. at 183; Tyrues, 23 Vet. App. at 177 (2009). On remand, the AOJ should conduct any necessary development, including asking the Veteran to complete a VA Form 21-8940, Application for Increased Compensation Based on Unemployability. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left hip disability, right knee disability and associated scars, and low back disability. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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) The examiner must 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. 2. Ask the Veteran to complete and return a VA Form 21-8940, Application for Increased Compensation Based on Unemployability. 3. Readjudicate the Veteran's claims. If any claim remains denied, issue a supplemental statement of the case, and allow the Veteran and his representative the opportunity to respond. Then return to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.Z. Wall, 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.