Citation Nr: 21030188 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 14-23 581 DATE: May 18, 2021 ORDER Entitlement to an increased rating in excess of 20 percent for right femur fracture with hip arthroplasty prior to February 16, 2016 is denied. Entitlement to an increased rating in excess of 30 percent, but no higher, for right femur fracture with hip arthroplasty from February 16, 2016 to April 22, 2019 is granted. Entitlement to a rating in excess of 70 percent from June 1, 2020 to April 29, 2021 for right femur fracture with total hip replacement is denied. Entitlement to an increased rating of 70 percent, but no higher, for right femur fracture with total hip replacement for the period from April 29, 2021 is granted. Entitlement to an increased rating in excess of 10 percent rating for right femur limitation of extension status post intramedullary rod surgical repair from January 17, 2019 to April 22, 2019 is denied. Entitlement to a compensable rating for right femur limitation of flexion status post intramedullary rod surgical repair January 17, 2019 to April 22, 2019 is denied. Entitlement to a compensable rating for right thigh impairment status post intramedullary rod surgical repair January 17, 2019 to April 22, 2019 is denied. Entitlement to an increased rating in excess of 10 percent for right lateral hip/buttock scar and right medial knee scar is denied. Entitlement to a compensable rating for right lateral knee scar is denied. REMANDED Entitlement to an increased rating in excess of 10 percent for neuroma of the right greater trochanteric incision is remanded. FINDINGS OF FACT 1. Prior to February 16, 2016, the Veteran's right femur fracture did not manifest to malunion with marked knee or hip disability, nonunion of the femur, limitation to 20 degrees, or ankylosis of any kind. 2. From February 16, 2016 to April 22, 2019, the Veteran was additionally limited by pain, fatigue, incoordination, and suffered pain on passive range of motion that more nearly approximated marked hip disability. 3. From June 1, 2020, the Veteran's right femur fracture post total hip replacement showed moderately severe symptoms with additional functional loss due to pain. 4. From January 17, 2019 to April 22, 2019, the Veteran's right femur limitation of extension is already provided the maximum rating available under the diagnostic rating criteria. 5. From January 17, 2019 to April 22, 2019, the Veteran's right femur limitation of flexion did not manifest to limitation of 45 degrees or less. 6. From January 17, 2019 to April 22, 2019, the Veteran's right thigh impairment did not manifest to limitation of rotation of, cannot toe out more than 15 degrees of the affected leg. 7. The probative evidence of record shows the Veteran only has two painful scars, which are the right lateral hip and right medial knee scars. 8. The Veteran's right lateral knee scar has not manifested to affecting an area of 144 square inches, is not painful or unstable, and does not affect associated underlying tissue. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 20 percent for right femur fracture with hip arthroplasty prior to February 16, 2016 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5255. 2. The criteria for an increased rating in excess of 30 percent, but no higher, for right femur fracture with hip arthroplasty from February 16, 2016 to April 22, 2019 have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5255. 3. The criteria for an increased rating in excess of 70 percent for right femur fracture with total hip replacement for the appeal period from June 1, 2020 to April 29, 2021 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5054. 4. The criteria for an increased rating of 70 percent, but no higher, for right femur fracture with total hip replacement for the entire appeal period from April 29, 2021 have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5054. 5. The criteria for an increased rating in excess of 10 percent rating for right femur limitation of extension status post intramedullary rod surgical repair from January 17, 2019 to April 22, 2019 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5251. 6. The criteria for a compensable rating for right femur limitation of flexion status post intramedullary rod surgical repair January 17, 2019 to April 22, 2019 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5252. 7. The criteria for a compensable rating for right thigh impairment status post intramedullary rod surgical repair January 17, 2019 to April 22, 2019 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.97, Diagnostic Code (DC) 5253. 8. The criteria for an increased rating in excess of 10 percent for right lateral hip/buttock scar and right medial knee scar have not been met. 38 U.S.C. § 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 4.1, 4.118, Diagnostic Code 7804. 9. The criteria for a compensable rating for right lateral knee scar have not been met. 38 U.S.C. § 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 4.1, 4.118, Diagnostic Code 7802. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1989 to August 1992. In August 2017, the Veteran was provided a hearing with the undersigned Veterans Law Judge and a transcript of the proceeding is of record. Most recently, the claims were brought before the Board in March 2018 and May 2020 and were remanded for further development. The Board notes that for the Veteran's right femur fracture with total right hip arthroplasty, the Veteran was provided a 100 percent rating from April 22, 2019 to June 1, 2020 for his total right hip replacement, and thus, the Board will only be considering the periods before and after his surgery that are on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his/her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the 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. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Additionally, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. However, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Further, when evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors in the regulatory provisions cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. Entitlement to an Increased Rating: Right Femur Fracture The Veteran's right femur fracture with total hip arthroplasty is rated as 20 percent disabling under Diagnostic Code (DC) 5255 for femur impairment prior to June 1, 2020, as 70 percent disabling from June 1, 2020 to April 29, 2021, and as 50 percent disabling thereafter under Diagnostic Code 5054 for hip replacement. Under DC 5255, a 20 percent rating is warranted for malunion with moderate knee or hip disability; a 30 percent rating is provided for malunion with marked knee or hip disability; a 60 percent rating for fracture of surgical neck of, with false joint; a 60 percent rating is warranted for fracture of shaft or anatomical neck with nonunion, without loose motion, weightbearing preserved with aid of brace; and a 80 percent is warranted for fracture of shaft or anatomical neck with nonunion, with loose motion (spiral or oblique fracture). See 38 C.F.R. § 4.71a, DC 5255. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, regarding the period the Veteran's disability is rated under DC 5054, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Under the rating criteria for DC 5054 in effect prior to February 7, 2021, the hip is rated as 100 percent for a maximum 13-month period after a hip replacement. 38 C.F.R. § 4.71a, Diagnostic Code 5054, Note 1. Following the 13-month 100 percent period, a minimum of 30 percent is automatically assigned. However, if there are moderately severe residuals of weakness, pain, or limitation of motion, a 50 percent rating is provided, a 70 percent rating is provided if there is markedly severe residual weakness, pain, or limitation of motion, and a 90 percent rating is provided if there is painful motion or weakness such as to require the use of crutches. 38 C.F.R. § 4.71a, DC 5054. A 90 percent rating is the highest rating permitted for the hip, aside from the periods where a 100 percent rating is expressly permitted. Under the revised rating criteria for DC 5054, effective February 7, 2021, resurfacing was added to the diagnostic code and was not to be given an automatic 30 percent rating following the 100 percent period, and instead, is to be considered under diagnostic codes 5250 through 5255. 38 C.F.R. § 4.71a, DC 5054, Note 1 (February 7, 2021). In September 2013, the Veteran attended a VA examination. The Veteran reported his condition had gotten worse. He reported more difficulty moving and daily pain that was dull, aching, throbbing, and radiating into the pelvis. He reported that his condition was aggravated with repetitive stairs, prolonged standing, sitting, walking, and running. He further reported that during flareups he is unable to do anything. The Veteran's range of motion was flexion was to 110 degrees and his extension was greater than 5 degrees, with pain. Abduction was not lost beyond 10 degrees and did not limit the Veteran from crossing his legs or toeing out more than 15 degrees. Range of motion remained the same following repetitive use testing, and he did not suffer additional limitation. The Veteran did have functional loss and/or impairment following repetitive use, to include pain on movement and interference with sitting, standing, and/or weight-bearing. There was pain on palpation. The Veteran had normal muscle strength and no ankylosis of the joint. The Veteran did have a leg length discrepancy. The Veteran had not had a total replacement or arthroscopic surgery. The Veteran did not have need for assistive devices. The examiner lastly noted that the Veteran would have 10 to 15 degrees of loss of overall range of motion, mild weakness, mild fatigability and mild loss of coordination secondary to repetitive activity and painful flare-up episodes. In February 2016, the Veteran received another VA examination. The Veteran reported that his pain has gotten worse over time with aching pain that is felt at the fracture site on occasions. He reported daily pain that is aching and throbbing in nature and is aggravated with prolonged sitting and standing. He reported that during flare-ups he cannot do much and will have to sit down and use a heating pad, or has to lay down, or take a relaxant for the pain. The Veteran's range of motion was forward flexion to 105 degrees, extension to 25 degrees, abduction to 45 degrees, and adduction to 25 degrees. Range of motion itself did contribute to functional loss due to pain and stiffness. Pain noted on examination did cause functional loss and was exhibited on flexion, extension, and internal rotation. The Veteran's adduction was not limited such that the Veteran couldn't cross his legs. There was evidence of weight bearing and tenderness to palpation over the lateral mid shaft. There was no objective evidence of crepitus. The Veteran was able to perform repetitive testing and did not suffer additional loss of function or range of motion. The Veteran was not being examined immediately after repetitive use over time or during flare-ups and the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use or during flare-ups. The examiner could not say whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time because the Veteran was not being observed. However, the examiner noted the Veteran did suffer from pain, fatigue, and incoordination that causes functional loss during flare-ups. In terms of range of motion, the examiner described it as forward flexion to 100 degrees, extension to 20 degrees, abduction to 45 degrees, and adduction to 25 degrees. Additional factors of his disability included interference with sitting and interference with standing. The Veteran had normal muscle strength and no muscle atrophy. There was no ankylosis. The Veteran did have a leg length discrepancy, which was a 1.5-centimeter (cm) discrepancy with the right greater than left measured at the medial malleolus. The examiner noted the Veteran had arthroscopic surgery and residuals were as described throughout the examination. The Veteran was noted as having degenerative arthritis. The Veteran attended another VA examination in May 2017. He reported constant pain in the hip that has gotten progressively worse over time. He reported that it gets worse going up and down stairs and walking on uneven ground, as well as not being able to run. He reported occasionally waking up due to pain and taking a muscle relaxer or attempting to walk off the pain. Prolonged walking, climbing stairs or ladders caused pain flare-ups. He reported functional loss in not being able to run, limited ability to perform yardwork, and limitation in activities that involve walking or moving. The Veteran's range of motion was forward flexion to 100 degrees, extension to 20 degrees, abduction to 45 degrees, and adduction to 25 degrees. Adduction was not limited such that the Veteran couldn't cross his legs. Range of motion itself did result in functional loss in the form of decreased range of motion that results in altered gait and pain in the hip. The pain noted on examination caused functional loss in flexion. There was evidence of pain with weight bearing. There was tenderness to palpation over the right groin area. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing and did not suffer additional loss of function or range of motion after. The Veteran was not being examined immediately after repetitive use over time or during flare-ups and the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use or during flare-ups. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner could not say whether pain, weakness, fatigability, or incoordination significantly limit functional ability during flare-ups due to the Veteran not being examined during a flare-up. There were no additional contributing factors of disability. The Veteran had full muscle strength and no muscle atrophy. The Veteran did not have ankylosis. The Veteran did have a leg length discrepancy and the examiner noted that the Veteran's right leg healed gaining length relative to the other side. The Veteran did not have use for any assistive devices as a normal mode of locomotion. Following diagnostic testing, the Veteran was noted as having mild degenerative changes of the right hip with a stable old well-healed fracture of the mid femur diaphysis. The examiner further noted that imaging studies demonstrate the pathology resulting in the pain the Veteran experiences. There was no evidence of pain on passive range of motion or when the joint is used in non-weight bearing and the opposing joint is undamaged. In July 2018, the Veteran attended a VA examination. The Veteran reported flare-ups that were described as dull soreness and ache that is constant in the right groin area and worse with standing and prolonged sitting. He reported functional loss in being unable to run, standing limited to 3 minutes at a time, walking limited to 15 to 20 minutes, and sitting limited to 20 to 30 minutes. He reported taking his prescribed Tylenol with codeine for pain. The Veteran's flare-ups caused him discomfort and to limp. He reported still being able to work on these days and taking medicine as soon as he gets home. The Veteran's range of motion was forward flexion to 65 degrees, extension to 10 degrees, abduction to 30 degrees, and adduction to 15 degrees. The Veteran could still cross his legs. His external rotation was to 60 degrees and internal rotation was to 0 degrees. There was pain noted on examination that caused functional loss exhibited on flexion, extension, abduction, adduction, and internal rotation. There was pain with weight-bearing. There was pain or discomfort regarding his peripheral neuropathy condition; however, there was no tenderness over right hip joint on palpation anteriorly. The Veteran was able to perform repetitive use testing and did not suffer additional loss after. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. Pain did significantly limit functional ability with repeated use over time and during flare-ups. Additional contributing factors were disturbance of locomotion, interference with sitting, and interference with standing. There was no muscle atrophy or ankylosis. The Veteran had continued leg length discrepancy which was the right leg being .5 cm in the thigh area, 2 cm longer below the knee. The Veteran did not have need for assistive devices. There was evidence of pain on passive range of motion and when the joint is used in non-weight bearing. The opposing joint was undamaged. Another examination was provided in February 2019. The Veteran reported continued pain and constant discomfort. He reported flare-ups in the form of not being able to run or walk past 2 minutes at a time, aches when sitting or standing, and groin pain. He reported his motion was limited due to pain. His range of motion was flexion to 90 degrees, extension to 0 degrees, abduction to 30 degrees, and adduction to 15 degrees. His external rotation was to 50 degrees and internal rotation to 5 degrees. Pain noted on examination caused functional loss and was shown in all ranges of motion. There was pain on weight-bearing and mild groin pain. There was no crepitus. The Veteran was able to perform repetitive use testing. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. The examiner could not say whether pain, weakness, fatigability, or incoordination significantly limited the Veteran during repeated use over time. However, pain did significantly limit the Veteran during flare-ups. Range of motion during flare-ups was described as limiting flexion to 85 degrees, external rotation to 45 degrees, and internal rotation to 0 degrees. There was no reduction of muscle strength or muscle atrophy. There was no ankylosis. The residuals of the Veteran's previous arthroscopy included limited motion of the hip with pain. Pain was evident on non-weight bearing and on passive motion. The examiner noted the Veteran's right hip condition is moderate in severity. In December 2020, the Veteran received a VA examination. He reported flare-ups that occur weekly that are moderate. He reported they last 1 to 2 days. He reported functional loss in being unable to climb on roofs, go in crawl spaces, and inspect homes as part of his job and needing to work at a desk due to pain. His range of motion was flexion to 125 degrees, extension to 5 degrees, abduction to 30 degrees, and adduction to 15 degrees. His external rotation was to 15 degrees and internal rotation to 25 degrees. The Veteran was able to cross his legs. Pain noted on examination caused functional loss and was shown in all ranges of motion. There was mild pain on palpation over the anterior groin and hip ball joint. There was evidence of pain with weight bearing. There was no crepitus. The Veteran was able to perform repetitive use testing with no additional loss. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. Pain, weakness, and lack of endurance did significantly limit the Veteran with repeated use over time and during flare-ups. The examiner was unable to estimate the limitation in range of without resorting to mere speculation. There was no reduction in muscle strength or muscle atrophy. There was no ankylosis. The Veteran had leg length discrepancy due to the fracture of the hip and hip surgery. The residuals of the Veteran's total hip replacement were noted as moderately severe with weakness, pain, or limitation of motion following implantation of prosthesis. The Veteran did have occasional use for a cane. There was evidence of pain on passive range of motion and pain on non-weight bearing in all range of motion measurements. Most recently, the Veteran was provided a VA examination in April 2021. He reported aching in his groin area. He reported flare-ups that occur weekly that are moderate and limited mobility, to include walking, standing, sitting, and climbing. His range of motion was flexion to 60 degrees, extension to 30 degrees, abduction to 45 degrees, and adduction to 25 degrees. His external rotation was to 60 degrees and internal rotation was to 40 degrees. The Veteran was able to cross his legs. Pain was shown in passive range of motion on flexion. Pain shown on passive motion did result in functional loss. There was moderate pain on palpation of the lateral hip. There was no crepitus. The Veteran was able to perform repetitive use testing and caused limitation in abduction that prevented the Veteran from crossing his legs. Pain did significantly limit the Veteran with repeated use over time and during flare-ups. There was no muscle atrophy or ankylosis. The Veteran did not have hip joint resurfacing. The residuals of the Veteran's total hip replacement were noted as moderately severe with weakness, pain, or limitation of motion following implantation of prosthesis. The Veteran did not have use for assistive devices. There was evidence of pain on passive range of motion and pain on non-weight bearing in all range of motion measurements. After review of the evidence of record, the Board finds that a rating in excess of 20 percent prior to February 16, 2016 is not warranted. The Veteran's femur impairment showed symptoms that were mild to moderate in nature. Although the Veteran was noted as having functional loss due to pain on movement and interference with sitting, standing, or weight-bearing, the Veteran maintained only a minimal decrease in range of motion. Further, the examiner noted the Veteran's condition was likely to have only a 10-15 degrees loss of range of motion, mild weakness, mild fatigability, and mild loss of coordination during flare-ups. Thus, the Board finds that the Veteran's femur impairment condition has only shown moderate hip disability for the period under consideration. See 38 C.F.R. § 4.71a, DC 5255. However, the Board finds from February 16, 2016 to April 22, 2019, a rating of 30 percent, but no higher, is warranted. During this period, the Veteran began being noted as having functional ability significantly limited by pain, weakness, incoordination and/or fatigue with flare-ups and/or repeated use over time. The Veteran further began having a decrease in his range of motion. The Veteran was also noted as occasionally having pain on passive movement. As provided above, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated and those factors are not contemplated in the relevant criteria when evaluating limitation of motion for joint disabilities. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca at 202. Therefore, the Board finds that under DeLuca, the Veteran's condition is more closely approximated by marked hip disability and a rating of 30 percent, but no higher, is warranted. See 38 C.F.R. § 4.71a, DC 5255. The Board notes that at no time has the Veteran been found to have nonunion of the femur or surgical fracture of the femur neck with false joint that would warrant a rating in excess of 30 percent under Diagnostic Code 5255 for the period prior to June 1, 2020. Moreover, following the Veteran's total right hip replacement, the Board finds that a rating of 70 percent, but no higher, is warranted for the entire period from June 1, 2020. Although the Veteran was noted as having only moderately severe residuals of weakness, pain, or limitation of motion, the Veteran was also noted as having pain on passive motion that resulted in functional loss, and pain that significantly limited functional ability during flare-ups and with repeated use over time. Therefore, the Board finds that under DeLuca, the Veteran's condition more approximately represents markedly severe residuals under the rating criteria, and thus, a rating of 70 percent, but no higher, for the entire period from April 29, 2021 is warranted. 38 C.F.R. § 4.71a, DC 5054. See also DeLuca at 202. However, a rating in excess of 70 percent from June 1, 2020 is not warranted because at no time has the Veteran been noted as needing crutches. Further, the Board notes that the Veteran has also at no time had forward flexion limited to 20 degrees or less, hip flail joint, ankylosis of any kind, or any resurfacing which would warrant consideration of higher rating under another Diagnostic Code for the hip during any of the above periods. See 38 C.F.R. § 4.71a, DC 5250-5255, and DC 5054, Note 1 (February 7, 2021). In light of the foregoing, the Board concludes that a rating in excess of 20 percent prior to February 16, 2016 is not warranted. However, a rating of 30 percent, but no higher, from February 16, 2016 to April 22, 2019 is warranted. A rating in excess of 70 percent from June 1, 2020 to April 29, 2021 is not warranted, but a rating of 70 percent, but no higher, for the period from April 29, 2021 is warranted for right hip femur fracture with total hip replacement. The benefit of the doubt doctrine has been applied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 2. Entitlement to an Increased Rating: Right Hip Limitation of Motion and Thigh Impairment From January 17, 2019 to April 22, 2019, the Veteran is service-connected for right hip/thigh limitation of flexion rated as non-compensable under Diagnostic Code 5252, right hip/thigh limitation of extension rated as 10 percent disabling under Diagnostic Code 5251, and right hip thigh impairment rated as non-compensable under Diagnostic Code 5253. Under Diagnostic Code (DC) 5251, a maximum 10 percent rating is provided for extension limited to 5 degrees. See 38 C.F.R. § 4.71a, DC 5251. Under DC 5252, a 10 percent disability rating is warranted for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is warranted for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is warranted for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is warranted for flexion of the thigh that is limited to 10 degrees. See 38 C.F.R. § 4.71a, DC 5252. Under Diagnostic Code 5253, impairment of the thigh may be rated based on limitation of abduction, limitation of adduction, or limitation of rotation. A 10 percent rating will be assigned for limitation of rotation where the individual cannot toe-out more than 15 degrees on the affected leg, or for limitation of adduction where the individual cannot cross the legs. A 20 percent rating will be assigned for limitation of abduction where there is motion lost beyond 10 degrees. See 38 C.F.R. § 4.71a, DC 5253. In February 2019, the Veteran was provided a VA examination. The Veteran reported continued pain and constant discomfort. The Veteran's range of motion was flexion to 90 degrees, extension to 0 degrees, abduction to 30 degrees, and adduction to 15 degrees. His external rotation was to 50 degrees and internal rotation to 5 degrees. Pain noted on examination caused functional loss and was shown in all ranges of motion. There was no crepitus. Abduction was not limited such that the Veteran could not cross his legs. The Veteran was able to perform repetitive use testing. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. The examiner could not say whether pain, weakness, fatigability, or incoordination significantly limited the Veteran during repeated use over time. However, pain did significantly limit the Veteran during flare-ups. Range of motion during flare-ups was described as limiting flexion to 85 degrees, external rotation to 45 degrees, and internal rotation to 0 degrees. There was no reduction in muscle strength or muscle atrophy. There was no ankylosis. After review of the evidence of record, the Board finds that a rating in excess of 10 percent for right hip limitation of extension, a compensable rating for limitation of flexion, and a compensable rating for right hip/thigh impairment are not warranted. Regarding the Veteran's limitation of extension, the Board notes that the Veteran is already provided the maximum rating allowed under the rating criteria. Thus, a rating in excess of 10 percent is not warranted. See 38 C.F.R. § 4.71a, DC 5251. For the Veteran's limitation of flexion, the Board notes that at no time did the Veteran have a limitation to 45 degrees or less. In fact, the Veteran's limitation during this period did not ever go below 85 degrees even when considering flare-ups. Therefore, a compensable rating for right hip limitation of flexion is not warranted. 38 C.F.R. § 4.71a, DC 5252. Lastly, regarding the Veteran's thigh impairment, the Veteran was not noted as having limitation of rotation with an inability to not toe out more than 15 degrees, an inability to cross legs, or limitation of abduction with motion lost beyond 10 degrees. Therefore, a compensable rating for right thigh impairment is not warranted. 38 C.F.R. § 4.71a, DC 5253. The Board acknowledges that the Veteran reported constant pain and was noted as being significantly limited by pain during flare-ups. However, the Board already considered the Veteran's additional limitation in granting the Veteran's 30 percent rating for right femur fracture during the overlapping period as noted above, and therefore, consideration under limitation of extension, limitation of flexion, and thigh impairment would constitute undue pyramiding. See 38 C.F.R. § 4.14. Thus, additional consideration under DeLuca is not warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca at 202. The Board also acknowledges the Veteran's assertions that he is entitled to higher ratings because his symptoms are worse. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the Board has considered the Veteran's statements and finds them credible and consistent with the ratings assigned. In light of the foregoing, the Board concludes that a rating in excess of 10 percent for right hip limitation of extension, a compensable rating right hip limitation of flexion, and a compensable rating for thigh impairment from January 17, 2019 to April 22, 2019 are not warranted. The benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 3. Entitlement to Increased Rating: Scars The Veteran's right lateral hip and right medial knee scars are currently rated as 10 percent disabling under Diagnostic Code (DC) 7804 for unstable or painful scars, and his right lateral knee scar is rated as noncompensable under DC 7802 for scars not of the head, face, or neck that are superficial or not associated with the underlying soft tissue. The regulations pertaining to rating skin disabilities were revised, effective August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. Under DC 7802, for scars other than on the head, face, or neck that are superficial and nonlinear, a maximum, 10 percent rating is warranted in an area or areas of 144 square inches (929 square centimeters) or greater. Note (1) indicates that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. 4.118, DC 7802 (2018). The amended criteria for DC 7802 now provide for scars other than on the head, face, or neck that are not associated with underlying soft tissue damage, but the rating criteria remain the same. 38 C.F.R. 4.118, DC 7802 (2019). Under DC 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable of painful. Lastly, A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board notes the rating criteria remained unchanged after the amendment. In September 2013, the Veteran was provided a VA examination for his right femur fracture. The Veteran was noted as having a scar related to his femur fracture that was not painful, unstable, or the total area greater than 39 square centimeters (cm). In January 2015, the Veteran attended a VA examination for his scars. The Veteran was noted as having a scar near the right lateral buttock and two scars around his knee. The examiner noted that two of the scars were painful, which were the right lateral buttock scar and the medial right knee scar. The Veteran reported the right lateral buttock scar as painful all the time and the medial right knee scar as tender to touch. None of the scars were unstable with frequent loss of covering of the skin or due to burns. The scar on his right buttock was a linear scar that was 6 cm by .2 cm wide and tender to palpation. His right medial knee scar was noted as being non-linear, 1 cm, and also tender to palpation. His right lateral knee scar was superficial, non-linear, not tender to palpation, and 1 cm. The Veteran received another VA examination in May 2017. The Veteran reported that the posterior hip scar was painful and gives a pulsating pins and needles type of pain. The Veteran's knee scars were noted as being barely visible and not painful. The examiner noted the posterior scar as the only painful scar. None of the scars were unstable with frequent loss of covering of the skin or were from burns. The medial right knee scar was 1 cm by 0.5 cm, and the lateral knee scar was the same and noted as barely visible. The scars were noted as being superficial and non-linear. The posterior trunk scar was noted as being 6 cm and linear. In June 2018, the Veteran attended a VA examination for his right lateral knee scar. The Veteran's right lateral knee scar was noted as being no longer visible and not affecting the underlying tissue. It was further noted that the scar was not painful. The scar was also not unstable or due to burns. On examination, the examiner noted that the lateral right knee scar was no longer visible and the Veteran was not able to identify it. The Veteran received a general scars VA examination in July 2018. The Veteran was noted as having three scars. The upper lateral thigh/hip scar was 7 cm by 0.1 wide and was sensitive to touch with discomfort. The right knee medial scar was 0.7 cm by 0.5 cm, and was non-tender and well healed, superficial, and non-linear. The third scar was the right lateral knee scar that was 0.7 cm by 0.5 cm, well-healed, non-tender, superficial, and non-linear. The Veteran was noted as having 2 painful scars. The right medial scar was non-tender; however, the Veteran reported deeper pressure over the medial proximal tibia that is tender and very close to the scar, as well as the upper thigh/buttock scar which was noted as still tender to light touch. None of the scars were unstable or due to burns. The examiner noted that the abduction of the right leg at the hip appeared to be limited by the right upper lateral thigh/hip scar. The Veteran attended another VA examination in July 2019. The Veteran was noted as having one painful scar of the right upper hip, which remains tender. The Veteran had no unstable scars. The Veteran reported that his incisional scar remains tender. However, the scar was noted as stable and healed. His two right knee scars were noted as stable and asymptomatic. The Veteran's right upper hip scar was 14 cm by .03 cm, the right medial knee scar was 4 cm by 0.2 cm, and his right lateral knee scar was 1.5 cm by 0.1 cm. The upper hip scar was not as tender to palpation. None of the scars had underlying tissue damage. Another VA examination was conducted in August 2019 for his right lateral hip scar. It was noted as painful. It was not unstable. His scar was described as 14 cm by 0.3 cm. There was no underlying damage. The Veteran reported radiating pulsating pain that was sensitive to touch. The Veteran was then seen shortly after in December 2019. The Veteran reported his right lateral hip scar was well healed following his hip replacement. His right lateral hip scar was noted as painful though with some numbness. None of his scars were unstable. The right lateral hip scar was 14 cm by 0.3 cm, his right medial knee scar was 4 cm by 0.2 cm, and his right lateral knee scar was 1.5 cm by 0.1 cm. None of the scars affected the underlying tissue. The approximate total area of his lower knee scars was 5.15 cm. The Veteran returned for another VA examination in December 2020. The Veteran was noted as having one painful scar of the right posterior hip that was tender to touch and painful with walking. None of the scars were unstable with frequent loss of covering or skin over the scar. The Veteran's right posterior hip scar was 13.5 cm by 0.5 cm, right medial knee scar was 0.5 cm by 0.1 cm, and his right lateral knee scar was 0.5 by 0.5 cm. His knee scars were not painful or tender to touch. His right lower extremity scars did not have underlying tissue damage. The right posterior hip scar was noted as limiting flexion of the hip caused by pain and pulling sensation at the incision area. Most recently, the Veteran was provided a VA examination in April 2021. The Veteran's right lateral hip scar was noted as painful and being 17 cm by 0.3 cm. The scar was also tender to palpation. The scars of the Veteran's right lower extremity were 5.1 cm collectively. None of the scars had underlying tissue damage. The Board recognizes that the April 2021 examination also addressed two other scars of the posterior back and abdomen. However, those scars are associated with the Veteran's lumbar spine condition. The Board notes that the Veteran has a pending claim for service connection for lumbar spine disability that was recently deferred by the Regional Office. Since the Veteran has not yet been service-connected for the condition, the Board cannot consider the scars associated with his lumbar spine disability. Upon review of the evidence of record, the Board finds that a rating in excess of 10 percent for the Veteran's scars of the right lateral hip and right medial knee is not warranted. As noted above, a 20 percent rating is provided when a Veteran has three or four scars that are painful. However, the Veteran's right lateral hip scar is the only scar that has been consistently noted as painful. The Veteran's right medial knee scar was occasionally noted as painful but has not been noted as such on examinations in several years. The Veteran has further not been found to have any other painful scars. Therefore, the Board finds a rating in excess of 10 percent for painful scars of the right lateral hip and right medial knee is not warranted. See 38 C.F.R. § 4.118, DC 7804. Further, a compensable rating for the Veteran's right lateral knee scar is also not warranted. As provided above, a 10 percent rating is provided for scars other than the head and neck not associated with underlying soft tissue when the scar has an area(s) of 144 square inches (929 square cm). However, the Veteran's right lateral knee scar has never been found to be more than 1.5 cm by 0.1 cm. The scar was also never noted as painful or unstable. Therefore, a compensable rating is not warranted. See 38 C.F.R. § 4.118, DC 7802. The Board notes that the evidence of record does not show that any of the Veteran's scars are deep and non-linear, associated with the underlying soft tissue, unstable, or affect the head, neck or face. Thus, consideration under Diagnostic Codes 7800-01 is not warranted. See 38 C.F.R. § 4.118, DCs 7800-01. In light of the foregoing, the Board concludes that a rating in excess of 10 percent for the Veteran's right lateral hip and right medial knee scars, and a compensable rating for right lateral knee scar are not warranted. The benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). REASONS FOR REMAND Although the Board sincerely regrets further delay, another remand is required to afford the Veteran every possible consideration. Entitlement to an Increased Rating: Neuroma The Veteran contends that his neuroma of the right greater trochanteric incision is more severe than the rating provided. In November 2020, the Veteran was provided a VA examination. The VA examiner diagnosed the Veteran with mild incomplete paralysis of the sciatic nerve. The examiner noted that this diagnosis was related to the previous diagnosis of neuroma of the greater trochanteric incision but has changed due to worsening post total hip replacement surgery. The Board notes the diagnosis was previously of the external cutaneous nerve. In December 2020, the Veteran attended another VA examination. The examiner diagnosed the Veteran with neuropathy of the right superior gluteal nerve. The examiner noted the nerves affected were mild incomplete paralysis of the sciatic nerve, anterior tibial nerve, internal popliteal nerve, and posterior tibial nerve. The examiner noted the established diagnosis of neuroma was confirmed and unchanged. The Board finds it is unclear which nerves are specifically related to the Veteran's neuroma condition associated with his right hip disability. Specifically, the Board finds that clarification is needed as to which nerves are related to the service-connected neuroma of the right greater trochanteric incision, as well as whether such symptoms are separate and distinct nerve conditions or are collective overlapping symptoms of the initial neuroma diagnosis. Therefore, a remand is required in order to obtain an opinion clarifying the above. The matters are REMANDED for the following action: Send the claims file to the examiner who conducted the December 2020 VA examination on the Veteran's neuroma of the right greater trochanteric incision. If the December 2020 examiner is not available, then the file should be sent to an appropriate examiner for the requested opinion. A copy of this remand should be made available to the examiner. If the examiner determines the requested opinion cannot be provided without an examination, then such examination should be scheduled and may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. After review of the evidence of record, the examiner is asked to identify what nerves are specifically affected by the Veteran's service-connected neuroma of the right great trochanteric incision. If multiple nerves are involved, please distinguish whether each nerve is a distinct and separate condition, or whether such affected nerves contribute to overlapping symptoms that are not possible to separate. In offering any opinion, the examiner must consider the full record, to include the lay statements regarding in-service incurrence, and the opinion should reflect such consideration. A clearly-stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Negron, 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.