Citation Nr: 21040687 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 14-33 837 DATE: July 6, 2021 ORDER Entitlement to an initial rating of 40 percent, excepting the periods of July 7, 2011 to September 1, 2011 and from March 1, 2012 to May 1, 2012 when the Veteran was at a 100 percent rating under 38 C.F.R. § 4.30, for sacroiliitis is granted. REMANDED Entitlement to a total disability rating due to individual unemployability (TDIU) prior to November 18, 2011 is remanded. FINDING OF FACT The Veteran's sacroiliitis did not manifest in unfavorable ankylosis during any portion of the relevant period. CONCLUSION OF LAW The criteria for an initial rating of 40 percent, but no higher, for sacroiliitis have been met. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5236. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 2008 to March 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in May 2018 and September 2020 Board decisions for further development. A remand by the Board imposes a concomitant duty to ensure compliance with the terms of the remand. Where the remand orders are not complied with, the Board itself errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Upon review, the Board finds that the remand directives have been substantially complied with. The September 2020 Board decision remanded the issues of entitlement to an initial increased rating for sacroiliitis with pubic synthesis; entitlement to service connection for pubic synthesis with plate disability and entitlement to TDIU. Following the Board's remand, a March 2020 rating decision granted service connection for pubic synthesis and granted TDIU beginning November 18, 2011. Thus, the only issues before the Board are entitlement to an increased rating for sacroiliitis and entitlement to TDIU prior to November 18, 2011. The claim for entitlement to TDIU prior to November 18, 2011 is addressed in the remand section below. General Rating Principles Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. 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. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that 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 regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be considered in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. §§ 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. §§ 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. Rating Principles- Sacroiliitis The Veteran is currently service connected for sacroiliitis under diagnostic code 5236 with a rating of 10 percent beginning March 21, 2009; a temporary total disability rating from July 7, 2011 to September 1, 2011; a rating of 10 percent from September 1, 2011 to November 10, 2011; a 40 percent rating from November 10, 2011 to March 1, 2012; a temporary total disability rating from March 01, 2012 to May 01, 2012 and a 40 percent rating from May 1, 2012 and thereafter. Diagnostic codes 5235 to 5243 are evaluated under the general rating formula for diseases and injuries of the spine. Under the general rating formula, a rating of 10 percent is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A rating of 20 percent is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. A rating of 30 percent is warranted for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A rating of 40 percent is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A rating of 50 percent is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A rating of 100 percent is warranted for unfavorable ankylosis of the entire spine. Note (1) instructs that any associated objective neurologic abnormalities including but not limited to bowel or bladder impairment, should be evaluated separately under the appropriate diagnostic code. 1. Entitlement to an initial rating in excess of 40 percent for sacroiliitis. Procedural History Following an initial denial, the Veteran filed a request to reopen her claim in November 2011. A January 2013 rating decision granted service connection for sacroiliitis with a rating of 10 percent beginning March 21, 2009 and a rating of 40 percent beginning November 10, 2011. The Veteran filed an informal notice of disagreement in January 2013. An April 2013 rating decision granted a temporary total disability rating beginning July 7, 2011, a 10 percent rating beginning September 1, 2011 and continued the 40 percent rating beginning November 10, 2011. Following the December 2013 statement of the case (SOC) the Veteran filed an appeal to the Board in February 2014. Subsequently, during the pendency of the appeal, a March 2020 rating decision granted a temporary total disability for the period from March 1, 2012 to May 1, 2012. The Veteran's rating of 40 percent was continued beginning May 1, 2012 and thereafter. As the Veteran has two periods of temporary total disability from July 7, 2011 to September 1, 2011 and from March 1, 2012 to May 1, 2012 the issue before the Board is entitlement to an initial rating in excess of 10 percent from March 21, 2009 to July 7, 2011; entitlement to a rating in excess of 10 percent from September 1, 2011 to November 10, 2011; entitlement to a rating in excess of 40 percent from November 10, 2011 to March 1, 2012 and entitlement to a rating in excess of 40 percent beginning May 1, 2012 and thereafter. Analysis In her January 2013 informal notice of disagreement, the Veteran asserted that her sacroiliac injury is rated incorrectly, noting that she has incapacitating episodes documented in the medical evidence totaling a duration of over 40 weeks per year. She also asserts that the rating criteria do not take into account the severity of her injury therefore, she is entitled to an extraschedular rating. Specifically, the Veteran alleges that while the rating criteria contemplates simple arthritic changes in her sacroiliac joint, she has also had multiple surgeries with large plates and screws inserted into her body and she may have lost the ability to have children due to these surgeries. Based on the evidence, as discussed below, the Veteran is entitled to a rating of 40 percent, but no higher for the entire period on appeal. Entitlement to an initial rating in excess of 10 percent from March 21, 2009 to July 7, 2011 and from September 1, 2011 to November 10, 2011. During April 2009 VA treatment the Veteran reported that she began having right hip pain approximately six months prior and has continued to reinjure her hip since that time. She noted that walking made her hip pop and hurt. The Veteran requested a referral to pain management clinic. May 2009 VA treatment records note that the Veteran participated in physical therapy for her sacroiliitis including aquatic exercises. The Veteran noted that during physical therapy she did not tolerate hip circles, but all other activities were helpful. She rated her pain as a 7/10. In January 2011, the Veteran complained of right sacroiliac joint pain and reported a pain level of 6/10. Notably, during a January 2011 physical therapy session, the Veteran rated her pain as 7-8/10 pre-treatment and 5-6/10 post treatment. The Veteran also reported that her pain was so severe that it was making her sick to her stomach. February 2011 imaging notes that the Veteran's sacroiliac joints were symmetric with no abnormal sclerosis or joint space narrowing. The rest of the osseous structures were unremarkable. February 2011 VA treatment records note some increased lordosis, and the Veteran had difficulty transitioning from sitting to supine position and from supine to prone position. The Veteran demonstrated trunk flexion to distal thighs with back pain, pain in the right sacroiliac joint and some pain with extension. Passive range of motion demonstrated hip flexion to 80 degrees on the right and right internal rotation to 20 degrees, with pain. Right hip pain was noted with any motion or stress and there was tenderness to palpation of the right sacroiliac joint. The Veteran was noted to have clinical signs of right sacroiliac irritation with no signs of improvement with conservative care. The Veteran was scheduled for pain management and referred to an orthopedist. March 2011 VA treatment records note dysfunction of the joints in the right hip for three years. The Veteran reported going to physical therapy which she did not feel was helping. She also reported treating her pain with Vicodin which was not helping. The Veteran was pregnant at the time of the examination and noted that pregnancy had exacerbated her symptoms. The physician indicated that while he expected the Veteran's symptoms to improve, post-partum treatment was unlikely to completely resolve the Veteran's symptoms. During an April 2011 VA appointment the Veteran reported that her hip pain was getting worse, requiring increased use of her crutches. The Veteran was given a Toradol injection for her sacroiliitis. May 2011 VA treatment records note complaints of bilateral hip pain for approximately three years. The Veteran reported a history of hip injections and pain medication which had become ineffective. She noted that the baseline for her hip pain had become unstable and requested to move forward with surgery of the sacroiliac joints. She also reported constantly using her crutches and characterized her pain as a level ten most of the time, noting that she was frequently on the verge of tears due to her pain. June 2011 private orthopedic treatment records note ongoing complaints of right sided low back pain and posterior hip pain. The Veteran reported developing increased pain in the right sacroiliac joint and new onset left sacroiliac joint pain after giving birth eight months prior. She reported her pain as being constant and noted that Percocet did not resolve her pain. Physical examination showed forward flexion from the waist to 20 degrees and then the Veteran began to experience significant right sacroiliac joint pain. There was no pain in the midline of the low lumbar spine, but the Veteran could not hyperextend and did not side bend well. Subjective decreased sensation was noted on the lateral side of the calf while sitting. Nonetheless, strength was good. There was no evidence of clonus. In the prone position the Veteran demonstrated minimal tenderness on palpation of the lower lumbar spinous processes. 3+ tenderness was noted about the right sacroiliac joint, and 2+ tenderness was noted on the left sacroiliac joint. There was tenderness in the sciatic notches bilaterally and some tenderness about the lateral aspect of the greater trochanter. In the supine position the Veteran demonstrated good range of motion of the hips with no evidence of any intrinsic pathology in the hip joints. Passive straight leg raise was negative for all nerve root irrigation and provocative test of the sacroiliac joint caused pain into the back and both groin areas. Gaenslen's test caused discomfort on the right, palpation about the symphysis pubis revealed tenderness and Patrick's test was positive. The physician opined that the vast majority of the Veteran's pain stemmed from the SI joint. The Veteran underwent surgery for her bilateral sacroiliac joints July 7, 2011. An October 2011 treatment note from the Veteran's primary physician indicates that following surgery on her bilateral sacroiliac joints the Veteran has severe mobility limitations and could not safely navigate stairs even with assistive devices. The physician noted that because the Veteran's surgery required fusion of the joints, she would not regain normal motion of the sacroiliac joints. October 2011 VA treatment records note that the Veteran's sacroiliitis includes severe spasms of the bilateral sacroiliac joints. The Veteran reported attending physical therapy two to three times a week and was noted to be making slow progress with physical therapy. Subjectively, the Veteran reported ongoing joint pain, abnormal gait, fatigue, and an inability to walk long distances. She also reported that her specialist advised that her recovery would take at least a year and a half. November 2011 VA treatment records note that the Veteran continued to complain of significant pain and continued to use crutches. The Veteran reported that her legs gave out on her twice resulting in a fall. She also reported some difficulty progressing in physical therapy. Ultimately, the evidence shows that for the period from March 21, 2009 to July 7, 2011 and from September 2011 to November 2011, the Veteran experienced significant pain, which the Veteran's June 2011 private physician noted stemmed from the Veteran's sacroiliac joint. By 2011 the Veteran reported an increase in her pain and was noted to use crutches. June 2011 private treatment records note that the Veteran was only able to complete forward flexion of the hips to 20 degrees, with significant sacroiliac joint pain at 20 degrees. Following her surgery, the record does not show any significant improvement in the Veteran's condition. The Veteran was noted to have severe mobility limitations, which the Veteran's physician noted were likely to be permanent. Further, the Veteran was noted to have spasms with ongoing joint pain and abnormal gait. In November 2011 the Veteran continued to report pain and noted that her legs gave out on her on two occasions. The evidence shows that for the period from March 21, 2009 through November 10, 2011 the Veteran continued to experience significant symptoms related to her sacroiliitis. However, during the period at issue, there was no evidence of unfavorable ankylosis of the thoracolumbar spine or the entire spine. Based on evidence showing forward flexion to 20 degrees with pain and the Veteran's ongoing complaints of significant pain, the Veteran's sacroiliitis meets the criteria for a rating of 40 percent. Because there is no evidence of unfavorable ankylosis of either the thoracolumbar spine or the entire spine, a rating in excess of 40 percent is not warranted. Further, although the Veteran alleges incapacitating episodes, this is not substantiated by the record, as there is no evidence of doctor prescribed bedrest. Additionally, the Veteran has not been diagnosed with intervertebral disc syndrome. The Board has considered the severity of the Veteran's symptoms including her pain and functional loss and find that the Veteran's symptoms are adequately compensated by a 40 percent rating. Extraschedular consideration is not warranted. The Board has considered whether a higher rating is warranted based on functional loss of the joints and painful motion. 38 C.F.R. §§ 4.40, 4.45, 4.49. In affording the Veteran a 40 percent rating the Board has considered the Veteran's complaints of pain, use of crutches and assistive devices as well the Veteran's complaints of pain on range of motion. The Veteran's 40 percent rating adequately compensates the Veteran for these factors. For the period prior to November 10, 2011 entitlement to a rating of 40 percent but no higher for sacroiliitis is granted. Entitlement to a rating in excess of 40 percent beginning November 10, 2011 and thereafter excepting the period from March 1, 2012 to May 1, 2012. Following her complaint of sacroiliac joint pain, the Veteran underwent an MRI of the lumbar spine in December 2011. Imaging showed normal vertebral body height and alignment with normal bone marrow signal, normal paravertebral soft tissues, no significant posterior disc disease, no significant facet arthropathy, no central stenosis or foraminal stenosis, and no visible nerve root impingement. January 2012 VA treatment records note that six months post bilateral SI joint fixation, the Veteran continued to complain of chronic back and hip pain. The Veteran was noted to require use of crutches and a walker. The Veteran reported that she was still in a lot of pain and requested a wheelchair. The Veteran was referred back to her surgeon for continued treatment and subsequently reported that she was scheduled for surgery in February 2012. February 2012 private orthopedic treatment records note that an EMG study showed no evidence of possible sciatic neuropraxia or piriformis syndrome. However, separate February 2012 private orthopedic records note that the Veteran reported increased pain about the symphysis pubis around Thanksgiving. She also noted some pain about the left sacroiliac joint but no significant pain about the right sacroiliac joint. The Veteran reported that all activities increase her pain. Upon examination, the Veteran demonstrated a slow, antalgic gait with forward flexion to 30 degrees before experiencing pain of the left sciatic joint; extension was also limited by pain. In the prone position, palpation revealed no tenderness about the spine but 2-3+ tenderness about the left sacroiliac joint area, mild tenderness about the left buttock and mild tenderness posterior to the greater trochanter. There was no tenderness directly over the greater trochanter on the left. On the right side the Veteran had 1-2+ tenderness about the right sacroiliac joint and 2+ tenderness on the right mid buttock. Examination with the Veteran in supine position showed full range of motion without discomfort and no impingement of the left hip. Provocative piriformis testing was positive at 2+ on the left with active abduction against resistance and active external rotation against resistance. The right side was 1+ positive on active abduction against resistance and 1+ positive on active external rotation against resistance. Both maneuvers caused pain about the symphysis pubis. Palpation about the symphysis pubis was 3+ positive and the provocative test caused pain about the symphysis pubic. Lumbar imaging showed a mild decrease in normal lumbar lordosis, but no significant facet arthropathy and no major degenerative disc disease. February 2012 VA treatment records note that the Veteran's previously scheduled surgery was rescheduled for March 1, 2012. A June 2012 private orthopedic examination notes tenderness to palpation in both buttocks, ongoing discomfort on the Veteran's right side, and posterior femoral thrust with minimal discomfort on the left side. There was also evidence of tenderness posterior to the greater trochanter. Prolonged fair positioning caused pain on the right in the buttock and back, and provocative piriformis testing on the right side for resisted abduction caused marked buttock pain on the right. Resisted external rotation also caused significant buttock pain. On the left side resisted abduction caused buttock pain and resisted external rotation caused iliotibial band pain. Beatty test was positive on both sides. A depo-medro/Marcaine injection was administered, and the Veteran was referred to pain management. July 2012 private orthopedic treatment records note that the Veteran presented with complaints of worsening right hip pain. The Veteran reported increased spasms since receiving steroid injections. While the Veteran endorsed bilateral hip pain, she noted that the pain was worse in the left hip than the right, characterizing her right hip pain as persistent, moderate to severe, sharp, and stabbing. The pain was aggravated by general physical activity. The Veteran required the use of a walker. Upon examination, the Veteran was able to stand erect but walked with baby steps and a shortened gait; she tended to walk with hips and pelvis slightly flexed but not to a great degree. The Veteran was slow in moving. In the supine position she demonstrated generalized tenderness of 1+ about the lower lumbar region, sacroiliac joint, both sciatic notches and around the greater trochanters. The Veteran maintained full range of motion in the bilateral position, however placing the hips in the FAIR position resulted in 1+ positive for possible piriformis syndrome. Passive internal rotation also caused some discomfort and provocative sacroiliac joint testing was positive at 1+. The Veteran also demonstrated 1+ positive faber testing on the right. The Veteran underwent a VA examination in November 2012. She endorsed flare ups, noting that her pain was constant, severe, and disabling with flares of pain with any movement. Upon examination initial range of motion demonstrated forward flexion to five degrees with pain at five degrees; extension to zero degrees with pain at zero degrees; right lateral flexion to five degrees with pain at five degrees, left lateral flexion to five degrees with pain at five degrees; right lateral rotation to five degrees with pain at five degrees and left lateral rotation to five degrees with pain at five degrees. The Veteran was unable to perform repetitive use testing. The examiner noted that functional loss included less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, instability of station, disturbance of locomotion and interference with sitting, standing and or weight-bearing. The Veteran experienced tenderness and pain to palpation and demonstrated guarding and muscle spasms. She also had an abnormal gait and abnormal spinal contour. Muscle strength testing demonstrated 2/5 muscle strength of the bilateral hip with flexion, 2/5 muscle strength with knee extension bilaterally, 3/5 strength with ankle dorsiflexion bilaterally and 2/5 strength with great toe extension. There was no evidence of muscle atrophy. A reflex exam of the knee was 3+ bilaterally which indicated hyperactive reflexes without clonus. Similarly, a reflex exam demonstrated 3+ reflexes of the ankle bilaterally. A sensation exam demonstrated decreased sensation of the thighs, knees, lower leg and ankle and feet/toes bilaterally. Similarly, a straight leg raise was positive bilaterally. The Veteran also demonstrated severe constant radicular pain of the bilateral lower extremities; moderate paresthesia of the right lower extremity; severe paresthesia of the left lower extremity and severe numbness of the bilateral lower extremities. The Veteran's radiculopathy involved the L2/L3/L/4 nerve root bilaterally as well as the L4/L5/S1/S2/S3 nerve roots bilaterally. The Veteran's radiculopathy was characterized as moderate. She also demonstrated other neurologic abnormalities including lack of bladder control and occasional bowel leakage with loss of frank bowel control. The examiner noted that the Veteran did not have intervertebral disc syndrome with incapacitating episodes. However, the Veteran was noted to use assistive devices including a wheelchair, cane, and walker on a regular basis. Imaging did not establish arthritis. With respect to functional impact, the examiner noted no demonstrated physical capability to stand, walk or transition her own body weight. The Veteran presented in a wheelchair and all minor physical capabilities involving the lower extremities were severely limited. The Veteran was noted to be in pain or greatly distracted by her physical condition which limited her ability to perform sedentary tasks. December 2012 VA treatment records note that the Veteran continued to have pain despite surgical intervention. The Veteran was also noted to have severely limited mobility. May 2013 imaging of the Veteran's lumbar spine noted status post fixation of the sacroiliac joints bilaterally with no evidence of acute abnormality, hardware loosening or failure. June 2013 VA treatment records note ongoing pubic bone pain and low back pain radiating down both legs. The Veteran reported that her local pain management specialist was unable to satisfactorily manage the Veteran's pain; the Veteran reported being treated with Lyrica three times daily. It was recommended that the Veteran be referred to an orthopedic surgeon. An MRI of the spine noted normal signal, normal alignment, well preserved discs, no herniations, no stenosis, no neural foraminal narrowing, no abnormal signal, no abnormal enhancement, and no significant degenerative changes. The Veteran was afforded another VA examination in October 2013 for her thoracolumbar spine. She continued to endorse flare-ups and reported that during a flare-up she is not able to do anything. Upon examination, the Veteran demonstrated forward flexion to 45 degrees with pain at 45 degrees; extension to 5 degrees with pain at 5 degrees; right lateral flexion to 10 degrees with pain at 10 degrees; left lateral flexion to 10 degrees with pain at 10 degrees; right lateral rotation to 10 degrees with pain at 10 degrees; left lateral rotation to 10 degrees with pain at 10 degrees. The Veteran remained unable to perform repetitive use testing. Functional loss included less movement than normal, weakened movement, pain on movement, instability of station, disturbance of locomotion, and interference with sitting, standing and weight bearing. The Veteran demonstrated tenderness on palpation of the lumbar and paraspinal muscle as well as guarding or muscle spasms that did not result in abnormal gait or spinal contour. The Veteran demonstrated 5/5 hip flexion, knee extension, plantar flexion, dorsiflexion, and great toe extension bilaterally. There was no evidence of muscle atrophy, but the Veteran demonstrated 3+ reflexes of the bilateral knee and ankle which is indicative of hyperactive reflexes without clonus. Sensation was normal throughout the Veteran's upper thigh, thigh/knee, lower leg, foot, and toes bilaterally and a straight leg raise test was negative, bilaterally. The examiner noted no radicular pain or other signs or symptoms due to radiculopathy and no other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome, but the Veteran was noted to require the constant use of a wheelchair. The examiner noted that the Veteran's sacroiliac pain significantly limits functional ability. The Veteran presented to VA for treatment in September 2017. She reported chronic back and neck pain and noted that she had not been seen for these issues for approximately one year and had been managing her pain on her own. February 2018 VA treatment records note normal balance and normal stance. April 2018 VA treatment records noted no lumbar tenderness on palpation or muscle spasms. Lumbosacral spine motion was normal with full range of motion and no pain was elicited by motion. The Veteran had a negative straight leg raise bilaterally, negative Patrick-Fabere test bilaterally, negative Hoover test bilaterally and mobility was not limited. The Veteran was afforded another VA examination in October 2018. Subjectively, she reported occasional flare-ups with increased activity or doing too much such as lifting and going up and down stairs. She reported that her flare-ups occurred once a week and were mild to moderate in nature, lasting approximately 24 hours. Functional loss included limited range of motion, inability to participate in sports, inability to walk on ice, or run. range of motion testing demonstrated forward flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 30 degrees and left lateral rotation to 30 degrees. Range of motion was noted not to contribute to functional loss. There was evidence of pain with extension, right lateral rotation and left lateral rotation, however pain did not cause functional loss. Similarly, there was no evidence of pain with weight bearing. The Veteran was able to perform repetitive use texting with no additional loss of function or range of motion after three repetitions. The Veteran was noted to have muscle spasms resulting in abnormal gait or spinal contour and less movement than normal due toa ankyloses, weakened movement due to muscle or peripheral nerve injury, and interference with sitting. The Veteran maintained 5/5 muscle strength bilaterally with flexion and extension and no muscle atrophy was noted. A reflex exam noted 2+ reflexes of the knee and ankle bilaterally, which is an indication of normal reflexes. A sensory exam was also normal for the bilateral lower extremities. A right straight leg raise was positive, while a left straight leg raise was negative. The Veteran was noted to have radiculopathy with no constant pain, mild intermittent pain of the right lower extremity, no intermittent pain of the left lower extremity, mild paresthesia of the right lower extremity, no paresthesia of the left lower extremity, mild numbness of the right lower extremity and no numbness of the left lower extremity. The Veteran's radiculopathy was noted to involve the L4/L5/S1/S2/S3 nerve roots of the right side. The Veteran was noted to have mild radiculopathy of the right side, and no radiculopathy of the left side. There was no evidence of ankylosis or any other neurological abnormalities and no evidence of intervertebral disc syndrome. The Veteran did not require the use of an assistive device and the Veteran was not noted to have any scars. Imaging studies did not demonstrate arthritis. The Veteran was afforded a VA examination for her hip and thigh condition in December 2019. The Veteran reported flare-ups noting that weather changes cause flare-ups if she overuses the hips. She reported that she cannot ride a bicycle, run, climb stairs, or jump due to hip pain. On examination, the Veteran's right hip demonstrated flexion to 45 degrees, extension to 20 degrees, abduction to 15 degrees, adduction to 15 degrees, external rotation to 20 degrees and internal rotation to 20 degrees. The Veteran's adduction was limited such that she could not cross her legs and the Veteran's limited hip movement was noted to be the cause of Veteran's functional loss. Pain was noted on examination with flexion, adduction, and rotation. There was no evidence of tenderness to palpation but evidence of pain with weight bearing and evidence of crepitus. Left hip range of motion examination demonstrated flexion to 60 degrees, extension to 30 degrees, abduction to 20 degrees, adduction to 25 degrees, external rotation to 60 degrees and internal rotation to 40 degrees. Limited hip motion was noted to be the core of the Veteran's functional loss and pain was noted with flexion and adduction. There was evidence of pain with weight bearing and evidence of crepitus. The Veteran remained able to perform repetitive use testing of the bilateral hips with no additional loss of function and the examiner noted that the exam was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain was noted to significantly limit functional ability with repeated use over time of the right hip but not the left hip. Pain and weakness were noted to limit functional ability of the bilateral hips resulting in less movement than normal bilaterally. Nonetheless, the Veteran demonstrated 5/5 muscle strength throughout and no muscle atrophy. The Veteran was noted to have intermediate ankylosis bilaterally due to surgical fusion but no malunion or nonunion. The Veteran was noted to use a cane occasionally. X-ray imaging did not confirm arthritis. There was objective evidence of pain on passive range of motion bilaterally, but no objective evidence of pain when joint is used in no weight bearing. The Veteran was afforded another VA examination for her hip and thigh condition in February 2020. The Veteran reported flare ups characterized as increased pain and numbness resulting in functional loss including difficulty walking, standing, and sitting for prolonged periods of time. Right hip range of motion demonstrated flexion to 50 degrees, extension to 25 degrees, abduction to 20 degrees, adduction to 30 degrees, external rotation and interna rotation to 20 degrees. Range of motion was noted to cause functional loss including limitation in hip movement. Pain was noted with rest/non-movement, as well as with flexion, adduction, external rotation, and internal rotation. There was no evidence of tenderness to palpation, pain with weight bearing, or crepitus. Left hip range of motion demonstrated flexion to 60 degrees, extension to 30 degrees, abduction to 20 degrees, adduction to 20 degrees, external rotation to 60 degrees and internal rotation to 40 degrees. Range of motion caused functional loss of limitation in hip movement. Pain was noted on exam on rest/non movement with flexion and adduction. There was no evidence of tenderness to palpation, pain with weight bearing or crepitus. The Veteran was able to perform repetitive use testing with no additional loss of range of motion bilaterally and no additional functional loss bilaterally. The examiner noted that the exam was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain and lack of endurance caused functional loss of the right hip daily for approximately four hours and was noted to be moderate in severity resulting in difficulty walking, standing, and sitting. Pain and weakness were noted to cause functional loss of the left hip with symptoms occurring daily lasting approximately four hours, moderate in severity and resulting in difficulty walking, standing, and sitting. Similarly, pain and weakness caused functional loss in the bilateral hip during a flare-up. Flare-ups were also noted to happen daily lasting four hours, moderate in severity and resulting in difficulty walking, standing, and sitting for a prolonged amount of time. The examiner also noted that there were additional factors contributing to the Veteran's disability including less movement than normal and slower movement. The Veteran maintained 5/5 muscle strength throughout, bilaterally. There was no evidence of atrophy or ankylosis, but the Veteran required the use of a cane occasionally. There was no evidence of pain with non weight bearing or passive range of motion bilaterally and passive range of motion was the same as active range of motion bilaterally. The Veteran was afforded a VA examination for her back in February 2020. The Veteran reported flare-ups described as increased pain with increased movement and functional loss including limitation in range of motion. Range of motion examination demonstrated forward flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees and left lateral rotation to 30 degrees. Pain was noted on exam on rest and non-movement with forward flexion and extension. There was no objective evidence of localized tenderness or pain on palpation and no evidence of pain with weight bearing. The Veteran remained able to perform repetitive use testing with no additional loss of range of motion. Pain was noted to limit functional ability with repeated use over time resulting in forward flexion to 75 degrees, extension to 15 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 25 degrees and left lateral rotation to 25 degrees. Pain was also noted to significantly limit functional ability with flare ups resulting in forward flexion to 70 degrees, extension to 10 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 25 degree and left lateral rotation to 25 degrees. There was no evidence of guarding or muscle spasms and the Veteran demonstrated 5/5 muscle strength bilaterally. There was no evidence of muscle atrophy, and a reflex exam of the knee and ankle was 2+ bilaterally, which is indicative of normal reflexes. A sensation exam was normal throughout the bilateral lower extremities and a straight leg raise was positive on the right but negative on the left. The Veteran was noted to have radiculopathy with no constant pain but mild intermittent pain, paresthesia, and numbness of the right lower extremity. The Veteran's radiculopathy was noted to involve the right L2/L3/L4 nerve root and right L4/L5/S1/S2/S3 nerve root. The Veteran's radiculopathy was characterized as mild on the right, with no evidence of radiculopathy on the left. There was no evidence of ankylosis, no evidence of other neurologic abnormalities and no evidence of intervertebral disc syndrome. The Veteran did not require the use of an assistive device and there was no x-ray evidence of arthritis, vertebral fracture with loss of 50 percent or more of height or any other significant diagnostic test findings. The examiner noted that the Veteran's thoracolumbar spine disability impacted her ability to work by resulting in limited ability to walk, stand or sit for prolonged period. There was objective evidence of pain with non-weight bearing. Passive range of motion measurements were noted to be the same as active range of motion. June 2020 imaging of the lumbar spine notes minimal discomfort loss at L5-S1 and post-surgical changes from previous sacroiliac joint fusion without acute osseous abnormality. July 2020 VA treatment records note that an MRI of the lumbar spine was unremarkable, with no central cord or nerve root compression. The Veteran characterized her pain as a 6/10. July 2020 and October 2020 VA physical therapy treatment records note ongoing complaints of pain characterized as dull, stabbing, numb, shooting, pinching constant pain, severe in nature. Sensation and reflexes remained within normal limits. Hip abduction was within normal limits bilaterally. Hip internal range of motion was 35 at the right hip and 45 at the left hip. Hip external range of motion was 40 degrees bilaterally. There was tenderness to palpation of the L1-L5 and the Veteran had positive Slum, straight leg raise, scour, and faber tests. The physical therapist noted that the Veteran demonstrated signs and symptoms of lumbar radiculopathy with dural tension signs, and signs of right hip pain that support joint inflammation and possible labral pathology. July 2021 VA treatment records note that the Veteran reported increased bilateral hip and low back pain. Ultimately, the evidence of record shows that for the period beginning November 10, 2011 and thereafter, while the severity of the Veteran's sacroiliac symptoms has waxed and waned, the Veteran's symptoms more nearly approximate a rating of 40 percent. Specifically, the Veteran continued to report symptoms of pain, and was noted to have reduced range of motion and positive straight leg raise. VA examinations noted that the Veteran's sacroiliitis required the use of assistive devices such as crutches. Moreover, VA examinations show that the Veteran's sacroiliitis impacts the Veteran's ability to engage in prolonged sitting and standing. Nonetheless, the record contains no evidence that the Veteran sacroiliitis results in unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine as required for a rating more than 40 percent. The Board has also considered the Veteran's subjective statements that she has had incapacitating episodes totaling a period of 40 weeks. Despite the Veteran's contentions, the record does not note a diagnosis of IVDS or incapacitating episodes for the entire period on appeal. In rendering a decision, the Board has considered the Veteran's pain, functional loss and subjective and objective symptoms and finds that a 40 percent rating adequately compensates the Veteran for the severity of her disability. As such, extraschedular consideration is not warranted. Entitlement to a rating in excess of 40 percent beginning November 10, 2011 and thereafter is not warranted. The Board has considered whether a higher rating is warranted based on functional loss of the joints and painful motion for the period beginning November 10, 2011 and thereafter. 38 C.F.R. §§ 4.40, 4.45, 4.49. The Board has considered the Veteran's complaints of pain, use of crutches and assistive devices as well the Veteran's complaints of pain on range of motion. The Veteran's 40 percent rating adequately compensates the Veteran for these factors. As the preponderance of the evidence is against any higher or separate rating, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Entitlement to a rating in excess of 40 percent beginning November 10, 2011 and thereafter is denied. Based on the evidence of record, for the entire period on appeal the Veteran's sacroiliitis was manifested by no more than forward flexion to 30 degrees or less of the thoracolumbar spine with no evidence of unfavorable ankylosis. REASONS FOR REMAND 2. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to November 18, 2011. The Veteran has been granted entitlement to total disability due to individual unemployability (TDIU) beginning November 18, 2011. However, pursuant to Harper v. Wilkie, an award of TDIU prior to November 18, 2011 is still pending in conjunction with the claims for increased rating. See Harper v. Wilkie, 30 Vet. App. 356 (2018) (holding that once entitlement to a TDIU is put in issue as part of a claim for a higher initial rating/increased rating and the RO grants a TDIU that does not span the entire period on appeal, the issue of entitlement to a TDIU for an earlier period is still on appeal). Here, a review of the record notes that the Veteran has not maintained full time employment since her separation from service in March 2009. This suggests that the Veteran may have been unemployable because of her service-connected disabilities. The Veteran does not meet schedular criteria for TDIU prior to November 18, 2011; therefore, the Board does not have jurisdiction to grant TDIU in the first instance. Remand is warranted to obtain an opinion from the Director of Compensation and Pension regarding the Veteran's entitlement to TDIU on an extraschedular basis prior to November 18, 2011. The matters are REMANDED for the following action: Obtain an opinion from the Director of Compensation and Pension as to whether the Veteran is entitled to a total disability rating due to individual unemployability (TDIU) on an extraschedular basis for the period prior to November 18, 2011. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Wimbish, 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.