Citation Nr: 21058162 Decision Date: 09/17/21 Archive Date: 09/17/21 DOCKET NO. 14-35 977 DATE: September 17, 2021 ORDER Service connection for right knee osteoarthritis, to include as secondary to the service-connected right hip disability is denied. Service connection for radiculopathy of the right lower extremity, to include as secondary to the service-connected right hip is denied. A 20 percent disability rating for limitation of flexion of the right thigh from April 15, 2021, is granted. A disability rating in excess of 20 percent for limitation of flexion of the right thigh from April 15, 2021, is denied. A compensable disability rating for limitation of extension of the right thigh prior to October 8, 2020, and in excess of 10 percent thereafter, is denied A disability rating in excess of 20 percent for right hip trochanter myositis ossificans is denied. FINDINGS OF FACT 1. Right knee osteoarthritis was not caused or aggravated by service; it did not manifest to a compensable degree within a year of service; and it was not caused or aggravated by the service-connected hip disability. 2. The Veteran's radiculopathy, right lower extremity, is not secondary to his service-connected right hip disability, did not begin in service, and is not otherwise related to an in-service injury or disease. 3. Prior to April 15, 2021, the Veteran's right thigh disability was not manifested by flexion limited to at least 45 degrees. 4. Since April 15, 2021, the Veteran's right thigh disability was not manifested in flexion limited to 20 degrees or less. 5. Prior to October 8, 2020, the Veteran's right thigh disability was not manifested by extension limited to 5 degrees. 6. Since October 8, 2020, the Veteran's right thigh limitation of extension is rated as 10 percent disabling which is the maximum schedular rating permitted for limitation of extension of the thigh. 7. For the entire period on appeal, the Veteran's right hip disability is rated as 20 percent disabling which is the maximum schedular rating permitted for impairment of the thigh. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee osteoarthritis, claimed as secondary to a right hip disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.310. 2. The criteria for service connection for radiculopathy, right lower extremity, to include as secondary to service-connected right hip disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for a 20 percent disability rating for right thigh limitation of flexion have been met since April 15, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252. 4. The criteria for a rating in excess of 20 percent for right thigh limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252. 5. The criteria for a compensable disability rating for limitation of extension of the right thigh prior to October 8, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251. 6. The criteria for a rating in excess of 10 percent for right thigh limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251. 7. The criteria for a disability rating in excess of 20 percent for limitation of abduction of the right hip throughout the appeal period have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5253. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1978 to June 1979. These issues are on appeal from a May 2016 rating decision. The Veteran testified before the undersigned Veterans Law Judge during a May 2018 hearing. The Board of Veterans' Appeals (Board) most recently remanded the claims for further development in March 2021. The matter has been returned to the Board for adjudication. Service Connection Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Secondary service connection may be granted for a disability that is proximately due to a service-connected disease or injury, or that a service-connected disease or injury aggravated (increased in severity) the nonservice-connected disability for which service connection is sought. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. 1. Service connection for right knee osteoarthritis, to include as secondary to the service-connected right hip disability While the Veteran is claiming secondary service connection for his right knee disability, diagnosed as osteoarthritis, the Board will first address direct service connection. Service treatment records (STRs) are silent for any symptoms, diagnoses or treatment for the right knee. The Veteran was provided a VA examination for his knee in February 2016. The only records reviewed were the Veteran's VA treatment records. The examiner diagnosed right knee joint osteoarthritis. The Veteran reported right knee pain with pins and needles and numbness from his right hip all the way down to his toes. The symptoms began in 1979. He reported being evaluated in 1984 and was diagnosed with bone spurs and arthritis at that time. The examiner opined that the Veteran's right knee minimal degenerative joint disease of the patella femoral joint was not due to his service-connected right hip condition. The Veteran's minimal degenerative joint disease at age 67 was due to aging. The symmetrical disease in the left knee corroborated the opinion. In April 2019 the Veteran was afforded another VA examination. The examiner opined the Veteran's right knee disability was less likely than not associated with his service-connected right hip disability. The examiner further opined that the Veteran's right knee condition was more likely related to an age-related degenerative condition. In a September 2019 addendum opinion, the examiner clarified that if there was significant disability of the Veteran's right hip that limited mobility over time there could be aggravation of the knee, but this was not found. Therefore, the examiner opined it was less likely than not that the Veteran's right hip disability aggravated his right knee resulting in osteoarthritis. In a June 2020 addendum opinion, the examiner opined the Veteran's right knee disability was less likely than not incurred in or caused by service. The examiner explained that there was no chronic diagnosis made regarding the right knee during active duty service. Further, the examiner noted the Veteran reported his right knee symptoms started a few years prior to 2013 which was well after the Veteran's active duty service. Additionally, X-rays were normal through 2012 and degenerative joint disease was not diagnosed until 2015. The examiner also pointed out that the Veteran's statements were inconsistent and not supported by the treatment record. The examiner could not establish a baseline level of severity of the Veteran's right knee disability; however, regardless of an established baseline, the examiner opined the Veteran's right knee disability was not at least as likely as not aggravated beyond its natural progression by a service-connected disability. The examiner explained there was no Trendelenburg gait from the right hip condition documented and through 2013 VA treatment records showed normal gait. Therefore, prior medical opinions were not supported by literature. There was also no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm so that the individuals gait pattern was altered to the extent that clinically there is an obvious Trendelenburg gait. The Veteran underwent another VA examination in May 2021. In June 2021, the examiner opined the Veteran's right knee disability was less likely than not incurred in or caused by service. The examiner explained that there was no evidence of a chronic right knee condition of any kind in service and there was no documented right knee evaluation or diagnosis ongoing during time in service. Therefore, it was not possible that the Veteran's right knee osteoarthritis began during service. The Veteran claimed right knee spurring was diagnosed as early as 1984; however, this is not possible given the normal right knee X-ray in 2012 as bone spurs do not resolve or disappear on their own. If the Veteran had bone spurs in the right knee as of 1984 then those bone spurs would have still been present in 2012. No records in the claims file supported a right knee diagnosis until 2012 which was over 30 years after service. In 2012 the Veteran was diagnosed with patellofemoral chondrosis which essentially mean cartilage deterioration. As injury and direct trauma to the right knee were repeatedly denied in 2012, this can be attributed to the wear and tear of aging. The Veteran continued to have intermittent right knee pain and a December 2015 X-ray confirmed patellar spurring consistent with early degenerative changes of the right knee. The examiner explained that the medical community did not endorse that degenerative changes or injury to one point promote degeneration in ipsilateral or contralateral joints. The development of degenerative joint disease in a given point was due to the effects of genetics and wear and tear on the joint, regardless of the other joints. The examiner noted that while VA providers may have suggested that the Veteran's right knee condition developed due to his right hip disability, no VA provider documented the assessment in the record or included any rationale to explain the relationship. The examiner further noted that no rationale could be given because it cannot be supported that the Veteran's right knee disability, a degenerative disorder by definition, developed due to the Veteran's right hip myositis ossicans, a separate and distinct disorder related to prior trauma. The examiner noted that there was one entry by VA orthopedics in 2016 that suggested the Veteran's right hip symptoms may be due to the Veteran's low back condition, but that had no bearing on the right knee condition. The examiner opined that the Veteran's right knee degenerative joint disease developed decades after time in service due to wear and tear of aging. The examiner opined the Veteran did not develop right knee complaints or a right knee disability within one year of service as there was no evidence of right knee complaints until 2012. While the Veteran claimed knee problems were evaluated as early as 1984, these claims are not credible given the Veteran claimed degenerative joint disease and bone spurs of the right knee as of 1984, but neither of which were identified over 20 years later at the time of the 2012 X-rays. Additionally, the examiner noted no continuous right knee symptomatology in service to the present could be identified. The claims file was silent for any chronic right knee condition or complaints in service. There was no right knee symptomatology in service that continued or recurred thereafter to establish chronicity for a right knee condition from the Veteran's time in service. Further, even if the Veteran did have right knee pain in 1984, that was still several years after time in service and was not followed up by ongoing right knee complaints or evaluations until over 25 years later. Based on the weight of the record, the examiner opined that the Veteran's right knee osteoarthritis developed due to aging and wear and tear, typical of degenerative joint disease and separate and distinct from the Veteran's service-connected right hip myositis ossicans. The examiner also determined that a baseline of severity of the right knee degenerative joint disease could be determined as a December 2015 X-ray showed mild degenerative changes with patellar spurring. While the current severity was greater, the examiner opined that this was not at least as likely as not aggravated beyond its natural progression by the service-connected disability. The examiner explained that there was slightly more patellar spurring and mild knee joint compartment narrowing on the February 2019 right knee X-ray that confirmed a slight progression of the right knee degenerative joint disease since the December 2015 diagnosis. The Veteran's right knee degenerative joint disease was still considered mild overall though slightly advanced since 2015. The progression of the Veteran's right knee disability was slower than expected for the disorder. Therefore, the examiner opined there was no aggravation of the Veteran's right knee degenerative joint disease beyond the normal course due to any cause that could be identified. Without any evidence of complaints or treatment during service, or symptoms manifesting to a compensable degree within a year of service the Board will deny direct service connection for right knee osteoarthritis. While the Board finds the Veteran competent to report symptoms of knee pain, the Board may also take account for the fact that a lack of contemporaneous medical evidence is available to show that the condition began manifesting several decades ago. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a layperson is competent to report certain observable symptoms); Buchanan v. Nicholson, 451 F.3d 1331, 133637 (Fed. Cir. 2006) (lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements); Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (negative inference may be drawn from the absence of complaints for an extended period). Regarding the Veteran's claim that his right knee disability was caused or aggravated by his service-connected right hip disability, VA examiners opined that the Veteran's right knee degenerative joint disease was less likely than not caused or aggravated by his service-connect right hip disability, finding no support for such a finding upon a review of medical literature and examination. Further, the June 2021 examiner noted there is no evidence that a VA provider stated that the Veteran's right knee disability was secondary to his service-connected right hip disability, and even if this had been stated it was not supported by the medical literature. A review of the post service treatment records reflect the Veteran has been diagnosed with right knee degenerative joint disease. However, none of these records provide a nexus or link between the Veteran's right knee disability and his service-connected right hip disability. With regard to the Veteran's contentions that his right knee disability is due to his right hip disability, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms of right knee degenerative joint disease, the claimed disability is not the type of condition that is amenable to lay determination regarding its cause, as specific findings are needed to properly determine cause. Id.; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As such, for the reasons noted above, the Board finds that the weight of the competent, probative evidence of record does not support a finding that there is any causal relationship between the Veteran's current right knee disability and his service-connected right hip disability. Thus, the criteria for service connection for a right knee disability, including as secondary to a service-connected disability, have not been met. The evidence weighs against the Veteran's claim. Service connection for a right knee disability must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Service connection for radiculopathy of the right lower extremity, to include as secondary to the service-connected hip disability The Veteran contends that he is entitled to service connection for radiculopathy, right lower extremity, to include as secondary to his service-connected right hip or thigh disabilities. The Board has closely reviewed the medical and lay evidence in the Veteran's claim file and finds no evidence that may serve as a medical nexus between the Veteran's radiculopathy, right lower extremity and his service or his service-connected right hip disability. The Veteran's service treatment records are associated with the claims file. The September 1978 entrance Report of Medical Examination reflects the Veteran had a normal examination, and he was determined to be fit for duty. A December 1978 record shows the Veteran complained of back pain and numbness in the thoracic region that radiated to the right hip. A May 1979 exit Report of Medical Examination reflects the Veteran had a normal neurological examination. The companion May 1979 Report of Medical History reflects the Veteran specifically stated he did not have neuritis. The Veteran was provided a VA examination in February 2016. The only records reviewed were the Veteran's VA treatment records. The examiner diagnosed right knee joint osteoarthritis. The examiner did not find a separate right leg diagnosis. The Veteran reported right knee pain with pins and needles and numbness from his right hip all the way down to his toes. The symptoms began in 1979. He reported being evaluated in 1984 and was diagnosed with bone spurs and arthritis at that time. The examiner opined the Veteran's symptoms in his right leg were due to his back condition with radiculopathy as the Veteran was known to have multilevel degenerative disc disease. The Veteran underwent a VA examination of his peripheral nerves in April 2019. The Veteran reported sharp pain that radiated down to his right leg and foot. The examiner diagnosed right lower extremity radiculopathy. The examiner opined that it was doubtful a single incident in service in 1979 would cause all the degenerative changes shown to the Veteran's lumbar spine. The examiner further opined the findings were likely related to years after service and unknown incidents since discharge. Therefore, the examiner opined it was less likely than not that the Veteran's right sided radiculopathy was associated with his military service. In a September 2019 addendum opinion, the examiner reiterated this opinion. In a June 2020 addendum opinion, the examiner opined that the Veteran's right lower extremity radiculopathy was less likely than not incurred in or caused by service. The examiner explained that there was no chronic diagnosis made for radiculopathy during active duty service. Treatment records first noted radiculopathy in 2012 and attributed it to a low back condition. Therefore, the Veteran's statements were not supported by treatment records. The examiner further opined that the right lower extremity radiculopathy was less likely than not proximately due to or the result of the Veteran's service-connected disability. The examiner explained that the conditions of radiculopathy and the service-connected right hip were not medically related. Radiculopathy was a separate entity entirely from the right hip and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. Radiculopathy is due to impingement of the nerve at the vertebrae, not the hip. The examiner could not determine a baseline of severity of the right lower extremity radiculopathy; however, regardless of an established baseline, the Veteran's right lower extremity radiculopathy was not aggravated beyond its natural progression by a service-connected disability. The examiner explained that the conditions of radiculopathy and the service-connected right hip were not medically related. Additionally, to Trendelenburg gait from the right hip condition was documented and through 2013 VA treatment records showed a normal gait. Therefore, prior medical opinions were not supported by literature. There was also no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm so that the individuals gait pattern was altered to the extent that clinically there is an obvious Trendelenburg gait. Therefore, no aggravation was plausible. In June 2021, an examiner opined the Veteran's right lower extremity radiculopathy was less likely than not incurred in or caused by service. The examiner explained that there was no evidence in the claims file to support the Veteran complained of or experienced pain radiating throughout the right lower extremity during or within one year of service. Service treatment records did not support any right lower extremity symptoms that continued to present consistent with radiculopathy or nerve compromise of the right lower extremity. The examiner noted the claims file was silent for complaints of right lower extremity pain, numbness, or tingling until 2012, other than the Veteran's noted pain in both the right and left thighs and calves after a work injury in 2007 and a pain in the right buttock as of 2011. There was no pain shooting all the way down the right leg alone until 2012 and at that time the Veteran specifically noted that the current right leg pains were different than those in 2007. The Veteran also reported that as of 2012 the right leg pains had been present since 1978; however, no mention of such pain was made in 2007 or otherwise in the record prior to 2012. Therefore, due to inconsistencies, the earliest it can be established that the Veteran developed any right lower extremity radiculopathy symptoms would be 2012. Electromyography and nerve conduction velocity (EMG/NCV) testing in 2013 indicated no abnormalities which the examiner explained meant that no permanent nerve damage had occurred or was ongoing at that time. Physical examination in 2019 showed all normal nerves in the lower extremities. Based on the Veteran's symptoms, other medical conditions, and normal nerve examinations, the examiner opined the Veteran's nerve symptoms of the right lower extremity represented intermittent and temporary pressure on nerve roots in the lumbar area due to the Veteran's lumbar degenerative disc disease. Therefore, this was a very mild right lower extremity radiculopathy due to lumbar spine degenerative disease that all developed decades after service and was unrelated to any time, event, or condition in service. The examiner further noted there was not right lower extremity nerve symptomatology in service that continued to the present. The examiner further opined the Veteran's right lower extremity radiculopathy was less likely than not proximately due to or the result of the Veteran's service-connected disability. The examiner explained there was no evidence in the claims file to support a relationship between the Veteran's service-connected right hip disability and right lower extremity nerve symptoms. The Veteran's EMG/NCV in 2013 was normal for the lower extremities with no nerve compromise at any level. The Veteran's physical findings in 2019 were all normal with no nerve compromise evident on objective examination. The Veteran had only subjective symptoms for a right lower extremity nerve condition and the Veteran's symptoms were most consistent with a right lower extremity radiculopathy originating within Veteran's lumbar spine region due to degenerative disease. As the Veteran had no objective evidence for a radiculopathy or any other type of neuropathy for the right lower extremity other than a very mild, intermittent pressure on the lumbar nerves that resulted in intermittent symptoms down the right lower extremity but no permanent nerve damage, the examiner opined this was the only reasonable conclusion to draw regarding Veteran's right lower extremity neuropathy. The Veteran had no objective or subjective evidence supporting the right hip as the source of Veteran right lower extremity symptoms. The examiner addressed the Veteran's May 2018 testimony but noted there was no documentation by a VA provider indicating that Veteran's right lower extremity symptoms were or may be due to the right hip. In fact, VA treatment records in 2016 specifically suggested that the right lower extremity nerve symptoms are likely due to the back issues. If a VA provider stated to the Veteran that his right hip caused right lower extremity nerve symptoms, that provider did not support that statement by putting it in the record. Based on the weight of the record, the examiner opined the Veteran's right lower extremity symptoms were consistent with a very mild right lower extremity radiculopathy due to Veteran's lumbar spine degenerative disease, separate and distinct from Veteran's service-connected right hip myositis ossicans. Further, the examiner noted a baseline level of severity could not be determined; however, regardless of an established baseline the Veteran's right lower extremity radiculopathy was not at least as likely as not aggravated beyond its natural progression by a service-connected disability. The examiner explained the Veteran had no physical findings of radiculopathy or any neuropathy or nerve compromise of the lower extremities on physical examinations overtime, including in the 2019 VA examination. EMG/NCV in 2013 was negative for any permanent nerve compromise of the right lower extremity. Therefore, the Veteran had no objective evidence for any nerve compromise. The Veteran would be considered to have a very mild right lower extremity radiculopathy, based on subjective symptoms alone, with intermittent nerve pressures at the level of the lumbar spine nerve roots due to degeneration of the lumbar spine. Given the normal physical examinations over time, no clinically significant progression of Veteran's right lower extremity radiculopathy occurred over time since it first manifested in 2012. As Veteran's right lower extremity radiculopathy remained very mild, without permanent nerve damage, no aggravation or exacerbation due to any cause can be identified. Thus, no condition, including the Veteran's service connected right hip myositis ossicans, aggravated the Veteran's right lower extremity radiculopathy beyond normal course. In light of the evidence noted above, the Board concedes that the Veteran has a current diagnosis of radiculopathy, right lower extremity. However, the Board notes that none of the Veteran's treatment providers have provided an opinion that any such disability is directly related to his military service. There is simply no competent medical evidence of record to suggest that the Veteran's radiculopathy, right lower extremity, is in any way related to his time on active duty. Thus, in this case, when weighing the evidence of record, the Board finds compelling the lack of evidence linking the Veteran's radiculopathy, right lower extremity, to his military service on a direct basis. Regarding the Veteran's claim that his radiculopathy, right lower extremity, was caused or aggravated by his service-connected right hip disability, the June 2021 examiner opined that the Veteran's radiculopathy, right lower extremity, is less likely than not caused or aggravated by his service-connect right hip disability, finding no support for such a finding upon a review of medical literature and examination. A review of the post service treatment records reflect the Veteran has been diagnosed with radiculopathy, right lower extremity. However, none of these records provide a nexus or link between the Veteran's radiculopathy, right lower extremity, and his service-connected right hip disability. In this case, the only evidence in favor of the Veteran's claim is his own statements concerning his belief that his radiculopathy, right lower extremity, is due to service, or to his service-connected disability. With regard to the Veteran's contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms of radiculopathy, right lower extremity, the claimed disability is not the type of condition that is amenable to lay determination regarding its etiology, as specific findings are needed to properly determine etiology. Id.; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As such, for the reasons noted above, the Board finds that the weight of the competent, probative evidence of record does not support a finding that there is any causal relationship between the Veteran's current radiculopathy, right lower extremity, and his service-connected right hip disability. Thus, the criteria for service connection for radiculopathy, right lower extremity, including as secondary to a service-connected disability, have not been met. The evidence weighs against the Veteran's claim. Service connection for radiculopathy, right lower extremity, must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examinations on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Effective February 7, 2021, several changes to the diagnostic codes used for rating musculoskeletal disabilities were made. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. Only the former criteria can be applied for the period prior to the effective date of the new criteria. However, both the old and new criteria can be applied as of that date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38U.S.C. §5110 (g); 38C.F.R. §3.114. While the Veteran has not yet been notified of all applicable regulatory changes and considered his claim under such regulations, the Board notes that the rating criteria prior to February 7, 2021 pertaining to the hips are significantly more favorable to the Veteran. As such, there is no prejudice to the Veteran in the Board considering the claims at this time. Disabilities of the hips are rated under DCs 5250 through 5255 of 38C.F.R. §4.71a. Specifically, limitation of motion of the hip or thigh may be rated under DC 5250 (ankylosis of the hip), DC 5251 (limitation of extension), DC 5252 (limitation of flexion), or DC 5253 (impairment of the thigh), DC 5254 (flail joint), and DC 5255 (impairment of the femur). Normal hip flexion is measured from 0 degrees to 125 degrees; abduction is measured from 0 degrees to 45 degrees. 38C.F.R. §4.71a, Plate II. Diagnostic Code 5250 provides ratings ranging from 60 percent to 90 percent for hip ankylosis. Under Diagnostic Code 5251 (limitation of extension of the thigh), a 10 percent rating is assigned with extension limited to 5 degrees. Under Diagnostic Code 5252 (limitation of flexion of the thigh), a 10 percent rating is assigned with flexion limited to 45 degrees; a 20 percent rating is assigned with flexion limited to 30 degrees; a 30 percent rating is assigned with flexion limited to 20 degrees; and a 40 percent rating is assigned with flexion limited to 10 degrees. Under Diagnostic Code 5253, pertaining to impairment of the thigh, a 10 percent rating is warranted for limitation of adduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe out more than 15 degrees; a 20 percent rating requires limitation of abduction with motion lost beyond 10 degrees. Separate ratings may be assigned under Diagnostic Codes 5251, 5252, and 5253. Cf. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). However, separate ratings for abduction, adduction, and/or rotation may not be assigned, as these are all evaluated under the same diagnostic code, Diagnostic Code 5253. Cullen v. Shinseki, 24Vet. App.74, 84 (2010). Under Diagnostic Code 5254, an 80 percent rating is assigned for flail joint of the hip. Diagnostic Code 5255 addresses the impairment of the femur. A 10 percent rating is assigned for malunion with slight knee or hip disability. A 20 percent rating is assigned for malunion with moderate knee or hip disability. A 30 percent rating is assigned for malunion with marked knee or hip disability. A 60 percent rating is assigned for fracture of surgical neck of, with false joint or fracture of the shaft or anatomical neck with nonunion without loose motion, weightbearing preserved with aid of brace. An 80 percent rating for fracture of shaft or anatomical neck with loose motion. Changes to Diagnostic Code 5255 became effective February 7, 2021. The former "marked," "moderate," and "slight" language for "malunion of" were deleted and provides that "malunion of" the femur is now rated under appropriate hip or knee Diagnostic Codes, "whichever results in the highest evaluation.". 3. A 20 percent disability rating for limitation of flexion of the right thigh from April 15, 2021 The Veteran's right thigh limitation of flexion is rated noncompensable under Diagnostic Code 5023-5252 from August 6, 2013, to May 12, 2021, and is rated as 20 percent disabling thereafter. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional Diagnostic Code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. An April 2016 VA examination report indicates the Veteran reported pain in the right hip that was constant, achy, and would wake him at night. He reported flare-ups at night, especially when he laid on his right side for too long. During flare-ups the pain would become more severe. He described his functional loss as an inability to stand on hard surfaces for longer than 10 minutes, sitting for longer than 10 minutes, and walking to 10 minutes before having to stop and rest. Right hip flexion was to 100 degrees, extension to 30 degrees, abduction to 15 degrees, adduction to 20 degrees, external rotation to 45 degrees, and internal rotation to 10 degrees. The Veteran reported adduction was limited such that the Veteran could not cross his legs. Pain was noted with flexion, abduction, and internal rotation range of motion which caused functional loss, and there was evidence of pain with weight bearing. The examination report indicated that there was no additional loss of function or range of motion with repetitive use testing. The examiner indicated that the examination was not being performed after repeated use over a period of time or during a flare-up and was therefore unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during a flare-up. Muscle strength was 4/5 for right hip flexion and abduction and 5/5 for right hip extension. There was no muscle atrophy or ankylosis. The examiner noted that the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy, and the Veteran reported constant use of a cane. The examiner indicated that the Veteran's hip disability impacted the Veteran's ability to work as he was unable to stand longer than 10 minutes, walk longer than 10 minutes before needing to stop and rest, sit longer than 15 minutes without changing positions, and unable to lay on his right side. During the May 2018 Board hearing, the Veteran stated that he cannot lay on his right side for more than 20 minutes. He had to hold something while walking as the hip would give way and he would almost fall. He used a walker. He said the hip was so painful it made him unstable. His hip would freeze two or three times a day. He could barely lift his leg forward and could not sit for long periods of time. He could not make his leg go backwards. He could not cross his legs. He could not move his leg out to the side. His lack of range of motion was always the same, but his pain would increase. An April 2019 VA examination reflected that the Veteran reported that his right hip pain was chronic and bothered him frequently, especially when he laid on his right side. The pain was throbbing in character and woke him at night. He did not report flare-ups. The Veteran described his functional impairment as chronic pain. Right hip flexion was to 85 degrees, extension to 30 degrees, abduction to 45 degrees, and adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. The examiner noted that adduction was not limited such that the Veteran could not cross his legs but could result in functional loss that interfered with activities of daily living such as squatting, walking, standing, and sitting. Pain was noted on flexion range of motion, but there was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus. There was no additional functional loss or loss of range of motion with repetitive use. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examination report indicated that less movement than normal, weakened movement, and disturbance of locomotion interfered with sitting and standing. Muscle strength in both hips was normal, there was no muscle atrophy, no ankylosis, and the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported constant use of a walker for gait stability. The examiner indicated the functional impact of could affect activities of daily living that entail walking, standing, sitting, and squatting movements as well as lying on the right hip area. Finally, the examiner noted that with repetitive real life use the Veteran may suffer increased pain that could affect his range of motion, but the examiner was unable to state the exact degree lost since it would be of mere speculation. A January 2020 VA treatment record noted the Veteran had mild loss of range of motion in the right hip and lateral side of the right thigh. The Veteran also reported difficulty with walking due to his back pain and right hip pain. In October 2020 the Veteran underwent another VA examination. The Veteran reported right hip pain that frequently gives out, intermittent popping, and impaired range of motion and pain to the right hip joint. The Veteran reported flare-ups that were an increase in pain. They occurred two times a week, were moderate in severity, and lasted a couple of days. The Veteran described his functional loss as an impaired ability for prolonged sitting, standing, and ambulation. Right hip flexion was to 65 degrees, extension to 15 degrees, abduction to 15 degrees, and adduction to 15 degrees, external rotation to 20 degrees, and internal rotation to 20 degrees. The examiner noted that adduction was limited such that the Veteran could not cross his legs. Pain was noted on all range of motion, but there was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus. There was no additional functional loss or loss of range of motion with repetitive use. Pain and weakness significantly limited functional ability with repeated use over time with a loss of five degrees of range of motion in all planes. Pain and weakness also significantly limited functional ability during flare-ups with flexion limited to 55 degrees, extension to 5 degrees, abduction to 5 degrees, adduction to 5 degrees, external rotation to 10 degrees, and internal rotation to 10 degrees. Muscle strength was 3/5, there was no muscle atrophy, no ankylosis, and the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported constant use of a walker for hip and back pain. The examiner indicated the Veteran's disability impacted his ability to perform occupational tasks as prolonged sitting aggravated the hip condition. In April 2021 the Veteran underwent another VA examination. The Veteran reported he was unable to sleep on his right side and the pain would wake him from his sleep. He could barely walk without a walker. He had limited range of motion and difficulty with walking or standing for long periods of time. The Veteran reported flare-ups that were an increase in pain and giving out. They occurred every day, were severe, and lasted two to seven days. The Veteran described his functional loss as difficulty walking or standing for a long period of time, difficulty sitting for long periods of time, and difficulty bending. Right hip flexion was to 30 degrees, extension to 10 degrees, abduction to 15 degrees, and adduction to 15 degrees, external rotation to 15 degrees, and internal rotation to 15 degrees. The examiner noted that adduction was limited such that the Veteran could not cross his legs. Pain was noted on all range of motion, but there was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus. The Veteran was unable to perform repetitive use testing. Pain, fatigability, weakness, and lack of endurance significantly limited functional ability with repeated use over time and during flare-ups with flexion limited to 30 degrees, extension to 10 degrees, abduction to 10 degrees, adduction to 10 degrees, external rotation to 10 degrees, and internal rotation to 10 degrees. There was no muscle atrophy, no ankylosis, and the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported regular use of a cane and walker due to his hip. The examiner indicated the Veteran's disability impacted his ability to perform occupational tasks as he had difficulty walking, standing or sitting for a long period of time and difficulty bending. Based on the foregoing, a 20 percent disability rating for the Veteran's right thigh limitation of flexion is warranted from April 15, 2021. The April 15, 2021 VA examination was the first indication that the Veteran's right thigh flexion was limited to 30 degrees. Thus, the Veteran's right thigh limitation of motion more nearly approximates flexion of the thigh limited to 30 degrees, therefore a higher, compensable rating is warranted under Diagnostic Code 5252. However, prior to the April 15, 2021 VA examination there was no indication that the Veteran's flexion was limited to at least 45 degrees. Thus, the Veteran's right thigh limitation of motion did not more nearly approximate flexion of the thigh limited to 45 degrees; therefore, a compensable rating is not warranted under Diagnostic Code 5252 prior to April 15, 2021. 4. A disability rating in excess of 20 percent for limitation of flexion of the right thigh from April 15, 2021 For a rating in excess of the 20 percent that has been assigned for the Veteran's right thigh flexion, the evidence would have to show flexion limited to, at least 20 degrees. The Board notes that while his right thigh condition results in limitation of motion, no VA examinations or treatment records reflect flexion limited to 20 degrees, as would warrant the next higher evaluation of 30 percent. In the absence of such an objective clinical finding, a higher disability rating is not warranted. Furthermore, even considering the impact of pain on motion, the Veteran was not shown to have limitation of motion to at least 20 degrees. After considering the totality of the record, the Board finds the preponderance of the evidence to be against a rating in excess of 20 percent for the Veteran's limitation of flexion of the right thigh. As a preponderance of the evidence is against the award of an increased rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). 5. A compensable disability rating for limitation of extension of the right thigh prior to October 8, 2020, and in excess of 10 percent thereafter The Veteran's right thigh limitation of extension is rated noncompensable under Diagnostic Code 5023-5251 prior to October 8, 2020, and is rated as 10 percent disabling thereafter. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional Diagnostic Code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Prior to the October 8, 2020, VA examination there was no indication that the Veteran's extension was limited to at least 5 degrees. Thus, the Veteran's right thigh limitation of motion did not more nearly approximate extension of the thigh limited to 5 degrees; therefore, a compensable rating is not warranted under Diagnostic Code 5251 prior to October 8, 2020. The Veteran is currently in receipt of a 10 percent disability rating for limitation of extension of the right hip from October 8, 2020. Under Diagnostic Code 5251, a maximum 10 percent rating is warranted for extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. As the Veteran is in receipt of the highest schedular rating for limitation of extension of the thigh, there is no basis to award a higher rating and the appeal is denied. 6. A disability rating in excess of 20 percent for right hip trochanter myositis ossificans The Veteran is already in receipt of a 20 percent disability rating, the highest schedular rating for impairment of the thigh. As such, there is no basis to award a higher rating. Thus, as the Veteran is already in receipt of the maximum schedular disability rating for the period on appeal, the appeal for a disability rating in excess of 20 percent under Diagnostic Code 5253 is denied. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gastoukian, Kelly 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.