Citation Nr: 1805786 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 13-18 347A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a bilateral foot disability, to include pes planus and plantar fasciitis. 2. Entitlement to service connection for a right hip disorder. 3. Entitlement to service connection for right ear hearing loss. 4. Entitlement to service connection for a night sweat disorder. 5. Entitlement to service connection for a sleep disorder. 6. Entitlement to an initial compensable rating for left ear hearing loss. 7. Entitlement to an initial compensable rating for a left ankle disability. 8. Entitlement to an initial compensable rating for a right ankle disability. 9. Entitlement to an initial compensable rating for a left knee disability. 10. Entitlement to an initial compensable rating for a right knee disability. 11. Entitlement to an initial rating in excess of 10 percent prior to January 25, 2016, and an evaluation in excess of 40 percent thereafter for a low back disability. 12. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to March 28, 2017. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Odya-Weis, Associate Counsel INTRODUCTION The Veteran served on active duty from October 2005 to August 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). As reflected above, the Board has recharacterized the Veteran's claims of entitlement to service connection for bilateral pes planus and bilateral plantar fasciitis as a claim for service connection for a bilateral foot disability to be consistent with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when determining the scope of a claim, the Board must consider the Veteran's description of the claim; symptoms described; and the information submitted or developed in support of the claim.). The Board notes that the Veteran limited his substantive appeal to the claims for increased ratings for the low back, right knee, and bilateral ankles, and service connection for a bilateral foot disability, right and left lower extremity sciatica, and a sleep disorder. In addition, at an August 2016 hearing before the undersigned, the Veteran provided testimony related to the issues of entitlement to increased ratings for PTSD, the left knee, and left ear hearing loss as well as service connection for a right hip disability, right ear hearing loss, and night sweats. Therefore, the Board will treat the above issues as on appeal, except for the claims for service connection for right and left lower extremity sciatica, which were granted in a March 2017 rating decision. Percy v. Shinseki, 23 Vet. App. 37 (2009); Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The issues of entitlement to service connection for a bilateral foot disability and right ear hearing loss and entitlement to a compensable rating for left ear hearing loss are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The competent evidence does not reflect a diagnosis of a right hip disorder during the pendency of the appeal. 2. The competent evidence does not reflect a diagnosis of a night sweat disorder during the pendency of the appeal. 3. The competent evidence does not reflect a diagnosis of a sleep disorder during the pendency of the appeal. 4. The Veteran's left ankle disability was manifested by stiffness, swelling, tenderness, and pain with prolonged walking but no limitation of motion or painful motion. 5. The Veteran's right ankle disability was manifested by stiffness, swelling, tenderness, and pain with prolonged walking but no limitation of motion or painful motion. 6. The Veteran's left knee symptomatology most nearly approximated painful motion with no limitation of motion or objective evidence of instability. 7. The Veteran's right knee symptomatology most nearly approximated painful motion with no limitation of motion or objective evidence of instability. 8. Prior to January 25, 2016, the Veteran's low back disability has been manifested by painful motion with flexion greater than 30 degrees, but not greater than 60 degrees. 9. The Veteran's low back disability has not been manifested by ankylosis of the entire thoracolumbar spine since January 25, 2016. 10. The Veteran's PTSD has been manifested by total occupational and social impairment since January 25, 2016. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for service connection for a night sweat disorder have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 4. The criteria for an initial compensable rating for a left ankle disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2017). 5. The criteria for an initial compensable rating for a right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2017). 6. The criteria for an initial 10 percent evaluation, but not higher, for a left knee disability have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2017). 7. The criteria for an initial 10 percent evaluation, but not higher, for a right knee disability have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2017). 8. The criteria for an initial 20 percent evaluation, but not higher, for a low back disability have been met prior to January 25, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 9. The criteria for an evaluation in excess of 40 percent for degenerative disc disease, lumbar spine, have not been met since January 25, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 10. The criteria for a 100 percent evaluation for PTSD have been met since January 25, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection may be granted for any 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) (2017). To establish service connection, the evidence generally 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 or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). I.A. Right hip disorder The Veteran contends that he has a right hip disorder, characterized by pain and inflexibility, due to active service and/or service-connected back disability. With respect to whether the Veteran has a current disability, the evidence does not reflect a diagnosis of a right hip disorder at any time during the period on appeal. The medical records document no treatment or complaints of a diagnosis of a right hip disorder; rather, the Veteran testified that he believed he had a right hip problem because the back disability affected his flexibility and resulted in pain that radiated down his legs to his feet. He indicated that he reported hip problems in 2010 and was recently treated for a back problems. March 2016 VA treatment records indicate the Veteran reported back pain that radiated to the hip area and assessed only chronic low back pain, but no hip disorder, after examination. In addition, a September 2010 VA examiner reviewed the Veteran's record, to include his lay statements and found no diagnosis related to the complaints of right hip pain was warranted after examination of the Veteran. Specifically, the September 2010 examination reported normal X-ray results of the right hip and concluded that there was no pathology to render a separate diagnosis. Rather, the evidence of record indicates such symptomatology may be encompassed by the Veteran's service-connected right lower extremity sciatica; the Board notes that a July 2017 VA examination related to the spine found a positive straight leg raising test on the right, with moderate right lower extremity pain, paresthesias, and numbness that involved the right sciatic nerve. See 38 C.F.R. § 4.14. The Board acknowledges the Veteran's reports of right hip pain and inflexibility and his contentions that he has a right hip disability due to his service-connected back disability or related to active service; however, there is no indication that he has the training or experience required to diagnose a right hip disability or determine its etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran is competent to report his observable symptoms, diagnosis of such disability is not capable of lay observation and requires medical expertise to determine. Accordingly, his opinion as to whether a disability existed and the etiology of such is not competent medical evidence. The Board notes that Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability during the period of the appeal. See 38 U.S.C. § 1110. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, in the absence of competent evidence showing a current diagnosis of a right hip disability, it is unnecessary to address the remaining elements of the claims for service connection. See Brammer, 3 Vet. App. at 225. Accordingly, the Board finds that the preponderance of the evidence is against the claims and service connection for a right hip disability is denied. In reaching this conclusion the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). I.B. Night sweat and sleep disorders The Veteran also claimed entitlement to service connection for night sweats and a sleep disorder due to active service. He indicated that the sleep disorder was secondary to pain from a service-connected back disability and that he experienced intermittent episodes of night sweats. With respect to whether the Veteran has a current disability, the evidence does not reflect a diagnosis of night sweats or sleep disorder at any time during the pendency of the appeal. The medical records document no treatment or complaints of a diagnosis of a sleep disorder; rather, the Veteran testified that he had difficulty sleeping at night due to anxiety and that he had never been treated or diagnosed with an additional sleep disorder. Similarly, medical records report no complaints or treatment for a diagnosis characterized by nightsweats and a September 2010 VA examiner reviewed the Veteran's record, to include his lay statements and found no diagnosis related to the complaints of night sweats was warranted after examination of the Veteran. Rather, the evidence of record indicates such symptomatology may be part of the Veteran's disability presentation for PTSD. See 38 C.F.R. § 4.14. The Board acknowledges the Veteran's reports of night sweats and difficulty sleeping and his contentions that he has disabilities related to active service; however, there is no indication that he has the training or experience required to diagnose a night sweat or sleep disability or determine their etiologies, as diagnosis of such disabilities is not capable of lay observation. See Jandreau, 492 F.3d at 1377. As Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability during the period of the appeal, in absence of competent evidence showing a current diagnosis of a sleep disorder or night sweat disability, there can be no valid claims and any further discussion of the remaining elements of the claims for service connection is not necessary. See 38 U.S.C. § 1110; Brammer, 3 Vet. App. at 225. Accordingly, the Board finds that the preponderance of the evidence is against the claims and service connection for a sleep disorder and a night sweat disorder is denied. As the preponderance of the evidence is against the Veteran's claims, the benefit of the doubt doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 53. II. Increased evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The Board notes that in May 2017, the Veteran filed a claim of entitlement to a total disability rating based on individual unemployability (TDIU) and indicated that he last worked full time in April 2016 as an electrician. As the Board is granting a total disability rating for PTSD for that entire period of the appeal, further consideration of a TDIU is moot. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with regard to the claims for increased ratings for the right and left ankle disabilities, right and left knee disabilities, low back disability, and PTSD. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). II.A. Left and right ankle disabilities The October 2010 rating decision on appeal granted service connection for right and left ankle disabilities and assigned 0 percent evaluations. The Veteran disagreed with the assigned ratings. The Veteran's ankle disabilities are rated by analogy under Diagnostic Code 5271, which assigns a 10 percent rating for moderate limitation of motion and a 20 percent rating for marked limitation of motion. 38 C.F.R. § 4.71a. The Board finds the preponderance of the evidence against a finding that either left or right ankle disabilities warranted a compensable evaluation during the appeal period. For a compensable rating, the evidence would need to show limitation of motion of the ankle or painful motion of the ankle. Id. at Diagnostic Codes 5003, 5271; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). However, the evidence indicates the Veteran had full range of motion of the ankles, with no pain on examination or after repetitive motion. Specifically, a September 2010 VA examination noted the Veteran reported weakness, stiffness, swelling, giving way, lack of endurance, tenderness, and pain to the bilateral ankles with no flare-ups that resulted in pain with prolonged walking. The examiner noted the Veteran's reports of functional limitations of pain, observed the Veteran with a normal, steady gait, and found no objective signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement upon examination with full range of motion that did not demonstrate pain or any limitation of motion on repetition. The record does not indicate any additional treatment or complaints of symptomatology related to left or right ankle disabilities during the appeal period. As such, the Board finds the preponderance of the evidence against findings of any limited motion or painful motion of the left or right ankles that would be indicative of compensable evaluations. The Board has considered whether there is any other basis for granting a higher or separate rating but has found none, noting that the September 2010 examiner found no evidence of any left or right ankle ankylosis, or malunion to the os calcis or astralgis. II.B. Left and right knee disabilities Service connection for right and left knee patellofemoral syndrome was granted in the October 2010 rating decision on appeal; each was assigned a 0 percent rating. The Veteran contends that his service-connected knee disabilities warrant a higher evaluation due to symptoms of pain, instability, locking, and crepitus that affects his ability to walk and stand for prolonged periods. As discussed below, the Board finds that the criteria for initial 10 percent ratings, but not higher, have been met for both knee disabilities. The right and left knee disabilities were rated 0 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5019, 5257 for bursitis and other knee impairment. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003 (2017); see also Burton, 25 Vet. App. 1. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 2017 U.S. App. Vet. Claims LEXIS 1704 (Nov. 29, 2017). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can also be assigned for knee disabilities affecting the meniscus, impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). In this case the evidence does not reflect and the Veteran does not allege that he has dislocated or removed semilunar cartilage, tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application. The Board concludes that the evidence is at least in equipoise that the Veteran's left and right knees were productive of painful motion of the joints throughout the appeal period. See 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; Burton, 25 Vet. App. 1. In that regard, a May 2017 examination reported functional limitations due to pain during physical activity and found objective evidence of localized tenderness or pain on palpation of the right knee. Further, the Board notes the Veteran is competent to testify regarding painful motion of his knees and specifically reported painful motion with prolonged standing, sitting, or walking and during flare-ups caused by physical activity. Jandreau v. Nicholson, 492 F.3d at 1377. The Board finds the Veteran consistently described painful motion throughout the appeal period affecting both knees. As such, 10 percent ratings are warranted. The Board finds the preponderance of the evidence is against assigning evaluations in excess of 10 percent for either knee at any point during the period of the claims. Range of motion testing was performed during VA examinations in September 2010 and May 2017 and revealed normal range of motion of both knees with noted crepitus but no additional limitation of motion with repetitive motion. See 38 C.F.R. § 4.71, Plate II. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. In this regard, the July 2010 examiner noted the Veteran's reports of stiffness, swelling, lack of endurance, locking, tenderness and pain with prolonged sitting, standing, or walking and the May 2017 examiner reported functional limitations due to pain during physical activity. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for higher ratings during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. In other words, although the Veteran has essentially stated that he has painful motion in his knees, he has not described a range of motion less than that found on examination, specifically the requisite limitation of motion necessary for a higher or separate rating. The Board has considered any estimated functional loss due to flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). At the September 2010 examination, the Veteran reported flare-ups consisting of pain for a few hours at a time as often as twice per week that was precipitated by physical activity and caused additional difficulty standing and walking. He described right knee flare-ups of pain with physical activity that was alleviated by sitting or relaxing and denied any flare-ups related to his left knee in the May 2017 examination. As the lay and medical evidence does not reflect specific range of motion findings during flare-ups and no loss of motion was found after repetitive use, the Board will consider the above findings on examination representative of the true range of motion experienced by the Veteran. Simply put, the lay evidence regarding flare-ups of painful motion does not more nearly approximate the criteria for a higher disability rating given the frequency and severity. See 38 C.F.R. § 4.7 (2017). To conclude, even when considering functional limitations due to pain on prolonged sitting, walking, and standing, the criteria for a higher or separate rating based on the Veteran's range of motion are not met and he has been compensated for painful motion in the 10 percent evaluations. See 38 C.F.R. § 4.59; see also Burton, 25 Vet. App. 1. The Board has considered whether there is any other basis for granting a higher or separate rating but has found none. Although the Veteran also testified to symptoms of swelling and locking of the knees; however, the evidence of record does not indicate any clinical findings of a semilunar cartilage disability to warrant a separate rating under Diagnostic Code 5258. Similarly, the Veteran testified that his knees felt unstable but no clinical findings of instability were reported at the September 2010 or May 2017 examinations. While the Veteran may experience a feeling that his knee may give way or is unstable, the medical findings regarding instability, dislocation, and subluxation are more probative as to the actual presence of these conditions. Notably, there are specific medical tests that are designed to reveal instability and laxity of the joints. These tests were administered by the medical professionals in this case and revealed no instability or laxity. Hence, the evidence is against a separate rating for the knee under Diagnostic Code 5257. 38 C.F.R. § 4.71a. Given the above, initial 10 percent ratings for left and right knee disabilities are granted; however, the preponderance of the evidence is against finding higher or separate ratings are warranted based on limitation of motion or reported symptoms of locking, swelling, and instability. 38 C.F.R. §§ 4.3, 4.7. II.C. Low back disability Service connection for lumbosacral strain with degenerative changes was granted in an October 2010 rating decision and assigned a 10 percent evaluation. A March 2016 rating decision increased the evaluation to 40 percent, effective January 25, 2016. The Veteran's degenerative disc disease of the lumbar spine is evaluated under Diagnostic Code 5242-5237, which assigns ratings based upon the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. For the period on appeal prior to January 25, 2016, the Board resolves reasonable doubt in favor of a 20 percent evaluation throughout the period on appeal. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Range of motion testing performed during a July 2010 VA examination reported flexion was limited to 45 degrees flexion due to pain. At the examination, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner. The Veteran described flare-ups as consisting of pain exacerbated by physical activity; however, the report does not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. The Board acknowledges that an August 2012 VA treatment record reported flexion to about 30 degrees before an increase in pain but finds the evidence most nearly approximates the criteria for a 20 percent evaluation. None of the other medical evidence reflects that the Veteran had flexion limited to 30 degrees or less, or that there was any ankylosis of the spine or intervertebral disc syndrome (IVDS) with incapacitating episodes. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine; Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Additionally, the Board finds the Veteran's statements, to include those regarding the frequency of flare-ups of pain with reduced motion in his back, do not more nearly approximate the criteria for a higher rating. 38 C.F.R. § 4.7; see Jandreau, 492 F.3d. at 1377. Rather, the limitations during flare-ups due to pain are contemplated in the current evaluation. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Given the above, a 20 percent rating, but not higher, is warranted prior to July 27, 2016. 38 C.F.R. § 4.71a, Diagnostic Code 5242. To warrant a higher rating since January 25, 2016, the evidence would need to show ankylosis of the entire thoracolumbar spine. Id.; see also DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003) (Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). The preponderance of the evidence is against a finding that the back disability warrants a rating in excess of 40 percent as there is no evidence of ankylosis of the thoracolumbar spine during the period of the appeal. The January 2016 VA examination (the basis of the 40 percent rating) and subsequent July 2017 examination found no ankylosis of the spine and no treatment provider has indicated that the entire thoracolumbar spine was ankylosed during the period on appeal. Further, although the Veteran competently stated that his low back pain and flare-ups cause functional limitations on bending, lifting, walking, squatting and standing, the lay statements do not indicate that the Veteran has ankylosis of the spine. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, a rating in excess of 40 percent is not warranted. The Board also considered whether separate ratings could be assigned based on neurological symptomatology and notes that service connection is in effect for bilateral lower extremity sciatica. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Veteran has not contended, and the medical evidence does not demonstrate, that the Veteran has any other neurological symptomatology that may be associated with lumbar spine disability. As such, any additional separate ratings are not warranted. II.D. PTSD Service connection was granted in a June 2012 rating decision for PTSD and assigned a 30 percent evaluation, effective August 12, 2010. In July 2013, the Veteran requested a new evaluation of the rating for PTSD and a May 2014 rating decision continued the 30 percent rating. In January 2016, the Veteran again submitted a claim for increase of the rating for PTSD, which was continued as 30 percent disabling in a March 2016 rating decision. As noted above, the claim for a rating in excess of 30 percent for PTSD is before the Board in accordance with Percy v. Shinseki, 23 Vet. App. 37 (2009), and will be considered since the last claim for increase was received by VA on January 25, 2016 PTSD is rated under Diagnostic Code 9411 under the General Rating Formula for Mental Disorders found in 38 C.F.R. § 4.130, which assigns ratings based upon the amount of social and occupational impairment. Throughout the appeal period the Board finds PTSD most nearly approximates total occupational and social impairment warranting a 100 percent evaluation. See 38 C.F.R. § 4.7. In this regard, the Board notes that August 2015 VA treatment records noted the Veteran's history of at least three documented suicide attempts in 2011, 2012, and 2015, and found he continued to be high risk for self-harm behavior. Although a November 2015 VA treatment record determined that he no longer met the criteria for high risk status, a June 2016 VA treatment record noted an additional suicide attempt within the past year, with ongoing passive suicidal thoughts, nightmares, flashbacks, emotional crying spells, depression that affected his relationships, and noted irritability. At the August 2016 hearing, the Veteran reported four or five suicide attempts with a lack of consistent psychiatric treatment and a June 2017 examination report confirmed the Veteran's PTSD resulted in total social and occupational impairment due to hypervigilance, exaggerated startle response, poor stress tolerance, depression, and severe panic attacks that resulted in chronic sleep impairment, mild memory loss, flattened affect, intermittently illogical speech, an inability to establish and maintain effective relationships, obsessional rituals, impaired impulse control, neglect of personal appearance, and multiple suicide attempts. The examiner noted that PTSD appeared severe and generated marked difficulties in any setting. The Board acknowledges that the March 2016 VA examination report found the Veteran's PTSD warranted, at most, a 30 percent evaluation, but finds the disability picture more nearly approximates a 100 percent evaluation due to the ongoing and persistent danger to self from suicidal ideation and documented suicide attempts. These symptoms are in line with a 100 percent disability rating. As such, with all reasonable doubt resolved in favor of the Veteran, a 100 percent evaluation is granted since January 25, 2016. ORDER Service connection for a right hip disability is denied. Service connection for a night sweat disability is denied. Service connection for a sleep disorder is denied. An initial compensable rating for a left ankle disability is denied. An initial compensable rating for a right ankle disability is denied. An initial 10 percent rating, but not higher, is granted for a left knee disability. An initial 10 percent rating, but not higher, is granted for a right knee disability. An initial 20 percent rating, but not higher, is granted for a low back disability prior to January 25, 2016. A rating in excess of 40 percent for a low back disability is denied since January 25, 2016. A 100 percent rating for PTSD is granted since January 25, 2016. REMAND Although the Board sincerely regrets any additional delay, additional development is warranted prior to the adjudication of the remaining claims on appeal. With regard to the claim for service connection for a bilateral foot disability, the Veteran contends that his bilateral foot symptomatology began in service and continued since. The Board notes that the evidence of record includes an entrance examination noting asymptomatic, mild bilateral pes planus. In addition, even though a September 2010 VA examination report declined to provide a bilateral foot diagnosis, the examiner noted the Veteran's reports of bilateral pes planus for three years with constant pain and swelling that was exacerbated by physical activity. Further, the Veteran testified to ongoing bilateral foot symptomatology. As the Veteran is competent to report symptoms of pain, swelling, and functional limitations affecting his feet, the Board finds an additional VA examination is warranted to ascertain whether he has a current bilateral foot disability. In addition, the Board notes that a preexisting disability will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. As bilateral pes planus was noted on entrance to active service and in light of the Veteran's reports of foot pain that began in service and continued since, the subsequent medical opinion must also consider whether any current bilateral foot disability is a continuation of the noted pes planus and, if so, whether there is clear and unmistakable evidence that the increase in pes planus in service was due to the natural progress of the disease. With regard to the claims for service connection for right ear hearing loss and a compensable rating for left ear hearing loss, the Board finds an additional VA examination and medical opinion is warranted based on Veteran's competent testimony that his hearing loss has worsened. The Board notes that his hearing loss was last evaluated in an August 2010 examination, at which time he was found to have noncompensable hearing loss in the left ear and that he did not meet the criteria for right ear hearing loss pursuant to 38 C.F.R. § 3.385. Given that about seven years have passed since the last VA examination and there is an indication that the Veteran's left ear disability may have worsened and that he may have right ear hearing loss for service connection purposes, remand is required. Allday v. Brown, 7 Vet. App. 517, 526-27 (1995) (where the record does not adequately reveal current state of disability, fulfillment of duty to assist requires a contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Updated VA treatment records should also be associated with the file. 38 U.S.C. § 5103A(c). Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the file updated VA treatment records dating since July 2017. 2. The claims file should be sent to an examiner to determine whether the Veteran has a current bilateral foot disability etiologically related to active service. If a new examination is deemed necessary to respond to the request, one should be scheduled. If the examiner determines the Veteran has a diagnosis of bilateral pes planus, the examiner is directed to provide a medical opinion as to whether there is clear and unmistakable evidence that preexisting pes planus was not aggravated beyond the normal progress of the disorder during active service. The examiner is directed to address the Veteran's statements of bilateral foot pain and swelling in active service and use of shoe inserts in service and since. For any bilateral foot diagnosis other than pes planus, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current foot disorder was incurred in active service or is otherwise etiologically related to active service, to include the Veteran's reports of foot pain that had onset in service and continued since. A rationale must be provided for any opinion expressed. 3. After completing any records development, the claims file should then be sent to an examiner to ascertain the current severity of service-connected left ear hearing loss as well as the nature and etiology of the Veteran's claimed right ear hearing loss. The claims file must be reviewed by the examiner. Any tests deemed necessary should be conducted, and all clinical findings should be reported in detail. Following a review of the claims file and examination of the Veteran, the examiner is directed to provide a medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that claimed left ear hearing loss began in service, was caused by service, or is otherwise related to service. Noise exposure during service has been conceded in this case. A rationale must be provided for any opinion expressed. 4. After completing the requested actions, and any additional actions deemed warranted, the AOJ should readjudicate the claims on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate review, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs