Citation Nr: 18156734
Decision Date: 12/11/18	Archive Date: 12/10/18

DOCKET NO. 16-41 379
DATE:	December 11, 2018
ORDER
As new and material evidence was received, the request to reopen a claim for entitlement to service connection bilateral carpel tunnel syndrome, is granted.
Entitlement to service connection for carpel tunnel syndrome is denied.
Entitlement to a rating in excess of 10 percent for cervical spine degenerative disease is denied.
Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to March 17, 2017, and for a rating in excess of 70 percent thereafter is denied.
The evaluation for the Veteran’s lumbar degenerative joint disease was properly reduced from 20 percent to 10 percent, effective April 7, 2016.
Entitlement to a rating in excess of 10 percent for the period prior to March 9, 2017 and in excess of 20 percent thereafter for lumbar degenerative joint disease is denied.
REMANDED
Entitlement to an initial compensable rating for post-concussive headaches, including on an extraschedular basis, is remanded.
Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded.
FINDINGS OF FACT
1. In a final June 2013 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for bilateral carpel tunnel syndrome.
2. The evidence received since the June 2013 rating decision is not cumulative or redundant of the evidence of record and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for carpel tunnel syndrome.
3. The Veteran’s bilateral carpel tunnel syndrome is not related to service.  
4. For the entire period on appeal, the Veteran’s cervical spine disability more closely approximated forward flexion of the lumbar spine greater than 30 degrees but not greater than 40 degrees; ankylosis of the spine and an abnormal gait were not shown.
5. For the period prior to March 17, 2017, the Veteran’s PTSD symptoms more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; symptoms causing occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total social and occupational impairment were not demonstrated.
6. For the period beginning March 17, 2017, the Veteran’s PTSD symptoms more nearly approximated occupational and social impairment with deficiencies in most areas; total social and occupational impairment was not demonstrated.
7. At the time of the April 2016 rating decision, which reduced the Veteran’s rating for lumbar degenerative joint disease from 20 percent to 10 percent, the Veteran had been in receipt of the 20 percent evaluation for less than five years; and the evidence available at the time of the decision demonstrated a sustained improvement in the Veteran’s lumbar degenerative joint disease in that his flexion was limited to 70 degrees and there was no guarding or muscle spasm which resulted in an abnormal gait or abnormal spinal contour.
8. For the period prior to March 9, 2017, the Veteran’s lumbar degenerative joint disease flexion was limited to 70 degrees and there was no guarding or muscle spasm which resulted in an abnormal gait or abnormal spinal contour.
9. For the period beginning March 9, 2017, the Veteran’s lumbar degenerative joint disease approximated range of motion at worst limited to 40 degrees of flexion and muscle spasm which resulted in abnormal going or spinal contour.
CONCLUSIONS OF LAW
1. The June 2013 rating decision denying the Veteran’s claims for entitlement to service connection for carpel tunnel syndrome is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1100.  
2. New and material evidence has been received to reopen the claim for entitlement to service connection for carpel tunnel syndrome.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.
3. The criteria for entitlement to service connection for carpel tunnel syndrome have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.
4. The criteria for a rating in excess of 10 percent for cervical spine degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5010-5237.
5. The criteria for an initial rating in excess of 30 percent for PTSD for the period prior to March 17, 2017, and for a rating in excess of 70 percent thereafter have not been met.  38 U.S.C. § 1155; 38 C.F.R. § 4.130, DC 9411.
6. The reduction of the rating for lumbar degenerative joint disease from 20 percent to 10 percent effective April 7, 2016, did not involve a due process violation, and was proper. 38 U.S.C. §§ 1155, 5112; 38 C.F.R. §§ 3.105(e), 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DCs 5010-5237.
7. The criteria for a rating in excess of 10 percent for the Veteran’s lumbar degenerative joint disease for the period prior to March 9, 2017, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.17a, DCs 5010-5237.
8. The criteria for a rating in excess of 20 percent for the Veteran’s lumbar degenerative joint disease for the period beginning March 9, 2017, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.17a, DCs 5010-5237.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from May 1987 to June 2007.
These matters come before the Board of Veterans’ Appeals (Board) on appeal from August 2015 and April 2016 rating decisions.
New Material Evidence
Historically, an October 2007 rating decision denied a claim for service connection for bilateral carpel tunnel syndrome on the basis that the Veteran did not have a diagnosis of carpel tunnel syndrome.  A subsequent June 2013 rating decision confirmed and continued the prior denial of the Veteran’s claim for service connection for carpel tunnel syndrome.  The Veteran did not appeal these decisions and they are now final.  38 U.S.C. § 7104.
In December 2014, the Veteran sought service connection for carpel tunnel syndrome.  VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a Veteran.  38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998).
The Board must consider the question of whether new and material evidence has been received because it goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim de novo.  Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996).  If the Board finds that no new and material evidence has been offered, that is where the analysis must end. Butler v. Brown, 9 Vet. App. 167 (1996).
New evidence is evidence not previously submitted to agency decision makers.  Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).
In determining whether new and material evidence has been received, VA must initially decide whether evidence associated with the claims file since the prior final denial is new.  That analysis is undertaken by comparing newly received evidence with the evidence previously of record.  After evidence is determined to be new, the next question is whether it is material.
The Board must review all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened.  Evans v. Brown, 9 Vet. App. 273 (1996).  For purposes of determining whether new evidence is material, the credibility of the new evidence is presumed.  Justus v. Principi, 3 Vet. App. 510 (1992).  New and material evidence is not required as to each previously unproven element of a claim.  Shade v. Shinseki, 24 Vet. App. 110 (2010).
The Board notes that its task is to first decide whether new and material evidence has been received, as opposed to whether or not the evidence actually substantiates the Veteran’s claim.  Pertinent evidence added to the record since the final June 2013 RO decision includes statements from the Veteran, a VA examination, VA and private medical records, and copies of his service treatment records (STRs), which were previously in his file.    
Of consequence in regard to the Veteran’s claim to reopen his claim for entitlement to service connection for bilateral carpel tunnel syndrome, a July 2016 VA examination of the Veteran which indicated the Veteran had a diagnosis of bilateral carpel tunnel syndrome.  Noting that the prior denial of the Veteran’s claim for carpel tunnel syndrome was a lack of a diagnosis of the disorder, and there has now been evidence admitted to the record which showed the Veteran had a diagnosis of bilateral carpel tunnel syndrome, the claim for entitlement to service connection for carpel tunnel syndrome is reopened.
Service Connection
Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service.  38 U.S.C. § 1131; 38 C.F.R. § 3.303.  That determination requires a finding of current disability that is related to an injury or disease in service.  Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992).  Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service.  38 C.F.R. § 3.303(d). 
Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service.  That presumption is rebuttable by probative evidence to the contrary.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. 3.307, 3.309(a). 
Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted.  That does not mean that any manifestations in service will permit service connection.  To show 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 entity is established, there is no requirement of evidentiary showing of continuity.  38 C.F.R. § 3.303(b).
If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptoms after service may serve as an alternative method of establishing service connection.  38 C.F.R. § 3.303(b).  Continuity of symptoms may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.  If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology.  Continuity of symptoms applies only to those conditions explicitly recognized as chronic.  38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 
The standard of proof to be applied in decisions on claims for Veterans’ benefits is set forth at 38 U.S.C. § 5107.  A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence.  38 C.F.R. § 3.102.  When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails.  See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 
The Veteran’s STRs indicated that he did not have complaints or symptomology of his wrists or hands upon his entrance into active service.
In January 1989, a STR showed the Veteran had an injury playing football to the third finger on his right hand.  An X-ray was negative for fracture.  He had swelling and decreased movement.  
In February 1989, a STR showed the Veteran had pain and a funny feeling in his left thumb after an injury playing volleyball.  His finger was tender and there was good strength and flexion and extension.  An X-ray taken was noted to be negative.  
In February 1989, a STR indicated the Veteran had follow-up for his right finger injury.  He was noted to have full range of motion and 5/5 strength.  He was noted to have edema, crepitus, and erythema.  The impression was a ligament tear.
In February 1993, a STR showed the Veteran to have left middle finger trauma after playing basketball.  He was diagnosed with left middle finger hyperextension.  
In September 1995, a STR showed the Veteran to have complaints of swelling in his hands around midnight.  He reported a history of swelling in his fingers.  The impression was dependent drainage.  
In March 2007, a STR consultation sheet indicated the Veteran had presented with numbness and tingling in his bilateral hands.  A provisional diagnosis was noted to be CTS.  He was given braces as indicated.  
A March 2007 STR showed the Veteran underwent X-rays of his bilateral hands.  Routine views of both hands revealed no evidence of fracture, dislocation, arthritic, or inflammatory change.  The impression was normal X-rays of his bilateral hands.
In March 2007, a STR separation medical assessment indicated the Veteran reported his hand sensation was worse.  He reported he could not type for extended periods of time and continual days.  He reported a bilateral hand condition.  He stated that his hand numbness was supposed to be related to his cervical spondylosis/neuritis.  
In a May 2007 VA examination, the Veteran complained of bilateral hand swelling and that his right hand would get sore with writing and typing, but there was no numbness.  He reported pain only and in the dorsum of his hands.  He reported his symptoms had been occurring for the past year and half or two years.  He reported the symptoms were fairly consistent in his hands and that his hands needed to be stretched out.  He reported being able to type for 305 minutes and type for 2 minutes.  He was able to use utensils and tools, but preferred not to grip for prolonged periods of time.  Upon examination, the Veteran’s bilateral writs were non-tender to palpation and demonstrated full range of motion with dorsiflexion to 75 degrees and palmar flexion to 75 degrees.  His ulnar deviation was to 40 degrees.  He could do motions repetitively without difficulty.  His Tinel sign was negative in the wrist and there was no atrophy of the intrinsic musculature of his hands.  The examiner found that there was insufficient evidence at that time to warrant a diagnosis of carpal tunnel syndrome.
In November 2007, a private medical record showed the Veteran to have been found to have an unclear and confusing etiology for his symptoms with no clear diagnosis achieved that day.  He reported a history of the last several years which he had chronic hand pain, worse on the right than left, with clumsiness, weakness, and swelling.  The Veteran reported his pain was predominantly in his thumbs at the MP joints, although the physical examination did not necessarily support that finding.  He denied significant numbness in his hands.  He reported his primary problem was pain, swelling, and clumsiness which were elicited by activities such as carrying or holding objects.  He reported trying a night splint which made his symptoms worse.  Upon examination he had tenderness to palpitation of the hand but no tenderness of the radial nerve.  He had a positive Tinel’s sign along his ulnar nerve but not his radial or median nerve.  He had no pain with radius-ulna compression stress test.
A November 2007 EMG study showed the Veteran to have normal median and ulnar motor and sensory nerve conduction studies.  He had a normal screening needle examination in his bilateral upper limbs.  The impression was a normal electrodiagnostic study and there is no evidence for median or ulnar neuropathy, or cervical radiculopathy to explain the patient’s symptoms.
In December 2011, a private medical record showed the Veteran had an assessment of carpal tunnel syndrome and recommended an electromyogram (EMG) study.    An additional December 2011 private medical record showed that the Veteran had a sensory nerve study of his right wrist.  The findings were that he had a normal nerve conduction study of the right hand, including difference of medical and ulnar sensory nerve at palm level.  There was no evidence of neuropathy in the right arm, no CTS.  Clinical correlation or other specialty evaluation might have been indicated.
A follow-up January 2012 private medical record indicated the Veteran had been assessed with osteoarthrosis and cervicalgia.  It was noted that the recent EMG study had been unable to identify specific areas of pain or any obvious precipitating or relieving factors.
In February 2012, a private medical record indicated that the Veteran had a several-year history of right greater than left hand pain. His symptoms were rather vague.  The physician noted that it was difficult to come up with a definitive diagnosis and his examination suggested finding of tendinitis, possible arthritis, possible trigger digits, and possible CTS.  He was fitted for a splint.  An X-ray of his left and right wrist showed no osseous or soft tissue abnormality.  The X-rays indicated that the Veteran’s left and right wrist were normal.
In March 2012, a private medical record indicated the Veteran was one-month post evaluation for right thumb pain.  His clinical examination indicated that his symptomology appeared to be a little bit better focused for a diagnosis of tendinitis which was indicated at his age would be the more likely diagnosis.  He underwent a steroid injection.
An April 2012, private medical record indicated that the Veteran had not had significant improvement in his overall symptoms. He was recommended for consideration of surgical intervention.  His clinical examination continued to suggest diagnosis of tendinitis as well as diffuse pain over the dorsal wrist.  He was referred to occupational therapy for scheduled tendinitis treatment.  
In June 2012, a private medical record indicated that he was unable to wear his right splint when he performs his computer work and wore his splint at night. His symptoms seemed to be the same regarding his pain.  He did not note any significant pain.  He continued to have the sensation of swelling in the mid dorsal aspect of the wrist with aching pain as well.  The assessment was chronic tendinitis of right wrist by history and physical examination.  His clinical examination still seemed to suggest diffuse tendinitis, but specifically points of tenderness involved the first and third dorsal exterior compartments. 
In March 2013, a VA examination regarding the Veteran’s bilateral hands indicated that the Veteran reported he had been diagnosed with tendonitis in 2001 at a private medical facility.  He stated that his current symptoms were constant fatigue, swelling, and pain in both hands.  He reported that there was gradual onset of the symptoms with no specific injury or trigger of the condition.  Concurrently performed X-rays of the Veteran’s hands were normal. 
In March 2014, a VA medical center (VAMC) record showed the Veteran to have presented for physical therapy consult after a long history of bilateral hand numbness with the right being worse than the left.  He also reported odd mid right-hand pain that woke him up at night.
In April 2014, a VAMC record indicated that X-rays of the Veteran’s right hand showed no significant abnormalities were demonstrated.  
In May 2014, a private medical record showed the Veteran was assessed for his bilateral wrist pain.  He reported he was being worked up for CTS.  He reported his hands went to sleep.  His assessment was right and left-hand pain which was probably a combination of CTS and tendinitis.  
In June 2014, a VAMC record showed the Veteran to have reported with a slow progression of numbness in both hands, right greater than left.  He reported swelling and grip giving out as he used his hands and pain when he woke at night.  The impression was overuse syndrome and trigger fingers and CTS.  The physician reported that the Veteran seemed to have an inflammatory process of some type that caused swelling and put pressure on the median nerve and caused the symptoms.  
In July 2014, a VAMC record indicated the Veteran underwent X-rays of his left wrist.  The impression was a normal left wrist examination.  
In July 2014, a private medical record indicated the Veteran underwent an EMG study which showed bilateral carpal tunnel syndrome and was suggestive of bilateral ulnar nerve entrapment at the elbows.  The Veteran reported a 15-year history of worsening symptoms in both hands.  He reported a searing, tingling pain in the first 3 digits in either hand.  He also described pain and swelling.  The impression was bilateral carpal tunnel syndrome by symptoms.  
In September 2014, a VAMC record showed the Veteran to have complaints of numbness in his hands which he reported had been a progressive problem for many years.  The impression was moderate chronic bilateral median neuropathies at the wrists (CTS), worse on the right side where clear demyelination was demonstrated.  
A December 2014 VAMC record showed the Veteran to have undergone surgery on his right wrist for carpel tunnel release.  
In December 2014, a VAMC record indicated that the Veteran reported moderate hand/wrist pain since his surgery.  He had persistent numbness to the tips of digits 3 and 4.   
In December 2014, the Veteran submitted a statement in which he reported that he began experiencing problems with his hands prior to his separation from service and existed from that time to the present.  
In June 2015 a VAMC record showed the Veteran to have undergone left CTS release surgery.  
In February 2016, the Veteran, through his representative, stated that he had trouble with his wrists while he was in-service, but did not receive a diagnosis until after he left service.
In July 2016, a VA examination determined that the Veteran had bilateral carpal tunnel syndrome.  The Veteran reported that while on active duty he developed bilateral “stabbing pain” in both hands.  The examiner noted that in-service it was felt that this was probably CTS and that probable diagnosis was recorded.  The examiner noted a private evaluation after the Veteran separated from service which determined the Veteran’s symptoms were due to tendonitis and that his EMGs revealed no evidence of carpal tunnel.  The Veteran currently reported limited improvement from his surgeries but still noted bilateral wrist and hand discomfort.  He reported trouble with gripping and using a keyboard and buttoning clothes.  He noted that his hands wore out easily and gave the example of having to stop and rest his hands when carving a turkey.  His symptoms attributable to a peripheral nerve condition was mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the bilateral upper extremities.  His muscle strength testing was normal. His sensory examination was normal.  He had decreased sensation of the bilateral hand/fingers at C6-8.  He had a positive Tinel’s sign bilaterally.  He was found to have mild incomplete paralysis of the median nerve.  The examiner noted that the Veteran had a normal EMG in 2007 but that an EMG in 2015 was positive for bilateral CTS.  The examiner opined that the Veteran’s CTS was less likely than not incurred in or caused by the repetitive job duties performed by the Veteran in service.  The examiner stated that if the CTS arose in service, it would have been evidence in the private 2007 evaluation, including the 2007 EMG.  However, the evidence clearly demonstrated that CTS was not present at that time.  Thus, the examiner did not find that the Veteran’s CTS was related to his active duty service. 
In November 2016, the Veteran, through his representative, indicated that he did have a diagnosis of tendonitis at a private medical facility while in-service.  The statement reported that the Veteran began to experience symptoms of hand pain while in-service.  The statement also indicated that the Veteran’s 2013 VA examination reported no pathology, regardless of the Veteran’s reports of pain, fatigue, and weakness.  The Veteran asserted that the VA had not addressed if his active duty service contributed or aggravated his current hand condition.
Direct service connection necessitates a link between the Veteran’s service and his CTS.  However, based on the foregoing, the evidence of record does not support a finding of such a link.  Thought there is an indication that the Veteran had bilateral hand/wrist pain and numbness while in-service and within a year of service, those records do not show that the Veteran had a conclusive diagnosis of CTS while in-service or within a year of service.  The 2007 STR indicated that the Veteran’s CTS was a provisional diagnosis, which does not establish that the Veteran had CTS.  Furthermore. The 2007 private medical records which related his post-service care clearly showed that the Veteran did not have CTS, which was confirmed by a 2007 EMG.  The Veteran’s providers at that time related his wrist/hand symptomology to tendonitis, not CTS.   Additionally, a 2011 EMG of the Veteran’s right hand/wrist also confirmed that he did not have CTS at that time and private treatment records throughout 2014 did not find or diagnose the Veteran with CTS.  Thus, the first direct diagnosis of CTS for the Veteran came in 2014 – 7 years after his active duty service.  The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection.  Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992).  The Board also finds it significant that none of the Veteran’s treating physicians, both private and VA physicians, directly linked or indicated that his CTS was related to his active duty service.  Indeed, during the course of the Veteran’s treatment there is no direct discussion of his CTS being related to or incurred in his active service aside from the Veteran reporting symptomology which existed since his service.  Significant, too, is the lack of the identification or introduction of any medical opinion that supports the claims for service connection or linked the Veteran’s CTS to his active duty service.  
The Board finds the July 2016 VA examiner’s medical opinion highly probative to the issue of whether the Veteran’s CTS is related to service.  The examiner possesses the necessary education, training, and expertise to provide the requested opinion.  Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinion was based on a review of the claims file and an interview of the Veteran. The examiner’s review of the Veteran’s claims file consisted of his STRs and post-service medical evidence, and his contentions, upon which the examiner relied upon in giving his opinion.  It is clear that the examiner took into consideration all relevant factors in giving his opinion. 
The Board has also considered the Veteran’s lay statements.  Although the Board recognizes that the Veteran is competent to describe his observable symptoms of his CTS, he is not competent to opine as to the etiology of his CTS, as he has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation.  Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  As such, the Veteran’s lay opinion that his CTS was related to his active duty service do not constitute competent medical evidence and lack probative value.  Furthermore, the Board has not found evidence in the Veteran’s claims file which supports his assertions. Specifically, in his November 2016 statement the Veteran, through his representative, reported he was diagnosed with tendonitis at a private medical facility while in-service.  The Board did not find such a diagnosis contained in the Veteran’s STRs, or in the medical records obtained from that facility, and notes that in his February 2016 statement, the Veteran stated that he did not have an in-service diagnosis regarding his wrists.  Also, the Board finds that the June 2016 VA examination did specifically address if his CTS was related in any way to his active duty service and found such a link was not present.  
In sum, the claims file does not contain competent and credible evidence that the Veteran’s CTS was related to his active duty service.  Accordingly, as the preponderance of the evidence is against the claims for service connection, the benefit-of-the-doubt rule is not for application, and the claims must be denied.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Increased Ratings
Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies.  38 C.F.R. § 4.7.  After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran.  38 C.F.R. § 4.3. 
The Veteran’s entire history is to be considered when making disability evaluations.  38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).  Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for different periods of time, based on the facts found, is required.  Fenderson v. West, 12 Vet. App. 119 (1999).  Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria.  Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).  
The Board notes that where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  Francisco v. Brown, 7 Vet. App. 55 (1994).  Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods.
Cervical Spine
The Veteran’s cervical spine disability is currently assigned a 10 percent rating under DCs 5010-5237.  See 38 C.F.R. § 4.71a.  Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  The additional code is shown after a hyphen.  Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  38 C.F.R. § 4.20. 
DC 5010 mandates that arthritis, due to trauma, substantiated by X-ray findings should be rated as arthritis, degenerative.  DC 5003 states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.).  
Under Diagnostic Code 5237, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 higher rating of 20 percent is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating 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 unfavorable ankylosis of the entire cervical spine.  A rating of 100 percent, the maximum available, is warranted for unfavorable ankylosis of the entire spine.
When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45.  The diagnostic codes pertaining to range of motion do not subsume sections 4.40 and 4.45, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups.  DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 
In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss.  Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion.  However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion.  Mitchell, 25 Vet. App. 32. 
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.  38 C.F.R. § 4.59.  As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present.  Burton v. Shinseki, 25 Vet. App. 1 (2011).
In January 2016, the Veteran sought an increase in the rating for his cervical spine disability.  He stated that his condition had become worse.  He reported that he had been diagnosed with stenosis in his neck and that his neck was stiff and caused him to have headaches.
In July 2015, a VAMC record indicated that the Veteran had full range of motion of his cervical spine, with some increase in neck pain without radicular pain.  
In November 2015, a VAMC record showed the Veteran reported he was tolerating activity well and had some neck pain.
In April 2016, a VA examination of the Veteran’s cervical spine showed the Veteran reported daily neck stiffness.  He reported flare-ups which were caused by repeated activities looking upward.  He reported his functional loss as loss of motion.  His range of motion was forward flexion to 40 degrees, extension to 40 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 70 degrees.  Forward flexion was found to exhibit pain.  There was objective evidence of localized tenderness or pain on palpitation which was noted to be mild paracervical tenderness noted on examination.  He was able to perform repetitive use testing with at least three repetitions without loss of range of motion and weakness, pain, fatigability, or incoordination did not significantly limit his functional ability over a period of time.  He did not have localized tenderness, guarding, or muscle spasm of the cervical spine.  His muscle strength was normal and he did not have muscle atrophy.  There was no radiculopathy found and there was no ankylosis of the spine.  He did not have intervertebral disc syndrome which required bed rest.  Arthritis was documented on diagnostic testing.  
In November 2016, a VAMC record showed the Veteran to have full range of motion of his neck without crepitus.  His gait was coordinated and smooth.
In February 2017, the Veteran, through his representative, reported that he did have muscle spasm of the cervical spine.  
In March 2017, a VA examination of the Veteran’s cervical spine found the Veteran reported neck pain and cramping which had become worse.  He stated the neck pain and cramping occurred approximately 5 days a week.  He reported that he turned his head he would have cramping and his head will cramp in that position.  He reported flare-ups which were described as cramping in a position and he had to wait for the cramp to pass and he reported his neck “locks up.”  His range of motion was forward flexion to 45 degrees, extension to 45 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 70 degrees.  Right and left lateral rotation were found to exhibit pain.  The Veteran reported that his limited range of motion effected his ability to drive.  There was no objective evidence of localized tenderness or pain on palpitation and no evidence of pain with weightbearing.  He was able to perform repetitive use testing with at least three repetitions without loss of range of motion and weakness, pain, fatigability, or incoordination did not significantly limit his functional ability over a period of time.  He did not have localized tenderness, guarding, or muscle spasm of the cervical spine.  Disturbance of locomotion was an additional factor found to contribute to his disability.  His muscle strength was normal and he did not have muscle atrophy.  There was no radiculopathy found and there was no ankylosis of the spine.  He did not have intervertebral disc syndrome which required bed rest.  He was not found to have any other neurologic abnormalities related to his cervical spine disability.
Based on the foregoing, the Board does not find that the Veteran’s cervical spine disability warrants a rating in excess of 10 percent at any time throughout the period on appeal.  The evidence of record establishes that the Veteran’s cervical spine flexion was at worst to 40 degrees, his extension to 30, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 70 degrees – all of which are squarely contemplated in a 10 percent rating pursuant to the appropriate diagnostic codes.  In order to warrant a rating in excess of 10 percent the Veteran’s range of motion would more closely have to approximate forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding, none of which were present in any of his physical examinations or in his VAMC treatment records.  Though the Veteran did report flare-ups and muscle spasm, there was no indication that those flare-ups limited his range of motion to the extent that a higher rating was warranted at any time and he did not report cervical muscle spasm to his March 2017 examiner.  The April 2016 and March 2017 VA examinations did not have findings of functional limitations due to fatigue, weakness, or loss of range of motion.  Indeed, the Veteran’s main complaint was pain, which was adequately considered in his 10 percent rating.  Furthermore, the Veteran’s VAMC records do not document the Veteran’s cervical spine disability warranted a rating in excess of 10 percent, as those records indicated the Veteran had full range of motion of the cervical spine and that he did not have an altered gait.  The Veteran’s reported reduction in range of motion still was contemplated by the 10 percent rating criteria and there were no findings of further reduction in range of motion, ankylosis, or incapacitating episodes which would warrant a rating in excess of 10 percent.  Ultimately, the Board finds that there is no evidence of record which would support a finding the Veteran’s cervical spine disability more closely approximated a limitation of motion to 30 degrees or less, even considering the Veteran’s pain complaints, which would be required to support a rating in excess of 10 percent for the Veteran’s cervical spine disability.  Further, the Board notes that the rating criteria for the evaluating the spine indicates the measurements are to be used with or without symptoms such as pain.  Simply put, there is no indication that the Veteran experienced functional impairment in excess of that reported in the VA examination reports or during a painful flare-up which would support a rating in excess of 10 percent.  As such, the Board finds the that the preponderance of the evidence does not support a finding that the Veteran’s cervical spine disability more closely approximated the criteria for a rating in excess of 10 percent at any time during the period on appeal.
The Board is mindful that the Veteran has consistently complained of pain in the cervical spine and that his neck will cramp or lock-up in a position.  Although VA may consider any demonstrated functional loss attributable to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, in conjunction with the rating criteria, the overall level of disability demonstrated by the Veteran was not commensurate with the degree of motion loss required for a rating higher than 10 percent even with consideration of pain and his reports of his neck cramping or locking-up.  The rating criteria specifically requires an altered gait due to muscle spasm, which was not demonstrated in the Veteran’s medical examinations or treatment.  Moreover, to the extent that the Veteran did report pain, no VA examiner noted any significant loss of motion or function that would support a finding of an increased rating.  The Board finds that a disability rating in excess of 10 percent may not be granted under the pertinent rating criteria.  Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a rating in excess of 10 percent for the functional impairment of the Veteran’s cervical spine disability at any point during the period on appeal.
The Board finds the April 2016 and March 2107 VA examiners’ medical findings and opinions highly probative to the issue of the severity of the Veteran’s cervical spine disability.  Specifically, the examiners interviewed the Veteran and conducted physical examinations.  Moreover, the examiners had the requisite medical expertise and had sufficient facts and data on which to base their conclusions.  As such, the Board accords the VA examination findings and opinions great probative weight.  
The Board has also considered the Veteran’s statements.  The Board finds that though the Veteran is competent to report observable symptoms the Veteran experienced through his senses, such pain, stiffness, and weakness, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes.  Layno v. Brown, 6 Vet. App. 465 (1994).  The identification of a spine disability and the determination of the range of motion of the spine requires medical expertise that the Veteran has not shown he possesses.  Determining whether the Veteran meets some of the criteria for a higher rating requires medical diagnostic testing.  Competent evidence concerning the nature and extent of the Veteran’s cervical spine disability has been provided by the medical personnel who examined him and who have made pertinent clinical findings in conjunction with those examinations.  The medical findings, as provided in the examination reports, directly address the criteria under which his disability is rated.  The Board finds that evidence is the most persuasive and outweighs the Veteran’s statements in support of his claim for a rating in excess of 10 percent.
The Board has also considered whether other higher ratings are available.  In order to obtain a rating in excess of 10 percent under DC 5237, the medical evidence must show either limitation of flexion to less than 30 degrees, some degree of ankylosis of the spine, or abnormal gait or contour. That is simply not the evidence in this case. Specifically, the Veteran’s VA examination reports reflected a clear finding of no ankylosis and no altered gait and the Veteran’s VAMC cervical spine treatment also did not find that he had an altered gait.    
Accordingly, the Board finds that the criteria for a rating in excess of 10 percent for the Veteran’s cervical spine disability are not met.  As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
As to separate ratings for any associated neurological impairment, the Board does not find that other neurological impairments in conjunction with the Veteran’s cervical spine disability are supported by the evidence of record.
PTSD
When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission.  VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.  38 C.F.R. § 4.126(a).  When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment.  38 C.F.R. § 4.126(b).
The Veteran was originally service connected for an anxiety disorder from the date of his separation from service in July 2007.  In January 2016, the Veteran sought an increased rating for his acquired psychiatric disorder, which had since been diagnosed as PTSD.  His anxiety rating was converted to evaluation pursuant to the diagnostic code for PTSD (9411) and his previously assigned 30 percent rating for his anxiety disorder was continued under DC 9411 as of January 4, 2016.  A 70 percent rating was assigned for the period beginning March 17, 2017, pursuant to DC 9411.  Almost all mental health disorders, including PTSD, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula).  See 38 C.F.R. § 4.130, DC 9411.  The Veteran contends his PTSD is more severe than reflected in the current ratings.  
Pursuant to the General Rating Formula, a 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).
A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.
A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.
A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.
The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned.  Mauerhan, 16 Vet. App. at 443.  
In November 2015, a VAMC mental health clinic note indicated that the Veteran reported trouble with panic attacks.  He stated he had worsening in his panic symptoms lately in enclosed spaces.  He reported infrequent but distressing nightmares.  Loud noises panic him, he avoids crowds and public places, and he had hard time trusting.  He reported reduced concentration and interest in things.  He reported a negative view about the world and had a shorter fuse.  He denied feeling suicidal and denied psychotic or manic symptoms.  Upon examination, he was alert and attentive and oriented times 3.  He had cooperative and reasonable behavior and a normal rate/rhythm of speech.  His affect was blunted/restricted/constricted and was congruent with his mood.  He did not have hallucinations or illusions and had a normal and coherent thought content.  His insight and judgment were good and his memory was intact.   
In December 2015, the Veteran submitted a statement which reported his mental health symptoms as: anger, anxiety, chronic sleep problems, depression, difficulty making decisions, emotional numbing, flashbacks, guilt, and inability to make and keep friends, isolation, lack of emotions, lack of self-esteem, memory loss, neglect family, nervousness, no friends, panic attacks, suspiciousness, take medications for mental conditions, and unable to share feelings.  
In January 2016, a VAMC mental health clinic note indicated that the Veteran reported he was feeling better in terms of depression, panic symptoms, and somewhat with his PTSD.  He appeared for his appointment on time with good grooming and hygiene.  His motor behavior was normal and his eye contact was good.  The Veteran’s facial expression was normal and responsive and his attitude was cooperative.  His mood was euthymic and his affect was mood congruent.  His speech was normal and his thought processes were logical and organized.  His thought content was normal and his insight was adequate.  There were no indications of homicidal or suicidal thoughts.  
In March 2016, a VA examination found the Veteran to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behaviors, self-care, and conversation.  The Veteran reported that his current support included his sister, parents, and brothers.  He reported he was in the process of getting a divorce.  He reported his symptoms as hypervigilance, exaggerated startle response, sleep disturbance, and feelings of detachment or estrangement from others.  His symptom that actively applied to the Veteran’s diagnosis was anxiety.  He arrived early for his appointment and was dressed neatly and was well-kempt.  His speech was logical and goal-oriented.  He was cooperative with the evaluation process and with answering questions.  The Veteran was orientated to person, place, situation, and time. His concentration and attention was good.  His judgment and insight were good.  He described his mood as he was existing a little below neutral. His affect was slightly depressed, though he was able to brighten at times during the evaluation.  The examiner stated that the Veteran’s PTSD symptoms were in the mild range that were resulting in transient to mild impairment.  The examiner found that his PTSD was likely a progression of his anxiety disorder.  The Veteran reported a good response to medication and had been reduced to twice yearly visits with his psychiatrist.  He did not report significant depression symptoms during the evaluation.  
In July 2016, a VAMC record showed the Veteran reported an increase in his symptoms of panic attacks.  He reported an increase in his anxiety and panic, which was not necessarily PTSD related, and depression.  He reported he was sleeping fine and did not have nightmares.  He appeared for his appointment on time with good grooming and hygiene.  His motor behavior was normal and his eye contact was good.  The Veteran’s facial expression was normal and responsive and his attitude was cooperative.   His mood was neutral and his affect was appropriate/variable.  His speech was relevant and spontaneous and his thought processes were logical and goal-directed.  His thought content was relevant and his insight was adequate.  There were no indications of homicidal or suicidal thoughts.
In November 2016, a VAMC record indicated that the Veteran had reported he was doing well.  He reported his mood was improving and his affect was appropriate to content of speech.  He denied suicidal or homicidal ideas.  He had no audio-visual hallucinations or suspicious or paranoid ideas.  He had slight panic attacks, but were controllable.  He did not have racing thoughts or flight of ideas.  He reported good exercise at work and that his sleep and appetite were good.  He reported that his quality of life had improved on his current medication.  He appeared for his appointment on time with good grooming and hygiene.  His motor behavior was normal and his eye contact was good.  The Veteran’s facial expression was normal and responsive and his attitude was cooperative.   His mood was neutral and his affect was appropriate/variable.  His speech was relevant and spontaneous and his thought processes were logical and goal-directed.  His thought content was relevant and his insight was adequate.  There were no indications of homicidal or suicidal thoughts.  The provider noted the Veteran had significant panic symptoms and residual depression and PTSD.
In February 2017, a VAMC record indicated that the Veteran had reported he was doing well, but that he needed to stretch his appointment to 4 months as he was working and the appointments affected his salary.  He reported his mood was improving and his affect was appropriate to content of speech.  He denied suicidal or homicidal ideas.  He had no audio-visual hallucinations or suspicious or paranoid ideas.  He had slight panic attacks, but were controllable.  He did not have racing thoughts or flight of ideas.  He reported good exercise at work and that his sleep and appetite were good.  He reported that his quality of life had improved on his current medication.  He appeared for his appointment on time with good grooming and hygiene.  His motor behavior was normal and his eye contact was good.  The Veteran’s facial expression was normal and responsive and his attitude was cooperative.   His mood was neutral and his affect was appropriate/variable.  His speech was relevant and spontaneous and his thought processes were logical and goal-directed.  His thought content was relevant and his insight was adequate.  There were no indications of homicidal or suicidal thoughts.  The provider noted the Veteran had significant panic symptoms and residual depression and PTSD.
In March 2017, a VA examination found the Veteran to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behaviors, self-care, and conversation.  The Veteran reported that he was divorced and had no children.  He stated he got along with his family “good” but that he did not talk to them as much as he should.  He denied having friends that he spent time with and identified his leisure activities as watching TV and reloading ammunition.  He stated that he if needed support, he could probably talk to his sister, but that he never did.  He reported that he was employed for the past six months and that he was able to work by himself in his current employment because he did not like to deal with people.  He stated he was jumpy and stated he struggled to maintain a healthy relationship with people and that it was a long time since he had a friend.  He reported he struggled to engage in normal conversation and talking to others.  He also stated he tended to become angry easily and that he struggled with remembering things and needing to write things down at work.  He reported his symptoms as hypervigilance, exaggerated startle response, problems with concentration, and irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects.  His PTSD was noted to cause significant distress or impairment in social, occupational, or other important areas of functioning.  He was found to have symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, an inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence.  He arrived on-time for his appointment and was adequately groomed and dressed.  He maintained eye-contact.  His affect was flat and his mood was dysthymic.  He appeared forthcoming with information and his thought process was logical and linear.    
In light of the above, the Board does not find that a rating in excess of 30 percent for the period prior to March 17, 2017, and in excess of 70 percent thereafter is warranted or supported by the record.  In this regard, for the period prior to March 17, 2017, the Veteran’s PTSD was primarily manifested by panic attacks and avoidance behavior.  In his November 2015 VAMC treatment, the Veteran indicted he had symptoms of anxiety and suspiciousness and also had mild memory loss, all of which are contemplated in a 30 percent evaluation.  Additionally, in his 2016 and 2017 VAMC treatment, the Veteran reported that his panic attacks were overall controllable.  Specifically, for the period prior to March 17, 2017, the Veteran’s PTSD did not show symptoms of difficulty in understanding complex commands, impairment of short and long term memory, impaired judgment and thinking, or disturbances of motivation and mood, all of which are contemplated by the 50 percent rating for PTSD. Though the Veteran did discuss his inability to establish and maintain effective relationships, this symptomology alone did not rise to the level to support a rating in excess of 30 percent.  Indeed, the March 2016 VA examination found that the Veteran’s main PTSD symptom was anxiety.  Though the Veteran did endorse symptoms of hypervigilance, exaggerated startle response, sleep disturbance, and feelings of detachment or estrangement from others, the examiner did not find that these symptoms were the overriding symptoms associated with the Veteran’s PTSD and the Board notes that these symptoms are all contemplated by a 30 percent rating.  The Veteran’s primary reported symptomology as evidenced by his treatment records and the March 2016 report was indicative of a 30 percent rating for the period prior to March 17, 2017.  Bowling v. Principi, 15 Vet. App. 1 (2001); Vazquez-Claudio v. Shinseki, 713 F. 3d 112 (Fed. Cir. 2013).  Overall, the evidence of record also does not show that the Veteran’s PTSD symptoms prior to March 17, 2017, were equivalent in severity to those associated with a either a 70 or 100 percent rating as the Veteran was not demonstrated to have a totality of symptoms associated with the criteria necessary to support such a finding.  In general, the Veteran was not, prior to March 17, 2017, shown to have either deficiency in most areas, such was work school, or family relations, or total occupational and social impairment.
Additionally, for the period beginning March 17, 2017, the Board does not find that the evidence of record supports a finding that the Veteran’s PTSD symptomology more closely approximates a rating in excess of 70 percent.  As of his March 2017 VA examination, the Veteran’s PTSD symptoms were noted to be depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, an inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence.  The evidence of record does not show that the Veteran had symptoms equivalent in severity to those associated with a 100 percent rating, which would equate to total social and occupational impairment.  The medical treatment of record did not indicate that the Veteran had gross impairment in thought processes or communication, persistent delusions or hallucinations, or persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place and memory loss for names of close relatives, own occupation, or own name, all of which are indicative of a total impairment.  The evidence of record, thus, does not otherwise show that the Veteran’s symptoms were equivalent in severity to those necessary to support a finding for total occupational and social impairment, despite the characterization of the VA physician.   The Board finds, then, that for the period beginning March 17, 2017, the Veteran’s PTSD symptomology was readily captured by the criteria for a 70 percent rating, which weighs against a finding that they are equivalent in severity, frequency, and duration to symptoms correlating with a higher percent rating.  See 38 C.F.R. § 4.130.  
In addition to the medical evidence, the Board considered the Veteran’s statements regarding his PTSD symptoms.  The Veteran’s statements regarding his PTSD symptomology are credible and supported by the evidence and adequately reported in his examinations.  However, the objective clinical findings outweigh his subjective assertions as to whether he has total social and occupational impairment due to his PTSD.
Accordingly, the Board finds that the criteria for a rating in excess of 30 percent for the period prior to March 17, 2017, and in excess of 70 percent thereafter for PTSD are not met.  38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Rating Reduction & Increased Rating - Lumbar Spine
In January 2016, the Veteran sought an increase in the rating for his service connected lumbar degenerative joint disease, which had a 20 percent rating, pursuant to DCs 5010-5237, since August 2012.  An April 2016 rating decision reduced the Veteran’s rating from 20 percent to 10 percent as of an April 7, 2016, VA examination which showed an improvement in the Veteran’s lumbar spine disability. A subsequent March 2017 statement of the case (SOC) increased the Veteran’s lumbar spine disability rating to 20 percent as of a March 9, 2017, VA examination.  The Veteran has disagreed with the reduction and requested a higher evaluation.  Thus, the Board will address the propriety of the reduction of the Veteran’s lumbar spine disability rating and also consider whether the Veteran’s lumbar spine disability warranted a rating in excess of 20 percent as of March 9, 2017.
First addressing the propriety of the reduction of the Veteran’s lumbar spine disability rating, as stated above, an April 2016 rating decision reduced the Veteran’s evaluation for his lumbar spine disability from 20 percent to a 10 percent following the results of an April 2016 VA examination. 
At the time of the April 2016 reduction, the 20 percent evaluation for the Veteran’s lumbar spine disability had been in effect from August 31, 2012, to April 7, 2016. Thus, as the rating for the Veteran’s lumbar spine disability had been in effect for less than five years, the provisions of 38 C.F.R. § 3.344(a), (b), which govern the reduction of protected ratings in effect for five years or more, do not apply in this case. Thus, the procedural requirements under 38 C.F.R. § 3.105(e) for reduction of the disability rating from 20 percent to 10 percent for a lumbar spine disability were properly carried out by the RO.
Nevertheless, in any rating-reduction case, regardless of whether the evaluation has been in effect for five years or more, certain general regulations need to be considered. Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the Veteran’s ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413 (1993); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13; 38 C.F.R. § 3.344(c) (authorizing reduction of a rating in effect for less than five years on the basis of examination disclosing improvement). A claim as to whether a rating reduction was proper must be resolved in the Veteran’s favor unless the Board concludes that a fair preponderance of evidence weighs against the claim. Brown, 5 Vet. App. at 421.
In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time that it effectuated the reduction, although the Board may consider post-reduction medical evidence in the context of evaluating whether the condition had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992).
As stated above, the Veteran’s lumbar spine disability was evaluated under 38 C.F.R. § 4.71a, DCs 5010-5237.  As discussed in regard to the rating for the Veteran’s cervical spine disability, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  The additional code is shown after a hyphen.  Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.  38 C.F.R. § 4.20. 
DC 5010 mandates that arthritis, due to trauma, substantiated by X-ray findings should be rated as arthritis, degenerative.  DC 5003 states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.).  
Under DC 5237, a 20 percent rating is assigned 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 40 percent rating is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine.  A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine.  Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine.  38 C.F.R. § 4.71a.
When rating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately, under an appropriate diagnostic code.  38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1).
Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees.  The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation.  38 C.F.R. § 4.71a, Plate V.
When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45.  The diagnostic codes pertaining to range of motion do not subsume sections 4.40 and 4.45, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups.  DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 
In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss.  Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion.  However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion.  Mitchell, 25 Vet. App. 32. 
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.  38 C.F.R. § 4.59.  As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present.  Burton v. Shinseki, 25 Vet. App. 1 (2011).
In March 2015, a VAMC record showed the Veteran to have reported that his low back was giving him trouble.  He reported he had no spasm and no straight leg raising pain was found.  There was no weakness, just back pain when he was very active.
In July 2015, a VAMC record showed the Veteran to have presented for a chronic pain assessment.  He indicated that he had low back pain which he described as aching, dull, sharp, sore, cramping, and numb.  The pain was worse with bending, exercise, sitting, laying down, standing, walking and changing positions.  His pain was better with medication.  The range of motion of his lumbar spine was somewhat reduced and side-bending was not painful.  
In September 2015, a VAMC record showed the Veteran’s lumbar range of motion to be flexion to 40 degrees, extension to 10 degrees, right and left side-bending to 10 degrees, and right and left rotation to 15 degrees.  His gait was antalgic with right stance phase.
In November 2015, a VAMC record showed the Veteran to have reported a general back ache all the time and that he could not sit, stand, or walk too long or it would hurt.  He stated that his worst pain was 6 out of 10 and his current pain was 2 out of 10.  
In April 2016, a VA examination found the Veteran to have reported that on a good day his pain was 3 out of 10 and on a bad day it was 7 out of 10.  He reported that some pain radiated into his buttock region.  He reported flare-ups with prolonged sitting and walking.  He reported his functional loss as loss of motion.  His flexion was to 70 degrees, extension was to 20 degrees, right and left lateral flexion was to 25 degrees, and his right and left lateral rotation was to 30 degrees.  Pain was noted on the examination, but did not contribute to functional loss.  He was able to perform repetitive use testing without an additional loss of function or range of motion.  Pain, weakness, fatigability, or incoordination did not significantly limit functional ability after three repetitions or after a flare-up.  He did not have guarding or muscle spasm.  His muscle strength testing was normal and he had not muscle atrophy.  His reflex examination was hypoactive.  He had a normal sensory examination, but it was noted that he could not preform the straight leg raising test.  He did not have radicular pain or other signs or symptoms of radiculopathy.  There was no ankylosis or other neurologic abnormalities.  He did not have IVDS.  He did not use assistive devices.  Arthritis was documented on diagnostic testing. 
In this case, the April 2016 VA examination showed that the Veteran’s lumbar spine disability limited his flexion to 70 degrees, his extension to 20 degrees, right and left lateral flexion to 25 degrees, and his right and left lateral rotation to 30 degrees.  There was no finding of muscle spasm or guarding and neither pain nor flare-ups were found to provide an additional limitation on his range of motion.  Thus, pursuant to the rating criteria set forth in DC 5237, the Veteran’s lumbar spine disability symptomology was within the criteria set forth for a 10 percent evaluation. As such, under DC 5237, there was a legitimate basis for reducing the evaluation of the Veteran’s lumbar spine disability, effective April 7, 2016.
Now, the Board must consider whether the Veteran’s lumbar spine warranted a rating in excess of 10 percent for the period from April 7, 2016, to March 8, 2017, and in excess of 20 percent for the period beginning March 9, 2017.  
In November 2016, a VAMC record indicated the Veteran’s gait was coordinated and smooth.
In February 2017, the Veteran submitted a statement which indicated that he did experience back pain which was exacerbated by activity.
Considering the foregoing, the Board does not find that there are any medical records of evidence which would indicate that the Veteran’s lumbar spine disability warranted a rating in excess of 10 percent for the period prior to March 9, 2017.  The Veteran’s gait was not found to be altered and his range of motion, as previously noted, was within the limits set forth in the criteria for a 10 percent rating.  As such, a rating in excess of 10 percent for the period prior to March 9, 2017 is not warranted or supported by the record.  
In March 2017, a VA examination found the Veteran to have reported that pain and difficulty with movement had become progressively worse.  He reported constant back pain.  He stated that pain was on both sides of his back and radiated down to the sciatic nerve especially when driving.  He reported flare-ups when driving with pain radiating down to his sciatic nerve and causing pain.  He also reported difficulty bending over.  Upon examination, his range of motion was noted to be normal with flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and his right and left lateral rotation to 30 degrees.  Pain was not noted on the examination and there was no objective evidence of localized tenderness or pain on palpitation. There was no pain with weightbearing.  He was able to perform repetitive use testing without an additional loss of function or range of motion.  Pain, weakness, fatigability, or incoordination did not significantly limit functional ability after three repetitions.  He had muscle spasm which resulted in an abnormal gait or abnormal spinal contour.  An additional factor was noted to be interference with sitting.  His muscle strength testing was normal and he had not muscle atrophy.  His reflex examination was normal.  He had a normal sensory examination, but it was noted that he could not preform the straight leg raising test.  He did not have radicular pain or other signs or symptoms of radiculopathy.  There was no ankylosis or other neurologic abnormalities.  He did not have IVDS.  He did not use assistive devices.  Arthritis was documented on diagnostic testing. The examiner noted that the Veteran had difficulty with lifting and carrying, prolonged sitting, or prolonged standing as the functional impact of his lumbar spine disability.
In a July 2017 statement, the Veteran, through his representative, indicated that he was entitled to a higher evaluation for his lumbar spine as he reported constant pain of the lumbar spine with flare-ups after prolonged sitting, riding in a vehicle, or lifting, and that any activity can trigger a flare-up.  He noted he was unable to perform repetitive use testing due to pain and that he had tenderness, guarding, and muscle spasm.  He also noted he reported his ability to work was limited because of his pain on all motion.
Considering the foregoing, for the period beginning March 9, 2017, the Board does not find that any evidence of record supports a rating in excess of 20 percent for his lumbar spine disability.  The Veteran’s VAMC care showed that his range of motion was, at worst, flexion to 40 degrees, extension to 10 degrees, right and left side-bending to 10 degrees, and right and left rotation to 15 degrees, with a gait that was antalgic with right stance phase.  His March 2017 VA examination showed normal range of motion with muscle spasm which resulted in an abnormal gait.  These limitations are clearly within the criteria set forth for a 20 percent disability rating.  In order to support a rating in excess of 20 percent, the Veteran’s range of motion would have to be shown to be limited to flexion of 30 degrees or less or some finding of ankylosis would have to be present.  Neither of those conditions was found in any of his medical treatment or in any of the Veteran’s own statements. As such, the Board finds that a rating in excess of 20 percent for the period beginning March 9, 2017, is neither warranted nor supported by the evidence of record.  
The Board is mindful that the Veteran has complained of constant pain and flare-ups in his lumbar spine.  Although VA may consider any demonstrated functional loss attributable to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, in conjunction with the rating criteria, the overall level of disability demonstrated by the Veteran was not commensurate with the degree of motion loss required for a rating higher than the assigned ratings for the appropriate period, even with consideration of pain and his reports of flare-ups.  Additionally, for the period when the Veteran was in receipt of a 20 percent rating, the criteria specifically mandates either a specific limitation of motion or ankylosis – which were not documented in the Veteran’s medical examinations or treatment.  Moreover, to the extent that the Veteran did report pain, no VA examiner noted any significant loss of motion or function that would support a finding of an increased rating for any of the periods on appeal.  The Board finds that a disability rating in excess of 20 percent may not be granted for under the pertinent rating criteria.  Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a rating in excess of 10 percent for the period prior to March 9, 2017, and in excess of 20 percent for the period beginning March 9, 2017, for the functional impairment of the Veteran’s lumbar spine.
The Board finds the medical records of evidence, specifically the VA examinations of April 2016 and March 2017, highly probative to the issue of the severity of the Veteran’s lumbar spine disability.  Specifically, the physicians and VA examiners interviewed the Veteran and conducted a physical examination.  Moreover, the physicians and examiners had the requisite medical expertise and had sufficient facts and data on which to base their conclusions regarding the severity and symptomology associated with the Veteran’s lumbar spine disability.    
The Board has also considered the statements submitted by the Veteran in support of the claim, specifically that his lumbar spine disability is both worse than indicated and has increased in severity.  The Board finds that the Veteran is a lay person and is competent to report observable symptoms he experiences through his senses.  Layno v. Brown, 6 Vet. App. 465 (1994).  However, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes.  Determining whether the Veteran meets some of the criteria for a higher rating requires medical diagnostic testing.  Competent evidence concerning the nature and extent of the Veteran’s lumbar spine disability has been provided by the medical personnel who have examined him and who have made pertinent clinical findings in conjunction with the examinations.  The medical findings, as provided in the examination reports, directly address the criteria under which his disability is rated.  The Board finds that evidence is the most persuasive and outweighs the Veteran’s statements in support of his claim.
Considering the above, the Board finds that the reduction in the rating for the Veteran’s lumbar spine disability was factually warranted and in accordance with governing law, and restoration of the 20 percent rating is not warranted.  Furthermore, the claims file does not contain competent and credible evidence that for the period prior to March 9, 2017, and beginning March 9, 2017, the Veteran’s lumbar spine disability warranted a rating in excess of 10 and 20 percent, respectively.   Accordingly, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
REASONS FOR REMAND
In an April 2016 rating decision, the Veteran was granted service connection for post-concussive headaches and assigned a noncompensable rating.  The Veteran, through his representative, in a February 2017 Notice of Disagreement (NOD), stated that his headaches warranted an increased rating as well as extraschedular consideration as his headaches occurred on a daily basis and that he took medication daily.  Additionally, in a July 2017 statement in support of his claim, the Veteran indicated that he reported more frequent headaches to his doctor and that he stated he was waking up with headaches frequently and took medication daily.  A review of the Veteran’s claims file does not indicate that there are any medical records associated with the treatment of the Veteran’s headaches after private medical records from 2013.  As such, a remand is necessary to obtain any medical records associated with the treatment of the Veteran’s headaches.
Additionally, in his February 2017 statement, the Veteran claimed he was entitled to a TDIU.  The Board finds that the Veteran’s claim for TDIU is inextricably intertwined with his claim for an increase in his post-concussive rating on appeal.  The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim.  Harris v. Derwinski, 1 Vet. App. 180 (1991).
The matter is REMANDED for the following action:
1. Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran, specifically including any treatment regarding his post-concussive headaches.  
2. Contact the Appellant and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant private medical treatment records for his post-concussive headaches.  After securing the proper authorizations where necessary, arrange to obtain all the records of treatment or examination from all the sources listed by the Veteran that are not already on file.  
3. After ensuring compliance with the development requested above, readjudicate the Veteran’s request for an initial compensable rating, including on an extraschedular basis, for post-concussive headaches and entitlement to a TDIU.  If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response.  Then, return the case to the Board.
 
LESLEY A. REIN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Parrish, Associate Counsel