Citation Nr: 18159661 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 10-39 308 DATE: December 19, 2018 ORDER Entitlement to service connection for a left ankle disability is denied. Entitlement to an initial rating greater than 10 percent for left hip arthritis prior to May 15, 2013 is denied; a temporary total rating is granted as of May 15, 2013 to May 31, 2014 based on implantation of prosthesis; and a rating of 30 percent disabling, but no higher, from June 1, 2014 is granted. Entitlement to an initial rating greater than 10 percent for right hip arthritis prior to July 24, 2014 is denied; a temporary total rating is granted as of July 24, 2014 to July 31, 2015 based on implantation of prosthesis; and a rating of 30 percent disabling, but no higher from August 1, 2015 is granted. Entitlement to an initial 10 percent rating for right shoulder residuals, rotator cuff repair and decompression, but no higher, is granted; the 10 percent rating is granted effective the date of service connection, March 31, 2009. Entitlement to an initial rating greater than 10 percent for degenerative disc disease of the lumbosacral spine is denied. Entitlement to an initial compensable rating for right shoulder scar is denied. Entitlement to an initial rating of 50 percent for posttraumatic stress disorder (PTSD), but no higher, is granted; the 50 percent rating is granted effective March 31, 2009. REMANDED Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for disability manifested by frequent urination, to include as secondary to service connected disabilities, is remanded. Entitlement to service connection for disability manifested by low libido, to include as secondary to service connected disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a current left ankle disability. 2. The Veteran’s range of motion does not warrant a rating of his left hip disability greater than 10 percent prior to May 15, 2013 or a rating greater than 30 percent from June 1, 2014; the disability was not represented by moderately severe residual weakness, pain or limitation of motion or more severe disability following left hip replacement; the Veteran underwent left total hip replacement surgery on May 15, 2013. 3. The Veteran’s range of motion does not warrant a rating of his right hip disability greater than 10 percent prior to July 24, 2014, or a rating greater than 30 percent from August 1, 2015; the disability was not represented by moderately severe residual weakness, pain or limitation of motion or more severe disability following right hip replacement; the Veteran underwent right total hip replacement surgery on July 24, 2014. 4. The preponderance of evidence does not show that the Veteran’s right shoulder is productive of ankylosis of scapulohumeral articulation, that abduction of the right shoulder is limited to 60 degrees, or that the right shoulder is productive of a limitation of motion to midway between the side and shoulder level. 5. The objective evidence of record demonstrates that forward flexion of the thoracolumbar spine was not limited to 60 degrees or less, nor was there muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 6. The Veteran’s right shoulder scar was not shown to cause a limitation of function; the scar is not painful or unstable. 7. Resolving all reasonable doubt in the Veteran’s favor, over the entire course of the period on appeal, the service-connected PTSD has been manifested by occupational and social impairment with reduced reliability and productivity; it has not been manifested by occupational and social impairment, with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left ankle disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for entitlement to an initial rating greater than 10 percent for left hip arthritis prior to May 15, 2013 have not been met; the criteria for a 100 percent evaluation from May 15, 2013, through May 31, 2014 for implantation of left hip prosthesis have been met; the criteria for a rating of 30 percent, but no higher, have been met as of June 1, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.30, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5013, 5054. 3. The criteria for entitlement to an initial rating greater than 10 percent for right hip arthritis prior to July 24, 2014 is denied; the criteria for a 100 percent evaluation from July 24, 2014, through July 31, 2015 for implantation of right hip prosthesis have been met; the criteria for a rating of 30 percent, but no higher, have been met as of August 1, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.30, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5013, 5054. 4. The criteria for entitlement to a 10 percent rating, but no higher, have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.71a Diagnostic Code 5201-5010. 5. The criteria for entitlement to an initial rating greater than 10 percent for degenerative disc disease of the lumbosacral spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242. 6. The criteria for a compensable rating for the Veteran’s right shoulder scar is not met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Code 7805. 7. The criteria for an initial 50 percent disability rating for service-connected PTSD, for the period on appeal prior to August 29, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1981 to September 1985, and from March 2006 to March 2009. The Veteran was afforded a Board hearing before the undersigned Veterans Law Judge in November 2014. The transcript is of record. The appeal was remanded by the Board in April 2015. 1. Entitlement to service connection for left ankle pain The Veteran contends that his left ankle pain is due to service. The Veteran’s service treatment records revealed a diagnosis of and treatment for a left ankle sprain in April 2006. However, the Veteran’s left ankle x-ray, dated in April 2006, revealed no evidence of a fracture or deformity. The Veteran was afforded a VA examination in July 2008. The Veteran expressed that he twisted his left ankle in service while he was running in April 2006. The Veteran was diagnosed with an ankle sprain. The Veteran expressed that with prolonged walked, his ankle swells up. Upon examination, the examiner reported a negative diagnosis of a left ankle disability. A Physical Evaluation Board Proceeding report dated December 2008 indicated that the Veteran had a diagnosis of intermittent left ankle pain with a history of recurrent sprains and mild degenerative changes. The Veteran was afforded a VA examination in August 2017. The Veteran reported that he gets pain in his left ankle after walking. The Veteran expressed that his left ankle is due to a sprained ankle during service. The VA examiner did not diagnose a left ankle condition and stated that there is no objective evidence of a current left ankle condition. The examiner stated that the physical examination and x-ray of the Veteran’s left ankle were normal. Here, the July 2008 and August 2017 examiner found no objective evidence or pathology which would support a current diagnosis in regard to the Veteran’s left ankle pain. The first requirement for any service connection claim is the existence of a current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Although there is evidence of an active duty sprain, post-service records fail to reveal any residuals of left ankle sprain. Therefore, absent evidence of current disability, service connection cannot be granted. Id. The Board has considered the Veteran’s statements regarding residuals of left ankle sprain as being among his current disabilities. However, the Board finds the conclusions of the August 2017 examiner, which are based on the results of diagnostic testing, to be more probative than references made by the Veteran. X-rays taken in August 2017 were negative. The Board has also considered the holding of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) but findings that the evidence does not reflect a disability during the appellate period, to include one in which pain causes a functional impairment. In the August 2017 VA examination, the examiner found no current disability, and indicated range of motion was normal. Although instability was suspected, testing did not confirm this. The Board finds this examination sufficient to determine no disability, to include when considering Suanders. In most cases, this is now the case to cite to regarding the presence of a disability when there are complaints of pain without a “diagnosed” disability. Please let me now if you would like to discuss. Because there is no evidence of a current disability, the weight of the evidence is against the claim; and the doctrine of reasonable doubt is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 1990). 2. Entitlement to an initial rating greater than 10 percent for left hip arthritis prior to May 15, 2013 and a rating greater than 30 percent disabling from June 1, 2014 The Veteran contends that he is entitled to a higher rating for his left hip disability. For a prosthetic replacement of the head of the femur or of the acetabulum, a 100 percent rating is assigned for the one-year period following implantation of prosthesis. Thereafter, a minimum 30 percent evaluation is assigned. A 50 percent rating is warranted for moderately severe residuals of weakness, pain, or limitation of motion. A 70 percent rating is warranted for markedly severe residual weakness, pain, or limitation of motion. A 90 percent rating is warranted for painful motion or weakness such as to require the use of crutches. 38 C.F.R. § 4.71a, Diagnostic Code 5054. Normal range of motion of the hip is from 0 degrees to 120 degrees flexion; and 0 degrees to 45 degrees abduction. 38 C.F.R. § 4.71, Plate II. The Veteran underwent a left total hip arthroplasty on May 15, 2013. See June 2013 post-operative report. Thus, the Veteran is entitled to evaluations of 100 percent from May 15, 2013, through May 31, 2014, and 30 percent from June 1, 2014 due to the left total hip arthroplasty. Prior to his left hip replacement in May 15, 2013, the Veteran was rated at 10 percent under diagnostic codes 5003-5013. The Veteran was afforded a VA examination in July 2008. The Veteran reported bilateral hip pain that limited his walking to 75 to100 yards before pain slowed him down. The Veteran expressed that the distance is approximately half when he carries something. VA physical examination of the Veteran’s hips revealed left hip range of motion as flexion to 80 degrees to pain; abduction to 35 degrees; adduction to 10 degrees; internal rotation to 10 degrees; and external rotation to 30 degrees. The examiner noted that impingement could not be done because the Veteran could not adduct to 90 degrees. Motor strength was normal. The examiner reported mild painful motion. The examiner noted that weakness was negative, lack of endurance was moderate to severe, and lack of coordination was mild. The examiner opined that for the left hip, additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance or incoordination could not be specified as degrees of lost motion without resorting to speculation. The VA examiner diagnosed left hip arthritis with significant limitation of motion. In light of the above evidence, the Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran’s left hip disability prior to the Veteran’s left hip replacement. See 38 C.F.R. § 4.71a, Codes 5003, 5013, 5252, 5253. With respect to the left hip, the record shows, flexion limited to 80 degrees, abduction limited to 35 degrees, adduction limited to 10 degrees, internal rotation limited to 10 degrees, and external rotation limited to 30 degrees, all of which warrant noncompensable ratings under all applicable Diagnostic Codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5252, 5253. In addition, a rating in excess of 10 percent is not warranted, as the record does not demonstrate ankylosis, flail hip joint, or impairment of the femur prior to May 15, 2013. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250-5255. Furthermore, although the examiner opined that additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance or incoordination could not be specified as degrees of lost motion without resorting to speculation, the examiner did report that there was only mild painful motion, weakness was negative, lack of endurance was moderate to severe, and lack of coordination was mild. The Board finds that the preponderance of the evidence does not indicate that such functional impairment would result in flexion limited to 30 degrees or less (which would be required for a higher rating under Code 5252) or limitation of abduction of the thigh where motion is lost beyond 10 degrees (which would be required for a higher rating under Code 5253) based on these overall findings. The evidence from this time period, to include when considering functional impairment as recorded in medical evidence and the Veteran’s testimony, does not reflect greater impairment. Accordingly, the Board finds that the Veteran’s range of motion does not warrant a rating of his left hip disability greater than 10 percent prior to May 15, 2013. See 38 C.F.R. § 4.71a, Codes 5003, 5013, 5252, 5253; see also Fenderson, 12 Vet. App. at 119, 126-127. The Veteran underwent a left total hip arthroplasty on May 15, 2013. See June 2013 post-operative report. Thus, the Veteran is entitled to evaluations of 100 percent from May 15, 2013, through May 31, 2014, and 30 percent from June 1, 2014 due to the left total hip arthroplasty. This is part of the rating considering during the appellate period, that include the period during which the Veteran received the hip replacement. As the Board has granted a separate evaluation for the Veteran’s left hip replacement surgery, the Board must now consider whether the Veteran is entitled to a rating greater than 30 percent as of June 1, 2014. The Veteran was afforded a VA examination in August 2017. The Veteran expressed that he does not take any regular treatment for his hip condition but when he gets pain, he occasionally takes pain medication. The Veteran did not report flare-ups of the hip or thigh. The Veteran reported having functional loss or functional impairment of the hips. The Veteran expressed that he has difficulty running and cannot lift more than 30 pounds. Upon physical examination, the Veteran’s range of motion for flexion was limited to 90 degrees; extension limited to 20 degrees, abduction limited to 40 degrees, and adduction limited to 25 degrees. External rotation was limited to 50 degrees and internal rotation limited to 30 degrees. The examiner indicated that the Veteran’s adduction was not limited in that the Veteran cannot cross his legs. The examiner noted that there was pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions. The examiner reported that there was no additional loss of function or range of motion after three repetitions. The examiner noted that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time. The examiner noted that muscle strength was normal. The Veteran does not have ankylosis. The Veteran does not have malunion or nonunion of femur, flail hip joint or leg length discrepancy. As for residuals of the Veteran’s total hip replacement, the examiner noted that the Veteran has a residual scar. Upon careful review of the evidence, the preponderance of the evidence weighs against assigning a disability rating in excess of 30 percent from June 11, 2014. In this regard, the Board acknowledges that the Veteran’s August 2017 VA hip examination report, in addition to private treatment records during this period, show that the Veteran’s symptoms included, objective evidence of pain and loss or range of motion. The Veteran also had some difficulty with running. However, the evidence of record does not indicate that the Veteran’s left hip disability was manifested by, or more nearly approximated, moderately severe residuals of weakness, pain, or limitation of motion during this period. See 38 C.F.R. § 4.71a, Diagnostic Code 5054. A higher disability rating requires evidence showing at least moderately severe residuals with weakness, pain or limitation of motion. The Board acknowledges that the evidence shows slight limitation of motion and pain. However, the preponderance of the evidence does not indicate that the Veteran’s residuals are consistent with moderately severe residuals. His limitation of motion would not be compensable under DCs 5251 through 5253. Thus, under any other applicable DCs, his left hip disability would be evaluated as 10 percent disabling, at most, for noncompensable painful limitation of motion under either 38 C.F.R. § 4.59 or DC 5003. As such, the left hip disability picture does not reflect a moderately severe limitation of motion consistent with a 50 percent disability rating under DC 5054. Rather, the 30 percent disability rating under DC 5054 is the more appropriate disability rating for the Veteran’s left hip disability that is now status post total hip arthroplasty. There is also no basis for assigning a higher rating based on consideration of factors such as pain on movement, weakness, excess fatigability, incoordination, swelling, or atrophy, to include as due to flare-ups and/or repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. In this regard, the Board finds significant that at his August 2017 VA examination, the Veteran reported that he did not experience any flare-ups of his disability. Moreover, the Veteran was able to perform three repetitions of ROM testing with no showing of additional limitation due to pain, fatigue, weakness, lack of endurance, or incoordination. It follows that even when considering functional loss due to factors such as pain on movement, weakness, fatigability, and disturbance of locomotion, the Veteran’s left hip disability has not been generally manifested by symptomatology approximating moderately severe residuals of weakness, pain, or limitation of motion so as to meet the criteria for a 50 percent rating under Diagnostic Code 5054. Instead, as demonstrated by the competent medical evidence of record, the 30 percent rating assigned adequately compensates the Veteran for the extent of functional loss resulting from these factors. As the evidence of record during this period contains no findings of ankylosis, flexion limited 10 degrees, flail joint, or impairment of the femur manifested by fracture of the surgical neck with false joint or fracture of the shaft or anatomical neck, there is no basis for a rating in excess of 30 percent under a different diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250 (ankylosis), 5252 (limitation of flexion), 5254 (flail joint), 5255 (impairment of femur). For the reasons set forth above, the Board has determined that the preponderance of the evidence is against a finding that the Veteran’s left hip disability was manifested by, or more nearly approximated, moderately severe residuals of weakness, pain, or limitation of motion during the period from June 1, 2014. Therefore, a disability rating greater than 30 percent is not warranted during this period. See 38 C.F.R. § 4.71a, Diagnostic Code 5054 3. Entitlement to an initial rating greater than 10 percent for right hip arthritis prior to July 24, 2014 and a rating greater than 30 percent disabling from August 1, 2015 The Veteran contends that he is entitled to a higher rating for his right hip disability. The Veteran underwent right total hip arthroplasty on July 24, 2014. See September 2014 post-operative report. Thus, the Veteran is entitled to an evaluation of 100 percent from July 24, 2014, through July 31, 2015, and 30 percent from August 1, 2015 due to the right total hip arthroplasty. Prior to the right hip replacement in July 24, 2014, the Veteran was rated at 10 percent under diagnostic codes 5003-5013. The rating criteria for osteoporosis with joint manifestations are listed under 38 C.F.R. § 4.71a, Diagnostic Code 5013. The disabilities rated under Diagnostic Codes 5013 through 5024 are to be rated on limitation of motion of affected parts, similar to ratings for degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint that is noncompensable under the appropriate diagnostic codes, a rating of 10 percent for each such major joint affected by limitation of motion is assigned. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Veteran was afforded a VA examination in July 2008. The Veteran reported bilateral hip pain that limited his walking to 75 to100 yards before pain slowed him down. The Veteran expressed that the distance is approximately half when he carries something. VA physical examination of the Veteran’s hips revealed right hip range of motion as flexion to 90 degrees with pain and restriction; abduction to 45 degrees; adduction to 25 degrees; internal rotation to 40 degrees; and external rotation to 60 degrees. Impingement was positive at neutral, and the Veteran could not abduct to 90 degrees. The examiner noted that painful motion was negative, limited motion weakness was negative, lack of endurance was mild, and lack of coordination was negative. The examiner opined that for the right hip, additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance or incoordination could not be specified as degrees of lost motion without resorting to speculation. The VA examiner diagnosed right hip arthritis with limitation of motion, symptomatic. In light of the above evidence, the Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for the Veteran’s right hip disability prior to the Veteran’s right hip replacement. See 38 C.F.R. § 4.71a, Codes 5003, 5013, 5252, 5253. With respect to the right hip, the record shows, flexion limited to 90 degrees, abduction limited to 45 degrees, adduction limited to 25 degrees, internal rotation limited to 40 degrees, and external rotation limited to 60 degrees, all of which warrant noncompensable ratings under all applicable Diagnostic Codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5252, 5253. In addition, a rating in excess of 10 percent is not warranted, as the record does not demonstrate ankylosis, flail hip joint, or impairment of the femur prior to July 24, 2014. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250-5255. Furthermore, although the examiner opined that additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance or incoordination could not be specified as degrees of lost motion without resorting to speculation, the examiner did report that the Veteran’s weakness and lack of coordination was negative and the Veteran’s lack of endurance was mild. The Board finds that the preponderance of the evidence does not indicate that such functional impairment would result in flexion limited to 30 degrees or less (which would be required for a higher rating under Code 5252) or limitation of abduction of the thigh where motion is lost beyond 10 degrees (which would be required for a higher rating under Code 5253). The evidence from this time period, to include when considering functional impairment as recorded in medical evidence and the Veteran’s testimony, does not reflect greater impairment. Accordingly, the Board finds that the Veteran’s range of motion does not warrant a rating of his right hip disability greater than 10 percent prior to July 24, 2014. See 38 C.F.R. § 4.71a, Codes 5003, 5013, 5252, 5253; see also Fenderson, 12 Vet. App. at 119, 126-127. The Veteran underwent right total hip arthroplasty on July 24, 2014. See September 2014 post-operative report. Thus, the Veteran is entitled to an evaluation of 100 percent from July 24, 2014, through July 31, 2015, and 30 percent from August 1, 2015 due to the right total hip arthroplasty. See 38 C.F.R. § 4.71a, DC 5054. As the Board has granted a separate evaluation for the Veteran’s right hip replacement surgery, the Board must now consider whether the Veteran is entitled to a rating greater than 30 percent as of August 1, 2015. The Veteran was afforded a VA examination in August 2017. The Veteran expressed that he does not take any regular treatment for his hip condition but when he gets pain, he occasionally takes pain medication. The Veteran did not report flare-ups of the hip or thigh. The Veteran reported having functional loss or functional impairment of the hips. The Veteran expressed that he has difficulty running and cannot lift more than 30 pounds. Upon physical examination, the Veteran’s range of motion for flexion was limited to 100 degrees; extension limited to 25 degrees, abduction limited to 45 degrees, and adduction limited to 25 degrees. External rotation was limited to 60 degrees and internal rotation limited to 40 degrees. The examiner indicated that the Veteran’s adduction was not limited in that the Veteran cannot cross his legs. The examiner noted that there was pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions. The examiner reported that there was no additional loss of function or range of motion after three repetitions. The examiner noted that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time. The examiner noted that muscle strength was normal. The Veteran does not have ankylosis. The Veteran does not have malunion or nonunion of femur, flail hip joint or leg length discrepancy. As for residuals of the Veteran’s total hip replacement, the examiner noted that the Veteran has a residual scar. Upon careful review of the evidence, the preponderance of the evidence weighs against assigning a disability rating in excess of 30 percent from August 1, 2015. In this regard, the Board acknowledges that the Veteran’s August 2017 VA hip examination report, in addition to private treatment records during this period, show that the Veteran’s symptoms included, objective evidence of pain and loss or range of motion. The Veteran also had some difficulty with running. However, the evidence of record does not indicate that the Veteran’s right hip disability was manifested by, or more nearly approximated, moderately severe residuals of weakness, pain, or limitation of motion during this period. See 38 C.F.R. § 4.71a, Diagnostic Code 5054. A higher disability rating requires evidence showing at least moderately severe residuals with weakness, pain or limitation of motion. The Board acknowledges that the evidence shows slight limitation of motion and pain. However, the preponderance of the evidence does not indicate that the Veteran’s residuals are consistent with moderately severe residuals. His limitation of motion would not be compensable under DCs 5251 through 5253. Thus, under any other applicable DCs, his right hip disability would be evaluated as 10 percent disabling, at most, for noncompensable painful limitation of motion under either 38 C.F.R. § 4.59 or DC 5003. As such, the right hip disability picture does not reflect a moderately severe limitation of motion consistent with a 50 percent disability rating under DC 5054. Rather, the 30 percent disability rating under DC 5054 is the more appropriate disability rating for the Veteran’s right hip disability that is now status post total hip arthroplasty. There is also no basis for assigning a higher rating based on consideration of factors such as pain on movement, weakness, excess fatigability, incoordination, swelling, or atrophy, to include as due to flare-ups and/or repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. In this regard, the Board finds significant that at his August 2017 VA examination, the Veteran reported that he did not experience any flare-ups of his disability. Moreover, the Veteran was able to perform three repetitions of ROM testing with no showing of additional limitation due to pain, fatigue, weakness, lack of endurance, or incoordination. It follows that even when considering functional loss due to factors such as pain on movement, weakness, fatigability, and disturbance of locomotion, the Veteran’s right hip disability has not been generally manifested by symptomatology approximating moderately severe residuals of weakness, pain, or limitation of motion so as to meet the criteria for a 50 percent rating under Diagnostic Code 5054. Instead, as demonstrated by the competent medical evidence of record, the 30 percent rating assigned adequately compensates the Veteran for the extent of functional loss resulting from these factors. As the evidence of record during this period contains no findings of ankylosis, flexion limited 10 degrees, flail joint, or impairment of the femur manifested by fracture of the surgical neck with false joint or fracture of the shaft or anatomical neck, there is no basis for a rating in excess of 30 percent under a different diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250 (ankylosis), 5252 (limitation of flexion), 5254 (flail joint), 5255 (impairment of femur). For the reasons set forth above, the Board has determined that the preponderance of the evidence is against a finding that the Veteran’s right hip disability was manifested by, or more nearly approximated, moderately severe residuals of weakness, pain, or limitation of motion during the period from August 1, 2015. Therefore, a disability rating greater than 30 percent is not warranted during this period. See 38 C.F.R. § 4.71a, Diagnostic Code 5054. The Board also notes that for the periods of a 100 percent ratings granted above following the hip replacements, statutory housebound ratings are to be granted as there is separate disability rated as 60 percent disabling or greater. See 38 U.S.C. § 1116(s) (SMC). 4. Entitlement to an initial compensable rating for right shoulder residuals, rotator cuff repair and decompression prior to August 27, 2017, and a rating greater than 10 percent disabling thereafter Initially, the Veteran’s service-connected right shoulder was evaluated as noncompensable under diagnostic code 5201. The Veteran’s service treatment records showed that in an April 2006 MRI of the right shoulder, the Veteran was noted to have degenerative changes at the glenohumeral joint. In addition, the Veteran was afforded a VA examination in October 2009. The Veteran reported limited motion in his right shoulder and it was noted that repetitive motion increases pain. Therefore, after review of the evidence of record, the Board finds that diagnostic code 5201-5010 for arthritis, due to trauma, substantiated by x-ray findings (DC 5010) and for limitation of motion of the arm (DC 5201) should be applicable for the entire period on appeal and a 10 percent rating for the entire period of appeal is warranted. The Board must now discuss whether a rating greater than 10 percent is warranted for the entire period on appeal. DC 5010 provides that traumatic arthritis is to be rated under DC 5003. DC 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate DCs, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate DCs, the compensable limitation of motion should be rated under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a. Under DC 5201, limitation of motion to shoulder level (e.g., flexion to 90 degrees) in the major or minor extremity warrants a 20 percent rating. Limitation of motion to midway between side and shoulder level (e.g., flexion between 25 to 90 degrees) in the minor extremity warrants a 20 percent rating and a 30 percent rating in the major extremity. Limitation of motion to 25 degrees from the side in the minor extremity warrants a 30 percent rating a 40 percent rating in the major extremity. 38 C.F.R. § 4.71a, DC 5201 (2017). Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. In addition, the Board must determine whether an initial evaluation in excess of 10 percent is warranted under any applicable diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Therefore, the following diagnostic codes are relevant: Under DC 5200, where there is favorable ankylosis of the scapulohumeral articulation, with abduction to 60 degrees, can reach mouth and head, a 20 percent evaluation is warranted for the minor upper extremity. Under DC 5202, humerus, other impairment of, malunion of, with moderate deformity, warrants a 20 percent evaluation (major and minor shoulder); malunion of the humerus with marked deformity, is evaluated as 20 percent disabling (minor shoulder); recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, is evaluated as 20 percent disabling (major and minor shoulder); recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are evaluated as 20 percent disabling (minor shoulder); a fibrous union of the humerus is evaluated as 40 percent disabling (minor shoulder). Under DC 5203, a 20 percent evaluation is warranted for clavicle or scapula, impairment of, dislocation of, or nonunion of, with loose movement, for both the major arm, and the minor arm. A review of the Veteran’s service treatment records show that in an April 2006 MRI of the right shoulder, the Veteran was noted to have degenerative changes at the glenohumeral joint. The Veteran was afforded a VA examination in October 2009. The Veteran reported limited motion in his right shoulder and no instability. It was noted that repetitive motion increases pain without any additional loss of motion. The Veteran indicated that activities of daily living are limited and that the Veteran’s work is affected. There is no history of flare-up. Upon examining the Veteran, the examiner noted that the Veteran’s right shoulder revealed normal contour, with no deformity or swelling noted. Range of motion revealed abduction of 145 degrees with pain; forward flexion to 100 degrees with pain; external rotation of 70 degrees with pain; and internal rotation of 80 degrees without any pain. The examiner noted that there was no instability. The examiner reported that there were no arthritic changes visualized. The examiner also reported that there was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance on repetitive use of the joint. There is minimal impairment of daily occupational activities due to his shoulder. The Veteran’s private medical records dated in March 2011 show that the Veteran reported right shoulder pain. The Veteran stated that he had difficulty lifting his arm and reaching behind. The Veteran denied any weakness in his right arm. The Veteran reported constant pain and that his shoulder did not get better after surgery. Upon physical examination, the examiner noted that there was no warmth, erythema, or edema. The Veteran’s active flexion was limited to 80 degrees and the Veteran’s passive flexion was limited to 100 degrees. The Veteran’s abduction was limited to 80 degrees. External rotation was limited to 20 degrees. The Veteran was afforded a VA examination in August 2017. The Veteran expressed that he gets right shoulder pain if he lifts his shoulder over his head. The Veteran takes pain medication for his pain. The Veteran did not report flare-ups of the shoulder. The Veteran reported having functional loss or functional impairment of the shoulder. Upon physical examination, the Veteran’s flexion was limited to 140 degrees. His abduction was limited to 150 degrees. The Veteran’s external rotation was limited to 70 degrees and internal rotation limited to 60 degrees. The examiner noted that there was no pain on the examination and no pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. The examiner reported that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time. The Veteran does not have muscle atrophy and does not have ankylosis. The Veteran’s right rotator cuff was suspected. The Veteran’s Hawkins’ Impingement Test, Empty-can Test, External Rotation Strength Test, and Lift-off Subscapularis Test were all negative. The Veteran does not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. The Veteran does not have malunion of the humerus with moderate or marked deformity. After review of all the evidence of record, the Board finds that the criteria for an initial evaluation in excess of 10 percent under DC 5200 and DC 5201 have not been met for the right shoulder. The evidence is insufficient to show that the Veteran’s right shoulder is productive of ankylosis of scapulohumeral articulation, that abduction of the right shoulder is limited to 60 degrees, or that the right shoulder is productive of a limitation of motion to midway between the side and shoulder level. Even when pain is taken into account, the limitations caused thereby do not equate to restricted motion that would warrant an initial increased evaluation. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the criteria for an initial evaluation in excess of 10 percent under DCs 5200 and 5201 have not been met for the right shoulder. In addition, there is no evidence to show a malunion, or recurrent dislocation, of the humerus, or a dislocation of, or nonunion of, the clavicle or scapula. The criteria for an initial evaluation in excess of 10 percent under DC’s 5202 and 5203 are therefore not met for the right shoulder. Finally, there is also no basis for assigning a higher rating based on consideration of factors such as pain on movement, weakness, excess fatigability, incoordination, swelling, or atrophy, to include as due to flare-ups and/or repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. In this regard, the Board finds significant that at his October 2009 and August 2017 VA examination, the Veteran reported that he did not experience any flare-ups of his disability. Moreover, the Veteran was able to perform three repetitions of ROM testing with no showing of additional limitation due to pain, fatigue, weakness, lack of endurance, or incoordination. A 10 percent rating is granted from the date of service connection based on painful arthritic motion; this 10 percent rating is effective March 31, 2009. Accordingly, the preponderance of the evidence is against assignment of an increased disability rating greater than 10 percent for the entire period on appeal for the Veteran’s service-connected right shoulder disability. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to an initial rating greater than 10 percent for degenerative disc disease of the lumbosacral spine The Veteran seeks an initial rating greater than 10 percent for his service-connected degenerative disc disease of the lumbosacral spine. The Veteran was afforded a VA examination in July 2008. The Veteran reported pain at the beltline that radiates to the buttocks with the left side greater than the right. Upon physical examination, the examiner noted an antalgic gait to the left and a short step, heel toe. The Veteran’s range of motion was 90 degrees flexion, but very painful. The examiner indicated that additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance or incoordination cannot be specified as degrees of lost motion without resorting to mere speculation. The Veteran was afforded a VA examination in August 2017. The Veteran did not report flare-ups of the back. The Veteran did report having functional loss or functional impairment of the back. The Veteran expressed having difficulty bending and walking with weight more than 30 pounds. Upon physical examination, the Veteran’s forward flexion was noted to be limited to 80 degrees and his extension was limited to 20 degrees. The examiner noted that there was no pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions. However, there was no additional loss of function or range of motion after three repetitions. The examiner reported that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time. The examiner noted that the Veteran does have guarding or muscle spasm of the thoracolumbar spine. The examiner noted that the Veteran does not have radicular pain or any signs or symptoms due to radiculopathy and that there was no ankylosis of the spine. The examiner noted that there was no other neurologic abnormalities or findings related to the back to include bowel or bladder problems. The Veteran was noted to use a brace for an assistive device as a normal mode of locomotion. However, it was noted that the Veteran wears it when he goes biking. In a September 2017 VA clarification opinion, the August 2017 VA examiner indicated that it was an error when he reported that the Veteran had guarding and muscle spasm as the examiner should have reported that the Veteran did not have guarding or muscle spasm. The Veteran’s private treatment records from Dr. V.M. reveal low back pain and show that the Veteran receives lumbar steroid injections to relieve the Veteran from pain. The record contains a buddy statement from J.V. who expressed that the Veteran has several physical issues that cause him difficulty getting out of chairs, in and out of cars, and daily functions. After review of all the evidence of record, for the entire period on appeal, the Board concludes that a rating greater than 10 percent is not warranted. The objective evidence of record demonstrates that forward flexion of the thoracolumbar spine was not limited to 60 degrees or less, nor was there muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. As such, the Board concludes that a rating greater than 10 percent under DC 5242 is not warranted. In addition, there is also no basis for assigning a higher rating based on consideration of factors such as pain on movement, weakness, excess fatigability, incoordination, swelling, or atrophy, to include as due to flare-ups and/or repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. In this regard, the Board finds significant that at his August 2017 VA examination, the Veteran reported that he did not experience any flare-ups of his disability. Moreover, the Veteran was able to perform three repetitions of ROM testing with no showing of additional limitation due to pain, fatigue, weakness, lack of endurance, or incoordination. Accordingly, the preponderance of the evidence is against assignment of an increased disability rating greater than 10 percent for the entire period on appeal for the Veteran’s service-connected back disability. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to an initial compensable rating for right shoulder scar The Veteran seeks a compensable evaluation for his service-connected right shoulder scar. The disability is currently rated under Diagnostic Code 7805. 38 C.F.R. § 4.118, DC 7805. The Veteran testified that a surgeon removed the “grizzle pad” from his shoulder and that he cannot carry a backpack on it because there is nothing to absorb the weight of the backpack. In July 2008, the Veteran was afforded a VA examination. The examiner noted that the Veteran had a (5cm x 1cm) scar alongside the distal right clavicle. The examiner noted that the scar was well-healed and there was no tenderness or excessive granulation. In August 2017, the Veteran was afforded a Scars/Disfigurement VA examination. The Veteran denied any pain at the scar site. The examiner indicated that there were no scars of the trunk or extremities that were painful and that there were no scars that were unstable, with frequent loss of covering of skin over the scar. The examiner reported that the Veteran’s scar was linear and the length was 5 centimeters. The examiner noted that there were no superficial non-linear scars or deep non-linear scars. The examiner reported that the Veteran’s scar (regardless of location) or disfigurement of the head, face, or neck does not result in limitation of function and does not impact the Veteran’s ability to work. The rating criteria for evaluating scars are set forth at 38 C.F.R. § 4.118, DCs 7800-7805. DC 7805 provides that scars (including linear scars) not otherwise rated under DCs 7800-7804 are to be rated based on any disabling effects not provided for by those codes. In addition, the effects of scars otherwise rated under DCs 7800-7804 are to be considered. 38 C.F.R. § 4.118, DC 7805. Therefore, the Board has considered all applicable DCs, as discussed further herein. Based on a review of the pertinent evidence, the Board finds that an increased compensable rating for the Veteran’s right shoulder scar is not warranted. In this regard, the Board concludes that, for the entire appeal period, the Veteran’s right shoulder scar was not of a size to warrant a compensable rating and does not result in functional impairment or other disabling effects. As noted above, the Veteran’s scar is currently rated as noncompensable under Code 7805, which provides that other scars (including linear scars), not otherwise rated under Codes 7800-7804 and including the effects of such scars otherwise rated under those codes, are also to be rated based on any disabling effects not provided for by Codes 7800-7804. 38 C.F.R. § 4.118, Code 7805. This includes, where applicable, diagnostic codes pertaining to limitation of function. Id. The Board notes, however, the August 2017 VA examination revealed no indication that the Veteran’s scar results in limitation of function as to routine daily activities or employment. As the evidence throughout the appeal period does not show any disabling effects due to the scar itself, a compensable rating is not warranted under Code 7805. The Board has also considered the applicability of other potentially applicable diagnostic criteria for rating the Veteran’s right shoulder scar, but finds that no higher rating is assignable under any other diagnostic code. To that end, Code 7800 contemplates scars of the head, face, or neck. 38 C.F.R. § 4.118, Code 7800. As the Veteran’s scar is located on his distal right clavicle, a compensable rating is not warranted under Code 7800. Code 7801 provides that scars other than on the head, face, or neck that are deep, nonlinear, and cover an area of at least 6 square inches (39 square (sq.) centimeters (cm.)) warrant a compensable evaluation. Id., Code 7801. A deep scar is one associated with underlying soft tissue damage. Id. As documented in the August 2017 VA examination report, there is no evidence that the Veteran’s scar covers an area of at least 6 square inches, or that it is deep or nonlinear. Hence, Code 7801 is inapplicable. Code 7802 provides that scars, other than on the head, face, or neck, that are superficial and nonlinear, and cover an area of at least 144 square inches (929 sq. cm.) warrant a compensable evaluation. Id., Code 7802. A superficial scar is one not associated with underlying soft tissue damage. Id. In this case, the Veteran’s scar does not cover a surface area of 144 square inches or greater; therefore, a compensable rating is not available under Code 7802. Code 7804 contemplates scars that are unstable or painful. Id., Code 7804. A 10 percent disability rating is assigned for one or two scars that are unstable or painful. Id. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note 1. If one or more scars are both unstable and painful, an additional 10 percent is to be added to the evaluation based on the total number of unstable or painful scars. Id., Note 2. In this regard, objective examination revealed that the scar was neither painful nor unstable. Therefore, based on the foregoing, the Board finds that the Veteran is not entitled to a compensable rating for his right shoulder scar. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to an initial rating greater than 30 percent for PTSD prior to August 29, 2017, and a rating greater than 50 percent disabling thereafter The Veteran’s service-connected PTSD is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This disability is rated under the General Rating Formula for Mental Disorders, which provides as follows: A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. A 70 percent disability rating is warranted when there is 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 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 30 percent disability rating is assigned 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). Id. The Board has reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a Veteran or obtained on her behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran seeks a disability rating greater than the currently assigned 30 percent for his PTSD prior to August 29, 2017, and greater than 50 percent thereafter. In November 2014, the Veteran testified that he cannot stand being around people. See Board hearing transcript at 10. The Veteran expressed that he also does not sleep well. Id at 13. The Veteran was afforded a VA examination in July 2008. The Veteran indicated that he lived by himself and that he has been divorced three times. The Veteran indicated that he has a very close relationship with his son. The Veteran denied ever being hospitalized for psychiatric purposes. The Veteran indicated that since returning home from his deployment, the Veteran has been engaged in individual psychotherapy once a week. The Veteran reported suffering from and engaging in avoidance phenomena and emotional numbing in the form of avoiding thoughts, feelings, conversations, and people and activities that may arouse recollections of his combat experience. The Veteran endorsed markedly diminished pleasure in activities that he used to enjoy such as hunting, shooting, and cleaning his guns. The Veteran reported avoiding people and would prefer to isolate himself on his farm. In addition, the Veteran reported suffering from increased arousal symptoms in the form of sleep difficulties, irritability and anger, desire to get into physical fights, and hypervigilance. Upon examination, the examiner indicated that the Veteran was appropriately dressed in casual attire. The Veteran’s grooming was good and his eye contact was good. The Veteran denied hallucinations and denied suicidal ideation or intent. The Veteran denied homicidal ideation or intent. The examiner indicated that the Veteran’s PTSD was chronic in nature and moderate to severe in intensity as the Veteran is experiencing serious social impairment and moderate occupational impairment. The examiner indicated that the Veteran has no friends and prefers to isolate himself and does not engages in hobby or leisure activities. Occupationally, the Veteran was noted to have many conflicts with co-workers and finds it difficult to complete tasks in a timely fashion. In a private psychiatric treatment note dated May 2016, the Veteran indicated a lack of motivation and that he must push himself to do anything. Dr. F.R. reported symptoms of depressed mood and noted that suicidal and homicidal ideation were not present. The Veteran was afforded a VA examination in August 2017. The examiner indicated that the Veteran’s PTSD was manifested by social and occupational impairment with reduced reliability and productivity. The Veteran expressed that he currently lives alone but gets along well with some neighbors. The Veteran described his relationship with his son as magnificent. The Veteran reported getting easily angered, irritable, and having mood swings, anxiety, road rage, and sleep difficulty since his tour in Iraq. The Veteran reported feeling irritable and frustrated when he forgets and cannot locate things around the house. The Veteran denied any psychiatric hospitalization. The VA examiner indicated that the Veteran experiences panic attacks that occur weekly or less often. The Veteran was noted to have mild memory loss, such as forgetting names, directions or recent events. The Veteran was reported to have difficulty in establishing and maintaining effective work and social relationships. The examiner indicated that the Veteran was casually and neatly dressed and that the Veteran’s thoughts were logical. In a private psychiatric treatment note dated October 2017, the Veteran was noted to be depressed and have a lack of motivation. The Veteran reported staying indoors and sleeping or watching television. Dr. F.R. reported symptoms of depressed mood, anxiousness, and irritability and noted that suicidal and homicidal ideation were not present Taking all factors into consideration with application of the approximating principles of 38 C.F.R. § 4.7, the Board finds that the Veteran’s PTSD most nearly represents occupational and social impairment with reduced reliability and productivity due to symptoms of the nature and severity as those contemplated by the 50 percent rating for the entire period on appeal; however, the criteria for a higher rating for PTSD have not been met at any time during the appeal period. The above-cited evidence reflects that during the entire period on appeal, the Veteran’s PTSD has been manifested by anxiety; depressed mood; panic attacks; sleep impairment; and difficulty in establishing and maintaining effective work and social relationships. Taken together, the Board finds the frequency, intensity, and duration of the Veteran’s PTSD symptoms to more nearly reflect the criteria for a rating of 50 percent for the entire period of appeal. Under such circumstances, all reasonable doubt is resolved in favor of the Veteran, and the claim is decided on that basis. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Based upon review of all the lay and medical evidence, the Board concludes that at no point during the appeal period, does the Veteran’s overall PTSD symptomatology meet the criteria for a disability rating in excess of 50 percent. In this regard, the medical evidence does not show the Veteran has exhibited the severity of symptomatology required to approach the criteria for the next higher ratings. Specifically, the preponderance of the evidence does not show such symptoms as speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation, or neglect of personal appearance and hygiene, as associated with a 70 percent disability rating. Nor does the evidence demonstrate that the Veteran 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, or disorientation to time or place, as associated with a 100 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board has considered the evidence contained in the lay and medical evidence regarding the overall impact of the Veteran’s service-connected symptoms, both listed in the schedule, and those that are not, and finds that they are not productive or more nearly productive of occupational and social impairment in most areas or total social and occupational impairment. Accordingly, the Board finds that an increase to 50 percent disabling, but no higher, from March 31, 2009 is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56. REASONS FOR REMAND 1. Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness, is remanded. 2. Entitlement to service connection for frequent urination, to include as secondary to service connected disabilities, is remanded. 3. Entitlement to service connection for low libido, to include as secondary to service connected disabilities, is remanded. After review of the VA examinations, to include those obtained upon last remand, the Board finds that these reports are inadequate to address the questions of undiagnosed illness under 38 C.F.R. § 3.317. The Board remands to obtain additional opinions. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Board finds that the claim of entitlement to TDIU is inextricably intertwined with the claims for service connection. All issues “inextricably intertwined” with the issue certified for appeal, are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). The issue of entitlement to TDIU is intertwined with the service connection claims because a decision on the latter claim may have an impact on the former claim. Thus, the claim of entitlement to TDIU must be remanded for the appropriate development, as well as contemporaneous adjudication. Id. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for a VA Gulf War/undiagnosed illness examination, with an appropriate examiner. The examiner must review the claims file in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed. The examiner is requested to state whether the Veteran’s gastrointestinal symptoms are attributable to a known clinical diagnosis or to a disease process other than a known clinical diagnosis. If the examiner cannot identify a known disease or disability which causes these symptoms, the examiner should so state. The examiner should clarify whether the symptoms in question are chronic in nature (e.g., present for 6 months or more). The examiner should also indicate whether the Veteran’s symptoms represent a medically unexplainable chronic multi-symptom illness defined by a cluster of signs or symptoms. If the Veteran’s symptoms are attributable to a known clinical diagnosis, the examiner should render an opinion as to whether such disability is at least as likely as not (e.g., a 50 percent or greater probability) etiologically related to active military service or events therein. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. 3. After completing directive #1, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s frequent urination. The examiner must review the entire claims file. The examiner is to diagnose any disability manifested by frequent urination the Veteran has had at any time during the pendency of this appeal, even if such disorder has now resolved. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed disorder is related to the Veteran’s active service, or is caused or aggravated by his service-connected disabilities. The examiner is requested to state whether the Veteran’s frequent urination symptoms are attributable to a disease process other than a known clinical diagnosis. If the examiner cannot identify a known disease or disability which causes these symptoms, the examiner should so state. The examiner should clarify whether the symptoms in question are chronic in nature (e.g., present for 6 months or more). The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. 4. After completing directive #1, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s low libido. The examiner must review the entire claims file. The examiner is to diagnose any disability manifested by low libido the Veteran has had at any time during the pendency of this appeal, even if such disorder has now resolved. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed disorder is related to the Veteran’s active service, or is caused or aggravated by his service-connected disabilities. The examiner is requested to state whether the Veteran’s low libido symptoms are attributable to a disease process other than a known clinical diagnosis. If the examiner cannot identify a known disease or disability which causes these symptoms, the examiner should so state. The examiner should clarify whether the symptoms in question are chronic in nature (e.g., present for 6 months or more).   The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.D.