Citation Nr: 1808852 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 14-09 731 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a liver disorder, to include liver function test abnormalities. 2. Entitlement to an initial, compensable rating for gastroesophageal reflux disease (GERD). 3. Entitlement to an initial rating in excess of 20 percent for lumbar strain with history of arthritis, prior to May 12, 2014. 4. Entitlement to a rating in excess of 40 percent for lumbar strain with history of arthritis, from May 12, 2014. 5. Entitlement to an initial rating in excess of 20 percent for cervical strain. 6. Entitlement to an initial rating in excess of 20 percent for left shoulder strain. 7. Entitlement to an initial rating in excess of 10 percent for bilateral plantar fasciitis. 8. Entitlement to an initial rating in excess of 10 percent for right knee strain. 9. Entitlement to an initial rating in excess of 10 percent for left knee strain. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from May 1990 to June 1999, October 2001 to October 2003, and from August 2007 to January 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. During the course of the Veteran's appeal, the RO assigned an increased 40 percent rating for lumbar strain with history of arthritis, effective May 12, 2014. As higher ratings for the disability are available prior to and from this date, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The issues of entitlement to increased initial ratings for cervical spine, left shoulder, plantar fasciitis, and right and left knee disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A liver disorder manifested by liver function test abnormalities is not shown by the record. 2. The Veteran's GERD is manifested by reflux and epigastric distress, but not nausea, vomiting and digestive pain, or other symptoms productive of considerable impairment of health. 3. Throughout the appeal period, the Veteran's lumbar strain with history of arthritis has been manifested by functional loss more nearly approximating forward flexion limited to 30 degrees or less, but unfavorable ankylosis of the entire thoracolumbar spine, neurologic impairment outside of right lower extremity radiculopathy, and/or incapacitating episodes as defined by VA have not been shown. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver disorder, to include liver function test abnormalities, have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for an initial 10 percent rating for GERD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§, 3.102, 4.114, Diagnostic Code 7346 (2017). 3. The criteria for an initial 40 percent rating for lumbar strain with history of arthritis, prior to May 12, 2014, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a Diagnostic Code 5237 (2017). 4. The criteria for a rating in excess of 40 percent rating for lumbar strain with history of arthritis, from May 12, 2014, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a Diagnostic Code 5237 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). The Court has established that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, that list includes cirrhosis of the liver. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including cirrhosis of the liver, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran's service treatment records reflect he had markedly elevated transaminases on routine lab work in December 2010. At that time, he had been taking Testim for two months, and this medication was discontinued. Repeat bloodwork completed two weeks later revealed further elevation of liver function tests and other medications were discontinued. Treatment reports reflect that if tests remained elevated, he was to undergo liver biopsy. While autoimmune hepatitis was a possible cause, the treatment providers felt the likely cause was related to medication. The Veteran underwent medical evaluation board in April 2011 to evaluate liver dysfunction. The examiner noted that the Veteran complained of fatigue. During routine blood work, elevation of liver enzymes was present. Clinical evaluation of the abdomen revealed normoactive bowel sounds, and soft, nontender, non-distended abdomen, with no masses and no organomegaly. Ultrasound of the gallbladder was negative for stones and showed only a tiny non-obstructing polyp. The liver demonstrated no evidence of intrahepatic ductal dilatation or mass. There was increased in echogenicity in the liver compatible with fibro-fatty changes. Medications suspected for causing these abnormalities in liver enzymes were discontinued, including Zocor, Hyzaar and Mysoline. There was a good response to this action. His enzymes went gradually down, but not completely. It was thought that all the transient abnormalities in transaminases were due to medications. The examiner noted that Mysoline especially was known to cause these types of abnormalities. The Veteran was under observation by gastrointestinal specialists, and if hepatic function tests remain abnormal, he was to undergone additional evaluation, that possibly would include liver biopsy. At the conclusion of the report, the medical evaluation board physician listed all diagnoses. No diagnoses pertaining to the liver were noted. On VA examination in January 2013, the examiner noted that the Veteran was placed on multiple medications in service, including primidone, Lipitor and exogenous testosterone for his multiple medical conditions. A combination of these medications caused some amount of liver damage, with an increase noted in his liver function tests. The multiple medications were discontinued or changed, and there was an appreciable decreased in his liver function tests. The Veteran informed the examiner that his liver function tests had returned to normal or near normal in recent months. The Veteran did not have any symptoms or other complications or sequelae related to this condition. The Veteran did not have known hepatitis. He did not require medication for control of his liver condition. He did not have cirrhosis, biliary cirrhosis, or a cirrhotic phase of slerosing cholangitis. There was no requirement for liver transplant, and he did not undergo liver surgery. The examiner diagnosed liver function test abnormalities. In an April 2014 statement, the Veteran reported that his liver function test abnormality was initially discovered during the course of routine blood tests in December 2010. He noted that he still had to take annual blood tests to monitor the condition. In sum, the evidence reflects abnormal liver function test findings, which was thought to be due to medication use. No underlying disease or injury has been identified. The Veteran has merely indicated that he has continued to be monitored, but has not identified a current liver disorder. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, where, as here, competent evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, without persuasive evidence of current diagnosis of an underlying liver disorder, there is no basis upon which to award service connection, and discussion of the remaining criteria for service connection is unnecessary. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Fagan, 573 F.3d at 1287 (Fed. Cir. 2009). II. Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). A. GERD The Veteran contends that he is entitled to an increased rating for GERD. The Veteran's GERD has been rated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7346. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Under Diagnostic Code 7346, hiatal hernia is assigned a 10 percent rating when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating contemplates pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. While still in service, on medical evaluation board in April 2011, the examiner noted that the Veteran had some gastric reflux episodes that occurred at night with the taste of acid in the throat coming from his stomach. This was usually noted when he slept supine on his back. He was instructed to sleep with elevation of the bed and avoid alcohol and meals late at night. He was symptom free at the time of examination. The examiner noted that the condition was stable and required no treatment. Diagnosis of GERD was indicated. On VA examination in January 2013, the examiner noted that the Veteran did not have infrequent episodes of epigastric distress, dysphagia, pyrosis, regurgitation, or substernal arm or shoulder pain, sleep disturbances, anemia, weight loss, nausea, vomiting, hematemesis, or melena. He does have frequent sleep disturbances caused by esophageal reflux, which occurred 4 or more times per year, lasting less than 1 day at a time. He also had 4 or more episodes of reflux lasting less than 1 day at a time. There was no evidence of esophageal stricture, spasm, or diverticula. There were no other findings, complications, conditions, signs or symptoms. The examiner diagnosed GERD and noted that the disability caused no functional impact as it related to the Veteran's ability to perform his occupation. In an April 2014 statement, the Veteran reported that his GERD had worsened over the past two years to the point that it caused nightly sleep disturbances caused by esophageal reflux. He took prescribed Zantac for the condition. On VA examination in May 2014, the Veteran stated that the frequency and severity of his condition had increased since his last examination. Specifically, he experienced daily symptoms that required daily medication. Signs and symptoms of GERD included reflux and sleep disturbances caused by esophageal reflux. The symptoms recurrent more than 4 times a year, and lasted a duration of less than 1 day. The Veteran did not have an esophageal structure, spasm of the esophagus, or an acquired diverticulum of the esophagus. The examiner diagnosed GERD, and indicated that the disability did not impact his ability to work. The examiner noted that the Veteran was gainfully employed in a sedentary occupation. Based on the foregoing, the Board finds that a 10 percent rating, but no higher, is warranted for the service-connected GERD. In so finding, the Board notes that VA examination reports reflect symptoms of recurrent epigastric distress and reflux. Accordingly, the criteria for a 10 percent rating under Diagnostic Code 7346 have been more nearly approximated. The Board has considered whether a rating in excess of 10 percent is warranted; however, abdominal pain, regurgitation, nausea, vomiting, and substernal pain, which are shown to be productive of considerable impairment of health has not been demonstrated. VA examinations and the Veteran's self-report do not indicate that the Veteran's GERD is productive of such symptoms. The Board has also considered the Veteran's statements regarding the severity of his reflux symptoms. Certainly, as a lay person, he is competent to attest to physical symptoms that he experiences, such as reflux. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Generally, these statements are credible, and the Board has granted an increased 10 percent rating, in part, with consideration of his reports of the type and frequency of his symptoms. However, neither the medical evidence nor the lay evidence of record suggests that an evaluation in excess of 10 percent is warranted at this time. Therefore, an initial 10 percent rating for GERD is warranted. B. Lumbar Strain with History of Arthritis The Veteran likewise contends that he is entitled to an increased rating for his lumbar spine disability, which has been rated as 20 and 40 percent disabling during the appeal period. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Code 5237. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 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; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, 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. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. A 10 percent disability rating is assigned for incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, with higher evaluations for incapacitating episodes of increased duration. Note 1 states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent ("flare-ups") due to the extent of her pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. In reviewing the VA examinations conducted during the course of the Veteran's appeal, Board has considered the decision of the United States Court of Appeals for Veterans Claims in Correia v. McDonald, 28 Vet. App. 158 (2016), which held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Given that the Board is assigning the maximum rating allowable for the service-connected lumbar spine disability on the basis of limitation of motion, the Board finds no prejudice to the Veteran. Accordingly, remand for an additional Correia-compliant examination is not warranted. Prior to discharge from service, on medical evaluation board examination in April 2011, the examiner noted that there was decreased range of motion with flexion while bending at the waist. Forward flexion was to 40 degrees with pain at the endpoint of range of motion. Extension was to 25 degrees, left lateral flexion was to 30 degrees, right lateral flexion was to 22 degrees, left lateral rotation was to 40 degrees, and right lateral rotation was to 45 degrees, each with pain at the end of range of motion. There was no appreciable change in range of motion after 3 repetitions. He had negative Waddell's sign. There was positive seated and supine straight leg raise with pain in the back, lumbar region. Right leg Lasegue's test was positive while the left leg was negative. Deep tendon reflexes were 2/4 at the knees and ankles. Strength was 4/5 bilaterally. X-ray of the lumbar spine revealed nonspecific degenerative changes. MRI revealed degenerative disc disease and small bilateral foraminal disc protrusions. The examiner diagnosed spinal degenerative changes with lumbar spine spondylosis. On VA examination in January 2013, the Veteran reported that he developed a lumbar spine condition as a result of a fall during service. He denied any flare-ups of the lumbar spine condition. Range of motion testing revealed lumbar flexion to 50 degrees, right and left lateral flexion to 20 degrees, right and left lateral rotation to 20 degrees, right and left lateral flexion to 20 degrees, and lumbar extension to 20 degrees. There was evidence of moderate to severe pain the lumbar spine with lumbar flexion 40 to 50 degrees, lateral flexion right and left to 10 degrees, rotation right to left from 10 to 20 degrees, lumbar extension from 10 to 20 degrees. In regard to functional loss or additional limitation of range of motion, excursion, strength, speed, coordination, and endurance were all normal for the lumbar spine. There was no additional limitation of range of motion following repetitive use testing in regard to functional loss or functional impairment. He had difficulty sitting for more than 1-1/2 hour, standing and walking more than one-half hour, being and lifting more than 30 pounds due to low back and lumbar pain as it related to his activities of daily living and his occupation as a laborer. There was less movement than normal. There was no evidence of weakened movement, excess fatigability, or incoordination. There was evidence of moderate to severe pain in the lumbar spine with ranges of motion, with mild to moderate swelling from L1 to L5 on palpation, but no deformity or atrophy of disuse. There was no instability of station. He presented with an antalgic gait. There was evidence of mild to moderate pain, mild to moderate muscle spasm, mild to moderate tenderness, and mild to moderate guarding the lumbar spine, resulting in an abnormal gait but no abnormal spinal contour. In addition, there was no evidence of intervertebral disc syndrome or incapacitating episodes. He used a lumbar brace on occasion. The examiner diagnosed lumbar strain with range of motion abnormality and history of lumbar spine arthritis. Functional impairment included difficulty sitting for more than one-half hour, standing and walking more than one-half hour, bending and lifting more than 30 pounds. On neurological examination at that time, the Veteran reported a tingling sensation in his right thigh. He described the numbness and tingling sensation as moderate. He denied pain. Muscle strength testing in his lower extremities was normal, including knee extension, ankle plantar flexion, and ankle dorsiflexion bilaterally. No muscle atrophy was noted. There was decreased sensation to light touch at the anterolateral thigh on the right side. The Veteran walked with a genu varum gait. MRI of the lumbar spine showed degenerative disc disease, L2-L3 through L4-L5. L2 and L3 had small broad-based central disc protrusions and small bilateral foraminal disc protrusion. There was L3-L4 right foraminal disc herniation and L4-L5 broad-based disc protrusion. There was a moderately sized left foraminal disc herniation with mass effect on the left nerve root. The examiner diagnosed right sciatic nerve neuropathy, incomplete paralysis of a mild quality. A February 2014 private treatment report reflects that the Veteran had severe back pain. He was barely able to ambulate and had to lie flat for pain relief during the office visit. He described a long history of back pain, with use of medication, physical therapy, and chiropractic treatment, all with little relief. He was given a trial of Celebrex with Percocet and referred to physical therapy. In an April 2014 statement, the Veteran reported that his lumbar spine condition had increased in severity over the course of the previous two years. He was prescribed Percocet and Celebrex during his last visit. He noted that his lumbar spine pain made siting in one position for more than one hour extremely difficult, and therefore travel was limited. Sleep was also difficult. He was barely able to ambulate. He rated his pain a level of 6 out of 10, with daily bouts of pain to 8 out of 10. He used a TENS unit as well as daily pain medication. He also used heat and a massage reclining chair during the day and heating pad at night to relieve the pain. On VA examination in May 2014, the Veteran reported continued low back pain and occasional flare-ups during which he experienced additional pain and decreased range of motion. Flare-ups occurred 2 to 3 times per week, and sometimes caused difficulties with performing activities of daily living. He had undergone multiple treatment modalities, including epidural steroid injections with continued symptoms. The Veteran had not had any incapacitating episodes as defined by a requirement to remain supine (prescribed by a physician). Range of motion testing revealed flexion to 35 degrees, with objective evidence of painful motion at 10 degrees. Extension was to 10 degrees, with objective evidence of painful motion at 5 degrees. Right and left lateral flexion and rotation were each to 20 degrees, with pain at 15 degrees. There was no additional limitation in range of motion following repetitive-use testing. Additional functional loss or impairment on repetitive use included pain on movement. The Veteran did not have localized tenderness or pain to palpation of the joints or soft tissue of the lumbar spine, muscle spasm, or guarding. Muscle strength testing revealed 4/5 strength bilaterally for hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. The Veteran did not have muscle atrophy. Reflex examination was normal on the right, and hypoactive (1+) on the right at the knee and ankle. Sensation was decreased in the right lower extremity, but normal on the left. A straight leg raising test was negative on the left but positive on the right. The examiner identified moderate radiculopathy on the right, but not the left. There was no ankylosis of the spine. The Veteran did not have any other neurologic abnormalities or intervertebral disc syndrome. He wore a brace on a constant basis. The examiner diagnosed lumbosacral strain, degenerative arthritis of the spine, and intervertebral disc syndrome. The examiner indicated that the condition impacted the Veteran's ability to work, specifically impacting any occupation which would require prolonged sitting, standing, walking, or other type of strenuous activity. The Veteran was gainfully employed in a sedentary occupation. Given reasonable accommodations, the examiner indicated that this condition should not impact his ability to perform a sedentary occupation. The examiner indicated that, during flare-ups, given the Veteran's description, he would be expected to have an additional loss of 10 degrees of range of motion in all planes. In a January 2015 statement, the Veteran reported additional loss of motion with repetitions with very frequent incapacitating episodes which have resulted in needing assistance with activities of daily living including bathing, dressing, and putting on socks and shoes. With respect to the period prior to May 12, 2014, the aforementioned evidence reflects that the disability has been manifested by consistent symptoms of pain, tenderness and limited range of motion with flare-ups. Given that these complaints have remained primarily the same throughout the entire appeal period, the Board finds that a 40 percent rating is also warranted for the period prior to May 12, 2014. In reaching this determination, we note that the evidence has varied. However, during this initial period, there was evidence of pain and limitation of motion with flare-ups. The Veteran also reported increased pain with more severe flare-ups that affected his ability to perform activities of daily living prior to the May 2014 VA examination. This evidence tends to establish that flexion was functionally limited to 30 degrees or less. Based on the foregoing, the Board concludes that a uniform, 40 percent rating for the Veteran's lumbar strain with history of arthritis, prior to May 12, 2014, is warranted. With respect to both periods prior to and from May 12, 2014, in order to warrant a higher rating, there must ankylosis of the thoracolumbar spine or ankylosis of the entire spine. Specifically, ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). Based on the aforementioned range of motion findings, it is apparent that the Veteran's lumbar spine is not fixated or immobile. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, the Veteran has been shown to be able to perform repetitive range of motion testing, and there is nothing to suggest fixation of the lumbar spine. The Veteran has reported periods of limited mobility, but has not otherwise indicated fixation of the spine. Consequently, a higher rating is not warranted on this basis. With regard to separate ratings for neurological abnormalities or chronic neurologic manifestations, the record reflects that the Veteran is already service connected for radiculopathy of the right lower extremity associated with his low back disability. This matter is not before the Board at this time. With respect to the left lower extremity, while some abnormal neurological findings with respect to the right lower extremity, such as decreased strength, have been documented, no radiculopathy of this lower extremity has been diagnosed. Accordingly, a separate evaluation for any right lower extremity neurologic manifestation is not warranted. No other neurological abnormalities have been demonstrated. The Board has considered other appropriate diagnostic codes, particularly Diagnostic Code 5243 Intervertebral Disc Syndrome. However, there is no evidence of intervertebral disc syndrome and incapacitating episodes as contemplated by the regulation. The Board has considered the 2014 treatment report noting that the Veteran had to lie down for relief of symptoms. Even if the Board were to consider this an incapacitating episode, there is no indication of these episodes occurring to the frequency of at least 6 months during a 12-month period, as is required for a next-higher, 60 percent rating. Therefore, the Board finds that a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted. The Board has also considered the Veteran's statements regarding the severity of his low back symptoms. Certainly, as a lay person, he is competent to attest to physical symptoms that he experiences, such as persistent low back pain. See Washington, 19 Vet. App. at 368. Generally, these statements are credible; however, neither the medical evidence nor the lay evidence of record suggests that an evaluation in excess of 40 percent is warranted at this time. The Veteran's statements have been non-specific and fail to establish a greater degree of functional impairment. Regardless, neither the medical nor lay evidence establishes ankylosis of the spine. C. Both Claims The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching the decisions on the proper ratings for the Veteran's service-connected conditions, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 at 1282, 1287. ORDER Entitlement to service connection for liver disorder, to include liver function test abnormalities, is denied. Entitlement to an initial 10 percent rating for GERD is warranted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial 40 percent rating for lumbar strain with history of arthritis, prior to May 12, 2014, is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 40 percent for lumbar strain with history of arthritis, from May 12, 2014, is denied. REMAND Upon review of the claims file, the Board believes that additional development on the remaining claims is warranted. The Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing conditions, and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Notably, with respect to the service-connected bilateral plantar fasciitis, in Southall-Norman v. McDonald, 28 Vet. App. 346 (2016), the Court further held that the plain language of § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joints that are painful, whether or not they are evaluated under a Diagnostic Code predicated on range of motion measurements. The Veteran was afforded various examinations pertaining to his service-connected cervical spine, plantar fasciitis, left shoulder and right and left knee disabilities in 2013 and 2014. Review of these examination reports reveals that range of motion testing in passive motion, weight-bearing, and nonweight-bearing situations were not conducted. In light of Correia, these VA examinations are insufficient. Accordingly, the Veteran should be afforded a new examination to determine the nature and severity of his service-connected cervical spine, left shoulder plantar fasciitis, and right and left knee disabilities, to include consideration of the range of motion testing requirements of Correia. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination). Accordingly, the case is REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records. 2. Schedule the Veteran for a VA examination(s) to ascertain the current severity and manifestations of the Veteran's service-connected cervical spine, left shoulder, right and left knee, and plantar fasciitis disabilities. The claims file should be made available to the examiner for review in connection with the examination. In particular, the examiner should be directed to perform range of motion testing to determine the extent of limitation of motion. Additionally, the examiner must include range of motion testing in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the lumbar spine is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES' SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should also indicate if there is ankylosis of the spine or resultant neurological impairment. In addition, the examiner should describe the frequency and duration of any incapacitating episodes due to the cervical spine disability, if applicable. The examiner should also comment on the impact of the Veteran's disabilities on his ability to work. The examiner must provide a complete rationale for all the findings and opinions. 3. The AOJ should undertake any additional development it deems warranted. 4. Then, the AOJ should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). ______________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs