Citation Nr: 1815265 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 15-05 431 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a chronic sinus disorder, to include chronic sinusitis. 2. Entitlement to service connection for chronic residuals of traumatic brain injury (TBI). 3. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial evaluation in excess of 10 percent prior to June 12, 2017, and in excess of 20 percent since June 12, 2017, for right shoulder impingement syndrome. 5. Entitlement to an initial evaluation in excess of 10 percent for left hip strain. 6. Entitlement to an evaluation in excess of 10 percent for left knee strain with retro patellar pain syndrome. 7. Entitlement to an initial evaluation in excess of 10 percent for left ankle strain/sprain. 8. Entitlement to an initial compensable evaluation for bilateral hearing loss. 9. Entitlement to an initial evaluation in excess of 10 percent for tinnitus. 10. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Carol J. Ponton, Attorney at Law ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from February 1990 to June 1992. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in April 2017. This matter was originally on appeal from rating decisions dated in June 2012 and October 2014 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In correspondence received by the Board in February 2015, the Veteran's attorney noted that Veteran was unemployed due to his service-connected PTSD. The United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009) noted that a request for a TDIU is not a separate claim for benefits and is best analyzed as a request for an appropriate disability rating as part of the claim for increased compensation. As such, the record before the Board can reasonably be construed to include a request for a TDIU. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for chronic sinusitis and for chronic residuals of a TBI as well as entitlement to increased ratings for the Veteran's service-connected left hip and left ankle 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. In May 2017, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through his attorney, that a withdrawal of this appeal is requested with respect to the issues of entitlement to an initial compensable evaluation for bilateral hearing loss and entitlement to an initial evaluation in excess of 10 percent for tinnitus. 2. At no time during the appeal period have the Veteran's PTSD symptoms been productive of total occupational and social impairment. 3. At no time prior to June 12, 2017, was the Veteran's right shoulder impingement syndrome manifested by limitation of motion of the arm to shoulder level, ankylosis of scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula. 4. At no time since June 12, 2017, has the Veteran's right shoulder impingement syndrome been manifested by limitation of motion of the arm midway between side and shoulder level, ankylosis of scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula. 5. At no time during the appeal period has the Veteran's left knee strain with retro patellar pain syndrome been manifested by moderate recurrent subluxation or lateral instability, flexion limited to 50 degrees, extension limited to 10 degrees, ankylosis, dislocated semilunar cartilage, or impairment of the tibia and fibula. 6. The Veteran's service-connected disabilities as likely as not prevent him from maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran's attorney have been met for the issues of entitlement to an initial compensable evaluation for bilateral hearing loss and entitlement to an initial evaluation in excess of 10 percent for tinnitus. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. At no time during the appeal period have the criteria for a 100 percent evaluation for PTSD been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.130, Diagnostic Code 9411. 3. At no time prior to June 12, 2017, were the criteria for an evaluation in excess of 10 percent for right shoulder impingement syndrome met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Code 5201. 4. At no time since June 12, 2017, have the criteria for an evaluation in excess of 20 percent for right shoulder impingement syndrome been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Code 5201. 5. At no time during the appeal period have the criteria for an evaluation in excess of 10 percent for left knee strain with retro patellar pain syndrome been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.7, 4.71a, Diagnostic Code 5257 (2017). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.1, 4.7, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters Pursuant to the Board's April 2017 Remand, the AOJ obtained outstanding treatment records, scheduled a VA orthopedic examination to determine the current severity of the Veteran's left knee and right shoulder disabilities, readjudicated the claim, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's April 2017 Remand. Stegall v. West, 11 Vet. App. 268 (1998). As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). With respect to the issue of entitlement to an evaluation in excess of 10 percent for service-connected left knee disability, the requirements of 38 U.S.C. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in December 2011, January 2012, and March 2017 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. With respect to the issues of entitlement to increased ratings for PTSD and right shoulder impingement syndrome, as service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C. § 5103(a) have been met. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. With respect to the issue of entitlement to a TDIU, in light of the favorable outcome of the appeal with respect to this issue, any perceived lack of notice or development under the VCAA should not be considered prejudicial. Withdrawal of Issues on Appeal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, in May 2017, VA received an email from the Veteran's attorney in response to a letter asking him to clarify the issues which he was pursuing. The Veteran's attorney noted that the Veteran was asking for increased ratings for his service-connected right shoulder, PTSD, left ankle, left knee, and left hip and that he was asking for service connection for his TBI, a sinus disorder, and a TDIU. As such, the Veteran, through his attorney, has withdrawn the appeal with respect to the issues of entitlement to increased ratings for hearing loss and tinnitus. As such, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal with respect to those issues and it is dismissed. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignments of disability evaluations following awards of service connection for PTSD and right shoulder impingement syndrome. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In addition, as the Veteran is requesting a higher rating for his already established service-connected left knee strain with retro patellar pain syndrome, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Right Shoulder and Left Knee Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). PTSD The Veteran seeks an initial evaluation higher than 70 percent for his service-connected PTSD. Under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Codes 9411-9440, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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); and inability to establish and maintain effective relationships. The maximum rating of 100 percent requires total occupational and social impairment due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In Mauerhan, the court rejected the argument "that the DSM-IV criteria should be the exclusive basis in the schedule governing ratings for PTSD." Id. at 443. Rather, distinctive PTSD symptoms in the DSM-IV are used to diagnosis PTSD rather than evaluate the degree of disability resulting from the condition. Although certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions, it is not the symptoms but their effects that determines the level of impairment. Id. The Global Assessment of Functioning (GAF) score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV); see also Carpenter v. Brown, 8 Vet. App. 240 (1995). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. In this case, as the case was pending before the AOJ on August 4, 2014, it is governed by DSM-V. At the March 2012 initial VA PTSD examination, the examiner noted that the Veteran experienced depressed mood, anxiety, sleep impairment, disturbances of motivation/mood, difficulty establishing/maintaining effective work & social relationships, difficulty in adapting to stressful circumstances, suicidal ideation. The examiner did not indicate that the Veteran exhibited grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place. A February 2014 letter from Dr. Mangold indicates that he interviewed the Veteran on December 23, 2013 and December 28, 2013 and that after a review of the record (the Veteran's claims file), he believed that the Veteran has PTSD and a concomitant mood disorder related to service with symptoms of suicidal ideation, nearly-continuous panic and/or depression, intrusive recollections, nightmares, social isolation, and impaired impulse control which impose severe limitations of functioning such as unprovoked irritability with periods of violence, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and an inability to secure or maintain a substantially gainful occupation since September 2011. Of record is a PTSD Disability Benefits Questionnaire completed by the Veteran's VA treating psychiatrist in November 2013 which she noted that the Veteran met the criteria for PTSD and also for mild mixed bipolar disorder. The psychiatrist noted that the Veteran's psychiatric diagnoses with symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances was productive of occupational and social impairment with deficiencies in most areas. In March 2014, the Veteran reported that he had an altercation with his common law wife which led to incarceration but then charges were dropped because she was the aggressor according to him. Positive developments noted at that time were that he was making friends, had a new place to live, was getting on well with his children, and was resigned to breakup of his relationship. The Veteran underwent VA examination in April 2014 at which time the examiner found that he had a diagnosis of PTSD and another specified bipolar and related disorder manifested by short duration hypomanic episodes with insufficient symptoms and major depressive episodes. The examiner noted that the Veteran exhibited depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, impaired impulse control, irritability, impatience, and limited social interaction. The examiner noted that the Veteran appeared appropriately dressed for the evaluation and behaved in a cooperative way. Eye contact was consistent, the Veteran's speech was understandable, and he provided information in a coherent and detailed manner. There were no significant deficits noted in the Veteran's memory, he maintained adequate emotional control throughout the assessment process, and no psychotic symptoms were displayed. The examiner noted that at least an average level of intelligence was estimated. The examiner noted that the Veteran met criteria for a diagnosis of PTSD. The examiner; however, noted that objective psychological testing completed during the examination produced invalid results due to the Veteran's symptom exaggeration; that as a result, the level of severity of impairment in Veteran's case was questionable; and that this data requires careful consideration when determining the actual level of distress/impairment. VA treatment records from 2014 to 2017 show no evidence of grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Mental Status Examinations during that time noted appearance to be alert, appropriate, and with no acute distress; motor activity to be calm; interpersonal to be cooperative; mood to be at times euthymic, depressed, anxious, and irritable; affect to be at times broad and restricted; thought process to be normal, linear, and goal oriented. The Veteran's speech, attention, and concentration were normal; his judgment and insight were good; and he was oriented to person, place, situation, and date. The Veteran's memory was at times normal, and at other times his short-term memory was considered a problem. For the most part, the Veteran's thought content to be absent hallucinations and delusions; however, in June 2014, he stated that he felt that he saw tanks and deserts. There was also no suicidal or homicidal ideation. The Veteran did report that in June 2014 that he saw a man creeping around his backyard, he asked him what he was doing in his backyard and then told him that he was going to kill him if he did not leave. The Veteran underwent VA TBI examination in June 2017 at which time the Veteran complained of mild memory loss. The Veteran's judgment was normal, his social interaction was routinely appropriate, he was always oriented to person, time, place, and situation, motor activity was normal. In this case, the Veteran's symptoms do not approach the severity contemplated for the 100-percent schedular rating at any time during the appeal period. As set forth above, the criteria for a 100 percent rating are met when the Veteran experiences total occupational and social impairment, which is clearly not demonstrated in this case. There has never been any indication that the Veteran's PTSD was productive of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living, disorientation as to time or place, or memory loss for names of close relative, own occupation or own name. With respect to whether there is a persistent danger of hurting himself or others, VA treatment records indicate that in November 2011, the Veteran had no thoughts of killing himself that day but had a plan of hanging himself from a tree in the park. The Veteran reported a 1993 suicide attempt by overdose. The Veteran's suicide risk level was moderate, and he reported his desire to hurt people who aggravated him. He denied any thoughts of hurting his family. The Veteran was hospitalized from March 2, 2012 to March 9, 2012, with suicidal ideation without a plan. In April 2012, the Veteran reported that he becomes aggressive with people (verbally, has not yet escalated to physical but worries that it may and said that he lost his last job due to aggression with coworkers. In July 2013, the Veteran reported, I get confrontational with people. Once someone bumped me with his shopping cart and I lost it and went after him. I get aggressive with other people when I don't mean to. For that reason, I try to go out late at night when there are no other people around. I will go to Wal-Mart for instance after midnight when it is almost vacant. Even with my friends I get angry and upset easily. Once I was at work, I was the manager of a company that did sandwiches for Starbucks. My friend put the sandwiches on the wrong truck and I lost it so badly I literally chased the guy all around the plant and I was going to choke him until another manager interfered. I am lucky I didn't hurt him. He was really scared and I just lost my mind. I lost control of myself and it was like I couldn't stop. Another time I was working with another guy who was a friend. He accidentally hit me with a pan, and I just went berserk. For that reason I don't really have any friends now. I get upset with my girlfriend now and it has affected my relationships in the past. It usually has something to do with my temper and lack of control. If this relationship doesn't work out it will be 4 failed relationships. Because of the way I act, and my inability to get along with people, there are times when I think of taking my life. I feel like I can't stop myself when I get out of control. In August 2013, the Veteran reported that he was getting angry and frustrated and violent at times. In September 2013, the Veteran reported that he did not trust himself to not overreact and hurt someone. In October 2013, the Veteran reported that he "blew up at his girlfriend" and was afraid that he would hit her and felt that he did not have control. In January 2014, the Veteran reported that he and his girlfriend had a major disagreement in which he became enraged; his wife hit him and broke two fingers. The Veteran did not get physical but was afraid that he could and stated that he did not trust himself. In a March 2014 VA risk assessment, the Veteran reportedly suffered from poor judgement, flashbacks, suicidal and homicidal ideation, and visual hallucinations; however he was noted to have a good ability to resist impulses. In April 2014, the Veteran stated, "I get very agitated easily and I take it out on my family ... I have a terrible temper and I take it out on my family." In October 2014, the Veteran reported that he was having increased angry outburst and had been in physical confrontations and explained that he had a recent physical confrontation with his girlfriend. The Board finds that the frequency and duration of symptoms of the Veteran's suicidal ideation and impaired impulse control with very few periods of violence fit squarely within the criteria contemplated under a 70 percent evaluation. A 100 percent rating is only available where there is persistent danger of hurting self or others. Episodic periods of suicidal ideation and infrequent episodic periods of violence, do not rise to the level of severity and duration necessary to be considered a persistent finding. The VA treatment records refute a finding that the Veteran persistent, i.e., constant, danger to self or others. On the contrary, in most VA treatment records, the clinicians ranked the Veteran with low suicide risk and no homicide risk. For the foregoing reasons, entitlement to a 100-percent evaluation is not warranted for the Veteran's service-connected PTSD. Right Shoulder The Veteran seeks an initial evaluation higher than 10 percent prior to June 12, 2017, and higher than 20 percent since June 12, 2017, for his service-connected right shoulder impingement syndrome. Disabilities of the shoulder and arm are evaluated pursuant to the criteria within 38 C.F.R. § 4.71a, including Diagnostic Code 5200 (ankylosis), Diagnostic Code 5201 (limitation of arm motion), Diagnostic Code 5202 (impairment of the humerus), Diagnostic Code 5203 (impairment of the clavicle or scapula). A distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. The Veteran is reported to be right handed. The Veteran's service-connected right shoulder disability has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5201 for limitation of arm motion. Under Diagnostic Code 5201, limitation of motion of the shoulder to shoulder level warrants a 20 percent evaluation for the major arm. Midway between the side and shoulder level warrants a 30 percent evaluation for the major arm. Motion no more than 25 degrees from the side warrants a 40 percent rating for the major arm. Normal (full) range of motion of the shoulder is forward elevation (flexion) to 180 degrees; abduction to 180 degrees, external rotation to 90 degrees and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. VA treatment records indicate that in October 2012, range of motion and strength were within full limits of right upper extremity. Right shoulder x-ray was normal. The Veteran underwent VA physical medicine rehabilitation consultation in January 2014 at which time he reported right shoulder pain associated with overhead activities, lifting the arm up and abduction. On physical examination, the Veteran demonstrated normal strength and normal range of motion of the right upper extremity. There was mild discomfort at abduction of the right shoulder, no pain at the acromioclavicular (AC) joint, and mild tenderness at the anterolateral aspect of the right shoulder and at the subacromial/subdeltoid bursa. NEER impingement test and Hawkins test were slightly positive. X-rays of the right shoulder were negative. The Veteran was diagnosed as having right shoulder pain and clinical presentation of mild impingement/bursitis. At the April 2014 VA examination, the Veteran demonstrated right shoulder flexion from zero to 125 degrees; abduction from zero to 100 degrees with pain at the end of motion. The examiner noted that there was no additional limitation in range of motion on repetitive use testing. There was functional loss due to less movement than normal and pain on movement. There was pain on palpation of right shoulder but no guarding. Muscle strength testing was normal, and there was no ankylosis. There were rotator cuff findings on Hawkins Impingement and Empty-can tests. There were no recurrent dislocations, subluxations, AC joint impairment, clavicle impairment, or scapula impairment. There was no arthritis. The Veteran was diagnosed as having right shoulder impingement syndrome due to fall from left knee giving out. At the June 2017 VA examination, the Veteran reported pain associated with pressure on the shoulder, lifting and carrying, and pain with shoulder level activities. The Veteran reported flare-ups two to three times per week for about an hour with severity of 8-9/10. He also reported functional impact during baseline and with flare-ups while pulling, occasionally pushing, and with shoulder level and overhead activities. The Veteran reported that he was right-hand dominant. On physical examination he demonstrated flexion to 80 degrees, abduction to 70 degrees, external rotation to 70 degrees, and internal rotation to 90 degrees. Pain was noted on flexion, abduction, external rotation, with passive motion, with weight bearing, and with non-weight bearing. The examiner found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner was unable to comment on whether pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups as the Veteran was not experiencing a flare-up at the time of examination. The examiner noted that the Veteran did not have additional functional loss or range of motion of the shoulder following repetitive use testing. There was no objective evidence of localized tenderness or pain on palpation of the shoulder joint or associated soft tissue and no objective evidence of crepitus. Muscle strength testing was normal, and there was ankylosis. The examiner noted that testing indicated a suspected rotator cuff condition. There was no instability, dislocation, or labral pathology suspected. There was also no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition, and no impairment of the humerus. The Board finds that an evaluation higher than 10 percent prior to June 12, 2017, is not warranted for right shoulder impingement as the evidence does not demonstrate limitation of arm motion to shoulder level. Shoulder level is 90 degrees; thus, in order to warrant a higher evaluation, the Veteran must demonstrate motion of the arm limited to 90 degrees or less. This has not been the case prior to June 12, 2017. In January 2014, the Veteran was noted to have normal range of motion; on VA examination in April 2014, the Veteran was noted to have flexion to 125 degrees and abduction to 100 degrees. As such, the Board finds that an evaluation in excess of 10 percent prior to June 12, 2017, for the Veteran's service-connected right shoulder impingement is not warranted. The Board also finds that an evaluation higher than 20 percent is not warranted since June 12, 2017, for right shoulder impingement as the evidence does not demonstrate limitation of arm motion to midway between side and shoulder level. As noted above, shoulder level is 90 degrees; thus, in order to warrant a higher evaluation, the Veteran must demonstrate motion of the arm limited to 45 degrees or less. This has not been the case. On VA examination in June 2017, the Veteran was noted to have flexion to 80 degrees and abduction to 70 degrees. As such, the Board finds that an evaluation in excess of 20 percent for the Veteran's service-connected right shoulder impingement is not warranted since June 12, 2017. The Board notes that the April 2014 and June 2017 VA examiners noted that there was no additional limitation in range of motion on repetitive use testing, and the June 2017 VA examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The June 2017 VA examiner also was unable to to comment on whether pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups as the Veteran was not experiencing a flare-up at the time of examination. Therefore, even considering any functional limitation, the Veteran's ranges of motion did not meet or more nearly approximate that required for a 20 percent rating prior to June 12, 2017, or that required for a 40 percent since June 23, 2017, for limitation of flexion. In addition, at no time during the appeal period has there been ankylosis of scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula warranting a higher rating under Diagnostic Codes 5200, 5202, or 5203. For the foregoing reasons, entitlement to an initial rating higher than 10 percent prior to June 12, 2017, and higher than 20 percent since June 12, 2017, is not warranted for the Veteran's service-connected right shoulder impingement syndrome. Left Knee The Veteran seeks an evaluation higher than 10 percent for his service-connected left knee strain with retro patellar pain syndrome. Disabilities of the knees are evaluated pursuant to the criteria within 38 C.F.R. § 4.71a , including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). The Veteran's service-connected left knee disability has been rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257 for recurrent knee subluxation or instability. Diagnostic Code 5257 provides for a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate subluxation or lateral instability. A maximum 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997) held that arthritis and instability of the same knee may be rated separately under Diagnostic Codes 5003 and 5257. Subsequently, VAOPGCPREC 9-98 further explained that if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). Diagnostic Code 5261 provides for a 10 percent rating is warranted where leg extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). Standard range of motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). Diagnostic Code 5262 provides for evaluation of impairment of the tibia and fibula. With malunion and slight knee or ankle disability a 10 percent rating is warranted; with moderate knee or ankle disability a 20 percent rating is warranted; and with marked knee or ankle disability a 30 percent rating is warranted. For a 40 percent rating there must be nonunion of the tibia or fibula with loose motion, requiring a brace. At the March 2012 VA examination, the Veteran reported left knee pain and instability. He did not report that flare-ups impacted the function of his knee. On physician examination he demonstrated flexion to 140 degrees or greater with pain at 140 degrees and extension to zero with no objective evidence of painful motion. The examiner noted that the Veteran did not have additional limitation in range of motion of the knee following repetitive use testing or functional loss or functional impairment of the knee. There was localized tenderness or pain on palpation of the left knee. Muscle strength testing was normal. There was no knee instability, evidence or history of recurrent patellar subluxation/dislocation, ankylosis, or any additional conditions. X-rays of the left knee in September 2011 showed no acute osseous abnormality. VA treatment records indicate that in October 2012, the Veteran reported having occasional left knee instability. Range of motion and strength were within full limits of left lower extremity. At the Veteran's January 9, 2014, Independent Medical Evaluation by Dr. Hitchcock, the Veteran's left knee had a well-healed vertical scar 8 centimeters inferior to the patella, muscle atrophy surrounding, and lateral knee tenderness. Range of motion of left knee was flexion to 38 degrees which became significantly painful; at 43 degrees, functional loss occurred. Extension was to 26 degrees which became significantly painful; at 42 degrees, functional loss occurred. There was lateral instability present with the lateral collateral ligament stress test. Dr. Hitchcock noted that the Veteran's left knee impairment was 20 percent disabling under Diagnostic Code 5260 and 30 percent disabling under Diagnostic Code 5261 as evidenced by the reduced range of motion upon flexion, extension, tenderness on examination as well as the instability of the left knee joint causing his inability to walk more than a few blocks intermittently, or stand for prolonged periods. In November 2014, Dr. Hitchcock provided an addendum to the January 2014 IME which indicated that she made a mistake with the percentages that that under Diagnostic Code 5261, the Veteran was entitled to a 50 percent rating. On January 30, 2014, the Veteran underwent a Physical Medicine Rehabilitation Consultation. On examination, the provider noted normal strength, normal range of motion for upper and lower extremities in all muscle groups. At the June 2017 VA examination, the Veteran reported left knee pain, recurrent giving way, and popping. The Veteran reported flare-ups four to five days per week for several hours with severity of 8/10. He also reported functional impact during baseline and during flares limited his ability to sit to no more than 10 to 15 minutes, limited his ability to stand for no more than 15 minutes, and limited his ability to walk for no more than 100 yards. On physician examination he demonstrated flexion to 90 degrees or greater and extension to zero degrees. Pain was noted on flexion and extension, with passive motion, with weight bearing, and with non-weight bearing. The examiner found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time and that pain caused functional loss during a flare ups. The examiner noted that the Veteran did not have additional limitation in range of motion of the knee following repetitive use testing or functional loss or functional impairment of the knee. The examiner noted that the Veteran's left knee had additional contributing factors of disability, namely, disturbance of locomotion, interference with sitting, and interference with standing. There was infrapatellar and lateral joint tenderness. Muscle strength testing was normal, and there was no atrophy. There was no ankle instability, ankylosis, or any additional conditions. Initially, the Board finds that the January 9, 2014 clinical findings of Dr. Hitchcock with respect to the Veteran's left knee disability are highly inconsistent with the other evidence of record to include VA examinations in March 2012 and June 2017 as well as a January 30, 2014, VA treatment record in which the VA physiatrist notes that on physical examination, the Veteran had normal strength, normal range of motion of bilateral upper and lower extremities in all muscle groups. The private physician's indication that the Veteran was only able achieve flexion to 43 degrees with pain at 38 degrees and extension to 42 degrees with pain at 26 degrees, and lateral instability with the lateral collateral ligament stress test causes the Board to question the accuracy of the findings. The private physician's range of measurements were less than half what the Veteran's worst range of motion measurements have been during VA treatment and on VA examination. Thus, the Board finds that the inconsistencies in the findings recorded by the private clinician in her evaluation report in January 2014 especially in light of normal findings in that same month, renders the findings contained therein unreliable and thus inadequate for evaluation purposes. The Board, thus, does not find that an evaluation higher than 10 percent is warranted or that separate compensable rating are warranted for the Veteran's left knee disability, as there is no objective evidence of instability, much less evidence of moderate instability. In addition, there is no competent evidence of left knee limitation of motion to a compensable level. At the March 2012 VA examination, testing for anterior instability, posterior instability, and medial-lateral instability were normal; there was no evidence or history of recurrent patellar subluxation/dislocations, and the Veteran demonstrated normal range of motion. At the June 2017 VA examination, testing for anterior instability, posterior instability, medial instability, and lateral instability were normal; there was no evidence or history of recurrent patellar subluxation/dislocations; and flexion was limited to 90 degrees and full extension. Furthermore, with respect to the Veteran's pain, the objective findings did not show that pain actually limited his left knee to such an extent as to satisfy the criteria provided for a compensable rating for either limitation of flexion or limitation of extension under Diagnostic Codes 5260 or 5261. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The March 2012 and June 2017 VA examiners noted that the Veteran did not have additional limitation in range of motion of the knee following repetitive use testing. The March 2012 VA examiner noted that the Veteran did not have any functional loss and/or functional impairment of the knee and lower leg. The June 2017 VA examiner noted that there was pain noted on examination but that it did not result in or cause functional loss and that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The June 2017 VA examiner noted that the examination was being conducted during a flare-up and that pain caused functional loss. Therefore, even considering the Veteran's right knee pain, he would not meet the criteria for a higher (or even a compensable) rating under Diagnostic Codes 5260 and 5261. Finally, at no time during the appeal period has there been ankylosis of knee, dislocated semilunar cartilage, or impairment of the tibia and fibula warranting a higher rating under Diagnostic Codes 5256, 5258, or 5262. For the foregoing reasons, entitlement to an initial evaluation higher than 10 percent is not warranted for the Veteran's service-connected left knee strain with retro patellar pain syndrome. TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). If, however, there is only one such disability, it shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran is in receipt of entitlement to service connection for PTSD rated 70 percent disabling, chronic headache disorder rated 30 percent disabling, right shoulder impingement syndrome rated 20 percent disabling, left knee strain and retro patellar pain syndrome rated 10 percent disabling, left hip strain rated 10 percent disabling, left ankle strain/sprain rated 10 percent disabling, tinnitus rated 10 percent disabling, and bilateral sensorineural hearing loss rated zero percent disabling. The Veteran has had a combined rating of 90 percent. He is, thus, eligible for consideration for a TDIU on a schedular basis. VA's General Counsel has concluded that the controlling VA regulations generally provide that Veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2,317 (1992). For a Veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other Veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the particular Veteran is capable of performing the physical and mental acts required by employment, not whether that Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In discussing the unemployability criteria, the Court, in Moore v. Derwinski, 1 Vet. App. 83 (1991), indicated in essence that the unemployability question, i.e., the ability or inability to engage in substantial gainful activity, must be looked at in a practical manner, and that the thrust of the inquiry was whether a particular job was realistically within the capabilities, both physical and mental, of the Veteran involved. As noted above, in his February 2014 letter, Dr. Mangold stated that the Veteran's PTSD prevented him from securing or maintaining a substantially gainful occupation since September 2011. At that time, Dr. Mangold noted that the Veteran experienced symptoms of suicidal ideation, nearly-continuous panic and/or depression, intrusive recollections, nightmares, social isolation, and impaired impulse control which impose severe limitations of functioning such as unprovoked irritability with periods of violence, neglect of personal appearance and hygiene, and difficulty in adapting to stressful circumstances. In January 2014, Dr. Hitchcock stated, [The Veteran] is unable to work and has not been able to sustain a substantially gainful occupation since September of 2011 when he last worked. It is my opinion that his service-connected left knee condition inhibits him from being able to perform even sedentary work because he is unable to sit for prolonged periods in order to do a desk job due to chronic knee pain instability locking and popping. He is also unable to walk or stand for prolonged periods due to his left knee impairment. His left ankle and left hip conditions also contribute to and inhibit his ability to maintain any kind of sedentary work due to the negative impact on his ability to sit, stand, and walk for prolonged periods. ... Furthermore, the severity and frequency of the migraine headaches have not been able to be controlled with any therapy the veteran has tried so far. He is unable to concentrate or focus when he has these unpredictable headaches. In my opinion, while he is afflicted with a migraine, it would be impossible for him to sit and concentrate in order to work and perform any tasks on a sustained basis even simple tasks. Because the migraines are so unpredictable and occur several times per week, he would not be able to reliably perform any sort of work activity. In sum the severity of his migraines starting in 2012 have been very frequent, completely prostrating, and meets the criteria for prolonged attacks productive of severe economic inadaptability. The migraines alone are completely disabling in and of themselves. The April 2014 VA examiner found that the Veteran's service-connected PTSD was productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. That examiner noted that in addition to PTSD, the Veteran also had a diagnosis of an other specified bipolar disorder manifested by intermittent hypomanic periods and recurrent major depressive episodes but that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder. The record includes a July 2014 Social Security Administration (SSA) decision in which the Administrative Law Judge (ALJ) found that the Veteran had been disabled since September 26, 2011. The ALJ found that the Veteran had the following severe impairments: history of seizure disorder, degenerative joint disease of the left knee, chronic left hip and ankle pain, status post right thumb amputation, PTSD, and bipolar disorder. The ALJ found that the Veteran had the residual functional capacity to perform light work with limitations and that the Veteran must never climb and was limited to no more than frequent handing and fingering with his right hand secondary to the loss of his right thumb. The ALJ also found that the Veteran was further limited to performing only simple and routine work tasks with no exposure to the public and only occasional collaboration with coworkers or supervisors. The ALJ found that the Veteran must work in an environment with only occasional workplace changes, and he would likely miss two to four days of work each month. The ALJ concluded that the Veteran was unable to sustain unskilled light work on a regular and continuing basis given his lost ability to perform critical decision making and his breakthrough seizure symptoms that occurred every week or so. At the June 2017 VA TBI examination, the Veteran reported that when he worked, his headaches would cause problems with his maintaining concentration. After review of the file, the examiner, a psychiatrist, noted that the Veteran's reports of cognitive impairment were likely related to medication side effects. The examiner noted that the Veteran was on Topamax, a medication that could have cognitive side effects commonly, as well as his mental health condition. The Board notes that the Veteran takes Topamax/Topiramate for both seizures and migraine headaches. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's service-connected disabilities preclude him from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. However, a more detailed discussion of the specific opinions, credentials of the diagnosticians, and circumstances of opinions in this case would not clarify the matter. As such, the Board finds that the competent medical evidence of record, both for and against findings that the Veteran's service connected disorders preclude him from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience is in a state of equipoise. Accordingly, reasonable doubt is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER The appeal is dismissed with respect to the issues of entitlement to an initial compensable evaluation for bilateral hearing loss and entitlement to an initial evaluation in excess of 10 percent for tinnitus. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder is denied. Entitlement to an initial evaluation in excess of 10 percent prior to June 12, 2017, and in excess of 20 percent since June 12, 2017, for right shoulder impingement syndrome is denied. Entitlement to an evaluation in excess of 10 percent for left knee strain with retro patellar pain syndrome is denied. Entitlement to a TDIU is granted subject to the law and regulations governing the payment of monetary benefits. REMAND As noted above, the Board remanded the issues of entitlement to service connection for a chronic sinus disability and for chronic residuals of a TBI for additional development. The Veteran underwent VA examination in June 2017 to determine whether the Veteran had chronic sinusitis related to his active duty service. The examiner noted that there was no evidence of chronic sinusitis based on physical examination or review of the medical records. The examiner stated that the Veteran's symptoms on examination and symptoms listed in VA medical records (diagnosis and treatment) which indicated a diagnosis of allergic rhinitis, not a sinus condition. There is no documentation of the actual examination demonstrate the symptoms of chronic sinusitis that the Veteran did not exhibit; and no x-ray findings. The Veteran also underwent VA examination to determine whether the Veteran had chronic residuals of an in-service TBI. In this case, the credible evidence indicates that the Veteran participated in boxing matches. The examiner, a psychiatrist, opined that the claimed mild TBI was less likely than not incurred in or caused by a head injury in active duty service and based the opinion on no description of a head injury during service where the TBI criteria were met. The Mayo Clinic indicates that a TBI usually results from a violent blow or jolt to the head or body, that TBI can have wide-ranging physical and psychological effects, and that some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later. The Mayo Clinic indicates that signs and symptoms of a mild TBI may include a headache and that some people with traumatic brain injury will develop seizures. The seizures may occur only in the early stages, or years after the injury. In this case, in December 1993, the Veteran underwent VA Gulf War Protocol examination at which time he reported headaches one to three times per week for the past year. In addition, the Veteran has a current seizure disorder. The September 2017 VA examiner noted that the Veteran's headaches are seen to already be service connected as an independent headache disorder. Without more of an explanation as to why the Veteran's headaches were not indications of an in-service TBI, the examiner's statement, "With no evidence of a TBI occurring, residuals from such a condition would not be considered" is not adequate. In addition, the examiner did not address the Veteran's seizures. When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312. As such, it is the Board's opinion that the Veteran be provided additional VA examinations concerning his claimed chronic sinusitis and chronic TBI residuals. With respect to the issues of entitlement to increased ratings for the Veteran's service-connected left hip and left ankle disabilities, the Veteran last underwent VA examinations in March 2012 and April 2014, respectively. As it has been a number of years since the Veteran underwent VA examination for his service-connected left hip and left ankle, the evidence of record is clearly stale. The Court has impressed on VA on many occasions the necessity of obtaining a recent VA examination. See, e.g., Green v. Derwinski, 1 Vet. App. 121, 124 (1991) [the duty to assist includes "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"]. Thus, the Veteran should be scheduled to undergo an appropriate VA examination to determine the current severity of his service-connected left hip and left ankle disabilities. In addition, the 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 and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. As such, pursuant to Correia, adequate VA joints examinations must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Thus, the Veteran should be scheduled to undergo an appropriate VA examination to determine the current severity of his service-connected left hip and left ankle disabilities. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The Veteran should be requested to indicate if he has received any VA or non-VA medical treatment for any sinusitis/rhinitis and/or residuals of TBI and for his service-connected left hip and left ankle disabilities that is not evidenced by the current record. If so, the Veteran should be provided with the necessary authorizations for the release of any treatment records not currently on file. These records should then be obtained and associated with the claims folder. The Veteran should be advised that he may also submit any evidence or further argument relative to the claim at issue. 2. The Veteran should be afforded a VA Ear, Nose, and Throat examination by an appropriate examiner. The examiner is to be provided access to Virtual VA and VBMS and must specify in the report that these records have been reviewed. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests, including sinus x-rays, and studies should be accomplished if needed. The examiner should (1) clearly determine whether or not the Veteran has chronic or recurrent sinusitis or rhinitis, as opposed to isolated acute episodes; and, (2) to identify the onset of etiology of the pathology. This should include a clear statement whether it is at least as likely as not that any current chronic or recurrent sinusitis or rhinitis (if found) had its onset in service or is otherwise related to the Veteran's active duty service, to include in-service sinus findings. The examiner should also provide an opinion as to whether it is at least as likely as not that such disorder is in any way related to (caused or aggravated by) the Veteran's a service-connected disability. 3. The Veteran should be afforded a VA neurologic examination by a physician, preferably with expertise in TBIs. The physician is to be provided access to Virtual VA and VBMS and must specify in the report that these records have been reviewed. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The physician should determine whether it is at least as likely as not that the Veteran suffered a TBI during service. The examiner must take into account and comment on the Veteran's lay statements as well as the buddy statement submitted in January 2015. The examiner must also take into account and comment on the Veteran's headaches both in service and post service as well as the Veteran's seizures which began post service. If the physician determines that it is at least as likely as not that the Veteran suffered a TBI during service, the physician should identify all current chronic residuals of the in-service TBI. If the physician determines that the Veteran it is less likely that the Veteran suffered a TBI during service, the physician should provide an opinion as to whether it is at least as likely as not that the Veteran's seizure disorder is in any way related to (caused or aggravated by) the Veteran's a service-connected disability. 4. The physician should be informed that service-connection has been established for PTSD, chronic headache disorder, hearing loss, tinnitus, and orthopedic disorders of the right shoulder, left knee, left hip, and left ankle. If aggravation by a service-connected disability is found, then the physicians should quantify the degree of such aggravation beyond the baseline of the disability It would be helpful if the physicians would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 5. The Veteran should be afforded a VA orthopedic-type examination. The examiner is to be provided access to Virtual VA and VBMS and must specify in the report that these records have been reviewed. In accordance with the latest worksheets for rating hip and ankle disabilities, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of his left hip and left ankle disabilities. A complete rationale for any opinions expressed must be provided. With respect to range of motion testing, the left hip and left ankle should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint (pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016)). 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. 6. The Veteran is hereby notified that it is his responsibility to report for the examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. In the event that the Veteran does not report for the aforementioned examinations, documentation should be obtained which shows that notice scheduling the examinations was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 7. After the development requested has been completed, the examination reports should be reviewed to ensure that they are in complete compliance with the directives of this REMAND. If any report is deficient in any manner, corrective procedures should be implemented at once. 8. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran and his attorney should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs