Citation Nr: 20028683 Decision Date: 04/23/20 Archive Date: 04/23/20 DOCKET NO. 14-15 255A DATE: April 23, 2020 ORDER Entitlement to service connection for Other Specified Trauma and Stressor-Related Disorder is granted. Entitlement to service connection for a sinus disorder manifested by recurrent epistaxis, to include as a result of service in Southwest Asia, is denied. Entitlement to service connection for a headache disorder, to include as a result of service in Southwest Asia and/or a service-connected disability, is denied. Entitlement to a rating in excess of 10 percent for a lumbar spine disability is denied. Entitlement to a rating in excess of 10 percent for a left clavicle disability is denied. REMANDED Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s diagnosed Other Specified Trauma and Stressor-Related Disorder, is shown to be etiologically related to service. 2. A chronic sinus disorder manifested by recurrent epistaxis was not manifest during active service and the preponderance of the evidence fails to establish that a present sinus disorder is etiologically related to service, to include as a result of service in Southwest Asia. 3. A chronic headache disorder was not manifest during active service and the preponderance of the evidence fails to establish that a present headache disorder is etiologically related to service, to include as a result of service in Southwest Asia and/or a service-connected disability. 4. Even in consideration of his complaints of pain and functional loss, the Veteran’s service-connected lumbar spine disability is manifested by no worse than forward flexion of the thoracolumbar spine to 60 degrees or greater. 5. Even in consideration of his complaints of pain and functional loss, the Veteran’s service-connected left clavicle disability is manifested by no worse than malunion of a minor extremity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for other specified trauma and stressor-Related disorder have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to service connection for a sinus disorder manifested by recurrent epistaxis, to include as a result of service in Southwest Asia, have not been met. 38 U.S.C. §§ 1110, 1117; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for entitlement to service connection for a headache disorder, to include as a result of service in Southwest Asia and/or a service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317. 4. The criteria for entitlement to a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 5. The criteria for entitlement to a rating in excess of 10 percent for a left clavicle disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5203. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from January 2008 to June 2010. He had service in Southwest Asia from September 2009 to May 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in July 2011 and September 2012 by the Montgomery, Alabama, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2015, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The case was remanded for additional development in April 2018. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The term “disability” for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). VA regulations provide that service connection for posttraumatic stress disorder (PTSD) requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). During the course of this appeal VA revised its regulations to reflect that mental disorder diagnoses are based upon the criteria provided in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association. 38 C.F.R. § 4.125(a). VA regulations provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability became manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). The Veteran in this case is shown to have served in Southwest Asia and these regulations are applicable to his claim. The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstrations of laboratory abnormalities. Chronic multisymptom illness of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Signs or symptoms involving skin, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurologic signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the respiratory system (upper or lower), (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 (Aug. 3, 1998). “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006); see also Gutierrez v. Principi, 19 Vet. App. 1, 10 (2004) (a Persian Gulf War veteran’s symptoms “cannot be related to any known clinical diagnosis for compensation to be awarded under section 1117”). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). VA can consider bias in lay evidence and conflicting statements of the claimant in weighing credibility. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim. See Brammer v. Brown, 3 Vet. App. 223 (1992). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. 1. Entitlement to service connection for an acquired psychiatric disorder. The Veteran contends that he has an acquired psychiatric disorder as a result of active service. At his October 2015 hearing he reported having experienced a mental break during service and having first received treatment at a VA facility in 2011. He asserted that he developed PTSD due to stressor events during service in Iraq, including when his vehicle was hit by a directional fragment after their convoy was hit by an improvised explosive device (IED). He stated he had a general fear of hostile or enemy terrorist activity while he was deployed. Service treatment records dated in November 2008 noted the Veteran reported symptoms including depression and emotional lability. A December 2008 report noted a diagnosis of adjustment disorder with mixed emotional features - resolved. A March 2010 behavioral health evaluation associated with consideration for a misconduct discharge found no Axis I diagnosis at that time. A March 2010 separation examination revealed a normal clinical psychiatric evaluation. In his March 2010 report of medical history, the Veteran denied having or having ever had depression or excessive worry. VA treatment records include a February 2011 report noting the Veteran stated he had been seen and briefly treated for attention deficit hyperactivity disorder as a child associated with his parent’s divorce. He described having been in an altercation with his platoon sergeant during service in Iraq and having been punished and housed with a Ugandan base security guard unit. He reported he had feared the Ugandans and the Iraqis near whom he was assigned. He described having been present during a rocket attack and having been fearful for his life. A diagnosis of PTSD was provided. Subsequent reports noted a history of PTSD. VA examination in June 2011 included a diagnosis of anxiety disorder, not otherwise specified, (features of PTSD). The examiner noted the Veteran met the diagnostic stress of criterion and that his PTSD stressor was considered to be at least partially related to combat experience/fear of hostile military activity. It was noted, however, that service treatment records indicated pre-combat mental health problems and pre-military mental health treatment. The examiner reported that it could not be stated without resort to mere speculation the extent to which combat experiences exacerbated the likely pre-existing mental health issues. It was further noted that substance abuse that began prior to service appeared to have contributed to psychosocial functional impairment over time. VA examination in June 2019 included diagnoses of unspecified depressive disorder and other specified trauma and stressor-related disorder. The examiner found the Veteran’s symptoms did not met the DSM-5 diagnostic criteria for PTSD, but that his other specified trauma and stressor-related disorder manifested by significant emotional and behavioral symptoms was most likely caused by or related to his fear of hostile military or terrorist active during active service in Iraq. It was noted his depressive disorder was multifactorial and was less likely caused by or related to his military service. Based upon the evidence of record, the Board finds an acquired psychiatric disorder, other specified trauma and stressor-related disorder, is etiologically related to service. The Veteran’s service in Iraq is verified and his reported fear of hostile military or terrorist activity is found to be consistent with the circumstances of his service. The June 2019 VA examiner’s opinion is persuasive. Therefore, entitlement to service connection for Other Specified Trauma and Stressor-Related Disorder is granted. 2. Entitlement to service connection for a sinus disorder manifested by recurrent epistaxis, to include as a result of service in Southwest Asia. 3. Entitlement to service connection for a headache disorder, to include as a result of service in Southwest Asia and/or a service-connected disability. The Veteran contends that he has a sinus disorder manifested by recurrent epistaxis (nose bleeds) and a headache disorder as a result of active service. At his October 2015 hearing he reported that he had experienced headaches before the incident when his convoy was hit by an IED. He added that a VA doctor had indicated his headaches and nose bleeds could be related to scarring of his septum and sinuses due to environmental exposures such as sandstorms and dust in the air. Service treatment records are negative for treatment or diagnosis of a sinus or headache disorder. The Veteran’s March 2010 separation examination revealed a normal clinical evaluation of the head, sinuses, and neurologic system. In his March 2010 report of medical history, the Veteran reported having frequent or severe headaches but denied having or having ever had sinusitis or nose trouble. The examiner noted that he reported having daily frontal headaches that were throbbing and band-like causing nausea and photophobia. They were unrelieved by any treatment. VA examination in June 2011 included diagnoses of tension headaches and recurrent epistaxis associated with sinus scarring. The Veteran reported that he began having spontaneous nosebleeds while in Iraq and that his last episode was approximately one to two months earlier. He denied any history of allergies or sinus infection and stated his doctor told him he had a scar to the septum. The examiner noted that tension headaches was a diagnosable illness with stress being the most common etiology and that recurrent epistaxis was a diagnosable illness with an etiology that may be due to dry nasal mucosa or sinus problems. There was no history of nasal injury or tumor. An X-ray study of the paranasal sinuses was normal. An additional VA examination was conducted in June 2019. The Veteran reported having nose bleeds three times per year from dryness and using an over-the-counter nasal spray. The examiner summarized the Veteran’s claims and the pertinent treatment reports of record. It was noted that he was treated for headaches and acute sinusitis in February 2011 and acute sinus infection with sinus headache in 2015. X-ray studies of the sinuses were noted to have been normal in 2011 and in June 2019. An examination revealed the sinuses and nose were normal with no epistaxis. It was the examiner’s opinion that the Veteran had no chronic sinus condition with epistaxis and that no chronic headache disorder was shown by the available treatment records. His headaches during acute sinus episodes did not warrant a present headache diagnosis and he had no chronic headache disorder per medical records. The examiner stated that opinions as to a relationship to service in Southwest Asia or a service-connected disability were not indicated due to lack of disease or condition. Based upon the evidence of record, the Board finds that a chronic sinus disorder manifested by recurrent epistaxis was not shown in service. There is similarly a lack of in-service evidence of a chronic headache disorder. The preponderance of the evidence fails to establish a present disorder is etiologically related to service. As such, entitlement to service connection on a direct basis is denied. See Brammer, 3 Vet. App. 223. The Board further finds that presumptive service connection under the provisions of 38 C.F.R. § 3.317 based upon service in Southwest Asia is not warranted. The Veteran has reported having experienced headaches and nose bleeds during the course of the appeal. However, the evidence fails to establish the presence of a chronic sinus disorder, recurrent epistaxis disorder, or chronic headache disorder due to an undiagnosed illness. The overall evidence of record, including the Veteran’s own statements, indicate any recurrent nose bleeds he has experienced were acute episodes associated with dryness or environmental exposures. There is no indication that his nose bleeds are due to chronic skin signs or symptoms to the nasal passages or to any unhealed scarring. The June 2011 VA examiner attributed his reported headaches to a diagnosis of tension headaches. The June 2019 VA examiner found his headaches were associated with acute sinus episodes. In either instance, the headaches symptoms are related to known clinical diagnoses. Entitlement to service connection compensation may not be established under 38 C.F.R. § 3.317. See Gutierrez, 19 Vet. App. at 10. The June 2019 VA examiner’s opinion is found to be persuasive. The examiner is shown to have reviewed the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Although the June 2011 examiner included diagnoses of tension headaches and recurrent epistaxis associated with sinus scarring, the June 2019 examiner’s opinion is found to be of greater probative weight as to the lack of chronic disability or pertinent chronic signs or symptoms based upon the review of a more extensive medical record. The June 2019 examiner is shown to have noted the Veteran’s reports as to symptom manifestations, but to have concluded that the overall record did not warrant a diagnosis of a chronic sinus condition with epistaxis or headache disability. Consideration has also been given to the Veteran’s personal assertion that he has chronic sinus and headache disorders as a result of active service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disabilities at issue are not conditions that are readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In conclusion, the Board finds service connection for a sinus disorder manifested by recurrent epistaxis and a headache disorder is not warranted. When all the evidence is assembled VA is then 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. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the Veteran’s claims. Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran’s disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. 4. Entitlement to a rating in excess of 10 percent for a lumbar spine disability. Disabilities of the spine, including for Diagnostic Code 5237, are rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. A 100 percent rating is provided for unfavorable ankylosis of the entire spine. A 50 percent rating is provided for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is provided for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is provided 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 10 percent rating is provided for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. When rating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. Normal combined range of motion of the thoracolumbar spine is 240 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note 2. The rating criteria for intervertebral disc syndrome (IVDS) require rating of the disability either on the total duration of incapacitating episodes resulting from intervertebral disc syndrome over the past 12 months, or by combining under 38 C.F.R. § 4.25 separate ratings of its chronic orthopedic and neurologic manifestations with rating for all other disabilities, whichever method results in the higher rating. A 20 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of least four weeks but less than six weeks during the past 12 months. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The regulations also provide for separate ratings for chronic orthopedic and neurological manifestations of intervertebral disc syndrome. Incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, moderate degree. 38 C.F.R. § 4.124a. Traumatic arthritis is rated pursuant to the criteria found in Diagnostic Code 5010, which directs that evaluations are to be made pursuant to the criteria for degenerative arthritis found in Diagnostic Code 5003. 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note (1). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id. Such evidence may include facial expression, such as wincing, muscle spasm, and crepitation. See 38 C.F.R. § 4.59. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). An adequate orthopedic examination should record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing, address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. See Correia v. McDonald, 28 Vet. App. 158 (2016). An examination does not need to be conducted during an actual flare-up in order to account for additional functional impairment. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Instead, examiners are asked to estimate the functional impairment experienced during a flare-up, considering all competent evidence of functional loss that is available in the record. Id. The Veteran contends that his service-connected lumbar spine disability is more severely disabling than reflected by the present evaluation. At his October 2015 hearing he reported having chronic lower back pain that affected his legs and prohibited prolonged standing and sitting. He stated he was unable to sit in certain positions and that his back occasionally locked up. He estimated that pain limited his forward flexion to about 30 degrees. He described having daily pain and weakness to the lower extremities. VA examination in September 2010 included a diagnosis of low back strain. The examiner noted there was objective evidence of tenderness and pain on motion, but that it was not severe enough to cause abnormal gait or abnormal spinal contour. Active range of motion studies revealed flexion to 90 degrees, extension to 0 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees, left lateral rotation to 30 degrees, and right lateral rotation to 30 degrees. There was objective evidence of pain on active motion and following repetitive motion without additional limitation after three repetitions of range of motion. Reflex examination findings were normal to the lower extremities. Motor examination findings were 5/5 to the lower extremities. Muscle tone was normal and there was no evidence of muscle atrophy. X-ray studies revealed no significant degenerative changes. VA examination in June 2011 included a diagnosis of lumbar spine strain. The examiner noted there were no abnormalities of the spinal muscles, such as guarding, spasm, or tenderness, and no evidence of ankylosis. Straight leg raise testing was negative. Thoracolumbar spine range of motion studies revealed active motion with flexion to 90 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees, left lateral rotation to 30 degrees, and right lateral rotation to 30 degrees. There was objective evidence of pain on active motion and following repetitive motion without additional limitation after three repetitions of range of motion. Reflex examination findings were normal to the lower extremities. Motor examination findings were 5/5 to the lower extremities. Muscle tone was normal and there was no evidence of muscle atrophy. VA examination in July 2012 included a diagnosis of lumbar strain. It was noted the Veteran complained of chronic daily low back pain that was worse at night and with prolonged sitting, walking, or standing. He described having intermittent pain down the legs, bilaterally, with numbness and tingling. He stated he had experienced two flare-ups of increased pain over the past year when he initially could not move with gradual improvement over one to two weeks. Range of motion studies revealed forward flexion to 70 degrees with objective evidence of pain at that point, extension to 30 degrees with no objective evidence of pain, right lateral flexion to 25 degrees with objective evidence of pain at that point, left lateral flexion to 25 degrees with objective evidence of pain at that point, right lateral rotation to 25 degrees with objective evidence of pain at that point, and left lateral rotation to 25 degrees with objective evidence of pain at that point. Motion was unchanged after repetitive-use testing. There was functional loss or functional impairment due to less movement than normal and pain on movement. There was no evidence of localized tenderness, pain on palpation, guarding, or spasm to the thoracolumbar spine. Muscle strength was normal to the lower extremities with no evidence of muscle atrophy. Reflexes and sensation were normal to the lower extremities. There were signs or symptoms of radiculopathy to the lower extremities, bilaterally, with mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. The examiner stated that no specific nerve was affected in the right or left lower extremity and that there were no other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome (IVDS) and did not use any assistive devices as a normal mode of locomotion. It was noted imaging studies did not document arthritis. The thoracolumbar spine condition would impact his ability to perform physical labor due to pain on bending and lifting but not for sedentary labor. VA examination in June 2019 included a diagnosis of lumbosacral strain. It was noted the Veteran complained of constant low back pain with intermittent spasms and occasional sharp pain. He stated he wore a low back brace in the mornings when he experienced the most pain. He described having flares of pain a couple of times per years if he twisted the wrong way and that very rarely, once per year, he had shooting pain down the legs with numbness. Range of motion studies revealed forward flexion to 80 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Range of motion itself did not contribute to a functional loss and there was no evidence of pain on weight bearing. There was no objective evidence of localized tenderness, pain on palpation, or additional loss of function or range of motion after repetitive-use testing. The examiner noted the examination was not conducted during a flare-up and that it was neither medically consistent nor inconsistent with the Veteran’s reported functional loss during flare-ups. There was no evidence of guarding or muscle spasm to the thoracolumbar spine. Muscle strength was normal to the lower extremities with no evidence of muscle atrophy. Reflexes and sensation were normal to the lower extremities. There were signs or symptoms of radiculopathy to the lower extremities, bilaterally, with mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. The examiner stated that the right and left lower extremities were not affected by radiculopathy. There was no evidence of ankylosis or other neurologic abnormalities. The Veteran did not have IVDS. It was noted he used a back brace occasionally. It was noted imaging studies did not document arthritis. X-ray studies revealed no significant/acute bony abnormality. The thoracolumbar spine condition would impact his ability to work with lifting of weight limited to no more than 35 pounds. Based upon the evidence of record, the Board finds the Veteran’s service-connected lumbar spine disability is manifested by no worse than forward flexion of the thoracolumbar spine to 60 degrees or greater. The overall evidence of records does not demonstrate combined range of motion of the thoracolumbar spine of 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Nor is there any evidence of ankylosis of the thoracolumbar spine or incapacitating episodes of IVDS. Therefore, the claim for a rating in excess of 10 percent for lumbar spine disability must be denied. The Board notes that an adequate discussion of functional loss includes consideration of manifest functional loss during flare-ups. Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38 C.F.R. § 3.344(a) and 38 C.F.R. § 4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given to the Veteran’s reports at his July 2012 VA examination that he had experienced two flare-ups of increased pain over the past year and in June 2019 that he had flares of pain a couple of times per years if he twisted the wrong way and that very rarely, once per year, he had shooting pain down the legs with numbness. Such would not warrant a higher evaluation. The reported flare-ups are not shown to additionally limit function in a quantifiable way and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. The June 2019 VA examiner found the examination was neither medically consistent nor inconsistent with the Veteran’s reported functional loss during flare-ups. In sum, the Board finds the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. Here, the reports of exacerbation or flare-ups are not quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38 C.F.R. § 3.344(a) regarding stabilization of ratings. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability has been provided by VA medical professionals who have examined him. The Board accords the available VA medical findings of record greater weight than the Veteran’s complaints as to symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). 5. Entitlement to a rating in excess of 10 percent for a left clavicle disability. VA regulations provide ratings for impairment of the clavicle or scapula with dislocation (20 percent, major; 20 percent, minor), with nonunion and loose movement (20 percent, major; 20 percent, minor), and nonunion without loose movement (10 percent, major; 10 percent, minor), or with malunion (10 percent, major; 10 percent, minor). The impairment is otherwise to be rated on impairment of a contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203. The Veteran contends that his service-connected left clavicle disability is more severely disabling than reflected by the present evaluation. In statements provided in support of his claim he asserted that he experienced difficulty maintaining employment because his back locked up. At his October 2015 hearing he reported experiencing chronic pain and weakness with pain that traveled down from his collar bone through the shoulder to his elbow. VA examination in September 2010 included a diagnosis of left clavicle fracture. The examiner noted left shoulder active range of motion with flexion to 180 degrees, abduction to 180 degrees, internal rotation to 90 degrees, and external rotation to 90 degrees. There was no objective evidence of pain on active motion or following repetitive motion without additional limitation after three repetitions of range of motion. Flare ups were denied. X-ray studies revealed a healed deformity of the mid left clavicle. VA examination in June 2011 included a diagnosis of closed fracture of the left clavicle with residual deformity. It was noted the Veteran complained of chronic daily pain in the area of a protuberant callus formation. He stated there was pain and deformity to the mid left clavicle but that the condition did not affect the motion of a joint. The examiner noted there was evidence of deformity and angulation with malunion at mid clavicle. There was no evidence of nonunion. X-ray study revealed a chronic, persistent mid clavicular fracture with stable bayonet apposition configuration. The examiner found there were no significant effects to occupation or usual daily activities. Flare ups were denied. VA treatment records noted a history of nonunion clavicle fracture with a date of diagnosis in November 2015. No rationale for the diagnosis was provided. VA examination in June 2019 included a diagnosis of left clavicle fracture. It was noted the Veteran reported that he was unable to pick up things weighing between 50 to 75 pounds. He denied any flare-ups. Range of motion studies of the left shoulder were normal. The examiner noted there was pain on flexion and abduction that did not result in or cause functional loss. There was no objective evidence of localized tenderness, pain on palpation, crepitus, or additional functional loss or range of motion after repetitive-use testing. Muscle strength was normal to the left shoulder with no evidence of muscle atrophy. Hawkins’ impingement, empty-can, external rotation/infraspinatus strength, and lift-off subscapularis tests were negative. Shoulder instability, dislocation, or labral pathology were not suspected. There was malunion to the left clavicle, but it did not affect range of motion of the shoulder. There was no tenderness on palpation of the acromioclavicular joint. A cross-body adduction test was negative. It was noted imaging studies did not document arthritis. X-ray studies revealed a healed deformity of the mid left clavicle. The condition would impact his ability to work with lifting of weight limited to 50 to 75 pounds. Based upon the evidence of record, the Board finds the Veteran’s service-connected left clavicle disability is manifested by no worse than malunion of a minor extremity. The overall evidence of record and VA examination findings are persuasive. It is noted that VA examinations in September 2010, June 2011, and June 2019 indicated symptom flare-ups were denied. The assigned disability rating is considered adequate to compensate for any loss of working time from exacerbations or illness. The Board accords the available VA medical findings of record greater weight than the Veteran’s complaints as to symptomatology. Therefore, the claim for a rating in excess of 10 percent must be denied. REASONS FOR REMAND 1. Entitlement to a TDIU is remanded. The Veteran contends that he is unemployable due to his service-connected disabilities. VA records show that a combined schedular disability of 20 percent is currently assigned for service-connected lumbar spine and left clavicle disabilities. As noted above, service connection is warranted for Other Specified Trauma and Stressor-Related Disorder. As an initial evaluation for this matter must first be addressed by the Agency of Original Jurisdiction (AOJ), the TDIU issue is be deferred. The matters are REMANDED for the following action: After completion of the action to implement the Board’s decision granting service connection for Other Specified Trauma and Stressor-Related Disorder, the AOJ must readjudicate the TDIU issue on appeal. If the benefit sought is not granted to the Veteran’s satisfaction, send him and his agent a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Douglas The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.