Citation Nr: 21061578 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 15-16 726 DATE: October 4, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, including unspecified trauma- and stressor-related disorder, is granted. Entitlement to compensation pursuant to 38 C.F.R. § 1151 for residuals of surgery for a deviated nasal septum is denied. Entitlement to a compensable disability rating prior to February 25, 2020 and in excess of 10 percent thereafter for bilateral hearing loss is denied. Entitlement to a 40 percent disability rating, but no higher, for a lumbosacral strain is granted. Entitlement to a disability rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the left hip is denied. Entitlement to a disability rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the right hip is denied. Entitlement to a compensable disability rating for limitation of flexion associated with trochanteric bursitis of the left hip is denied. Entitlement to a compensable disability rating for limitation of flexion associated with trochanteric bursitis of the right hip is denied. REMANDED Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. Entitlement to service connection for a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation (SMC), including based on the need for aid and attendance, is remanded. FINDINGS OF FACT 1. The evidence establishes that the Veteran has an acquired psychiatric disorder, including unspecified trauma- and stressor-related disorder, that is etiologically related to service. 2. The evidence does not establish that the Veteran has a disability caused by the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical care. 3. Prior to February 25, 2020, the Veteran exhibited Level I hearing in the right ear and Level IV hearing in the left ear. 4. From February 25, 2020, the Veteran exhibited Level II hearing in the right ear and Level V hearing in the left ear. 5. There is sufficient indication of a long-term demonstrated loss of mobility of the thoracolumbar spine, when factoring in functional loss as applicable VA law requires, to establish forward flexion of 30 degrees or less. 6. The Veteran is in receipt of the maximum schedular rating permitted for limitation of extension associated with trochanteric bursitis of the left hip. 7. The Veteran is in receipt of the maximum schedular rating permitted for limitation of extension associated with trochanteric bursitis of the right hip. 8. The Veteran's trochanteric bursitis of the left hip did not result in flexion limited to 45 degrees. 9. The Veteran's trochanteric bursitis of the right hip did not result in flexion limited to 45 degrees. CONCLUSIONS OF LAW 1. The criteria for acquired psychiatric disorder, including unspecified trauma- and stressor-related disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.104, 3.105, 3.156(a), 3.303. 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for residuals of surgery for a deviated nasal septum have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.361. 3. The criteria for entitlement to a compensable rating for service-connected bilateral hearing loss prior to February 25, 2020 and in excess of 10 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for a 40 percent disability rating for lumbosacral strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 5. The criteria for a rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251. 6. The criteria for a rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5251. 7. The criteria for a compensable disability rating for limitation of flexion associated with trochanteric bursitis of the left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252. 8. The criteria for a compensable disability rating for limitation of flexion associated with trochanteric bursitis of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Army from January 1968 to December 1971. This case was most recently before the Board in March 2019, at which time the issues on appeal were remanded for additional development. The case has since returned to the Board for appellate consideration. The Board notes that an August 2020 rating decision granted the Veteran's claim of entitlement to service connection for right ear hearing loss. Therefore, the Board has recharacterized the claim of entitlement to an increased disability rating for left ear hearing loss to encompass both ears (i.e. bilateral hearing loss). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The Board notes that in adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § § 5107 (b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for an acquired psychiatric disorder The Veteran seeks service connection for an acquired psychiatric disability. At the outset, the Board notes that the evidence shows the Veteran has a current acquired psychiatric disability. Specifically, during a February 2020 VA examination, a psychologist diagnosed the Veteran with unspecified trauma- and stressor-related disorder. Therefore, the Board's analysis will focus on whether the Veteran's current disability is related to service. Turning to the evidence, the Board notes that of record is an October 2012 " report of consultation and examination" from Dr. P.Y., a chiropractor, who, among other things, opined that the Veteran had symptoms of posttraumatic stress disorder (PTSD) that included insomnia, sleep deprivation, anxiety, anger, rage, isolation, memory loss, hypervigilance, depression, and memory loss. Dr. P.Y. conceded that he would defer to a mental health specialist's judgment regarding PTSD, but he wrote that he had followed the progress of many PTSD patients under the care of appropriate practitioners such that he could provide a provisional diagnosis of PTSD. He further wrote that given the history and elements of the Veteran's PTSD, it was "far more likely than not" that PTSD was related to military service. Also of record is an October 2012 psychological evaluation report from psychologist W.A., who performed an extensive review of the Veteran's personal history and records. Dr. W.A. described the Veteran's past and current psychiatric symptoms and determined that his symptoms were consistent with the presence of PTSD and depression. Specifically, the Veteran described the reexperiencing, avoidance, and hyperarousal symptoms found in individuals suffering from PTSD. He reported that his PTSD symptoms began just after military service, as estimated by the time frame of onset of his cognitive and physiological responses to trauma cues. His wife reported that his depressive symptoms had been apparent throughout most of his second marriage. Significant depressive symptoms, including anhedonia, were indicated at the time of examination. Dr. W.A. also noted social and work-related functional impairments, significant cognitive difficulties, and difficulties with impulse control. She concluded that the symptoms of PTSD were at least as likely as not service-connected, though she did not explain this conclusion. The Veteran submitted a March 2013 statement in support of his claim in which he attributed his psychiatric symptoms to incidents in service, including one in which he hit his head when jumping out of a plane and ended up in the hospital, and another incident in which he witnessed the death of a fellow servicemember when his parachute failed to open. Service treatment records (STRs) include an undated note documenting an incident in which the Veteran experienced syncope while parachuting. STRs also include a June 1968 notation documenting an incident in which the Veteran vomited before jumping from an aircraft and then didn't remember anything about the jump aside from when he hit the ground entangled in his chute. The Veteran was first afforded a VA examination in July 2013. The examiner diagnosed major depressive disorder related to the Veteran's wife and daughter's health problems. He did not otherwise provide a nexus opinion because PTSD was not diagnosed. The Veteran was afforded another VA examination in February 2020. The examiner diagnosed unspecified trauma- and stressor-related disorder. The examiner noted that the Veteran did not meet the full criteria for PTSD but indicated that his current diagnosis could be considered a sub-threshold PTSD condition. The examiner wrote that the Veteran's unspecified trauma- and stressor-related disorder was not a new diagnosis, but instead was a "longstanding, chronic condition that was at least as likely as not incurred in or caused by his claimed in-service stressors." During the examination, the Veteran reported several stressors, including an incident in which he was rendered unconscious during a parachuting accident and another incident in which he witnessed the death of a fellow soldier who's parachute failed to open, and yet another incident when he witnessed a soldier fall overboard and get "chewed up by the propellers." In an accompanying opinion, the examiner wrote that the Veteran's unspecified trauma- and stressor-related disorder was at least as likely as not incurred in or caused by his in-service events, to include the June 1968 incident in which the Veteran experienced syncope while parachuting, as well as the incident in which he witnessed the death of another soldier who's parachute failed to open during a jump. The examiner again described the Veteran's condition as longstanding and chronic, and he explained that his current symptoms were consistent with the mechanism of injury during service, with report of continued symptoms since that time and without an interval injury. The examiner further wrote that the Veteran's claimed depressive condition was a symptom of his unspecified trauma- and stressor-related disorder. VA treatment records show the Veteran has a history of depression and has been prescribed medication to treat depression during the period on appeal. He was diagnosed with major depressive disorder and panic disorder without agoraphobia following an October 2013 psychology consultation. In December 2013, the Veteran was diagnosed with depressive disorder secondary to "generalized medical condition." However, more recent depression and PTSD screens have been negative for either condition. Overall, after careful review of the record, the Board concludes that the weight of the evidence shows that the Veteran has a current acquired psychiatric disabilityspecifically, unspecified trauma- and stressor-related disorderthat is etiologically related to service. The Veteran is competent to report the circumstances of his in-service stressor, as well as the onset of his psychiatric symptoms, and his reports are generally corroborated by the objective evidence of record, including STRs and psychiatric examination reports. Private psychologist W.A. and the February 2020 VA examiner, also a psychologist, both determined, after review of the evidence and interview with the Veteran, that the Veteran's psychiatric symptoms were at least as likely as not incurred in or caused by his in-service stressors. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disability, including unspecified trauma- and stressor-related disorder, is warranted given the evidence of a current disability and evidence showing a connection between his current disability and in-service stressors. Therefore, service connection is warranted. 2. Entitlement to compensation pursuant to 38 C.F.R. § 1151 for residuals of a deviated nasal septum A Veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C. § 1701 (3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. To establish causation, the evidence must show that the hospital care, medical or surgical treatment or examination resulted in the Veteran's additional disability or death. Merely showing that a Veteran received care, treatment or examination and that the Veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361 (c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuation or natural progress. 38 C.F.R. § 3.361 (c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. 38 C.F.R. § 3.361 (d)(1). Consent may be express or implied as set forth in 38 C.F.R. § 17.32 (b). In this case, the Veteran contends that he is entitled to compensation under U.S.C. § 1151 for residuals of surgery he underwent for a deviated nasal septum. Specifically, he asserts that the surgery was performed without his consent. In support of his claim, he submitted an October 2012 report by Dr. P.Y., a chiropractor, who wrote that the Veteran had chronic rhinitis, disfigurement of the nose itself, frequent nasal and sinus infections, and pain of the nose as a result of the "improper surgery" performed during a stay at the VA hospital in Miami in 1980. Turning to the evidence, the Board notes that VA treatment records show that the Veteran complained of chronic nasal obstruction on the right side in April 1988. He was found to have a nasal deviated septum to the right, as well as a bulbous tip. Surgery was indicated, and of record is an April 1988 form showing he consented to septorhinoplasty to repair the inside and outside of his nose. No complications were noted as a result of the surgery In November 2013, a VA examiner completed a review of the records and provided an opinion concerning the Veteran's claim. The examiner noted that VA treatment records showed the Veteran presented to the ear, nose, and throat (ENT) clinic in March 1988 due to recurrent ear infections. At that time, a full ENT evaluation was performed which clearly identified and documented ENT disease with nasal septal deviation and increased size of the nasal turbinates. The examiner noted that records also documented an already existing deformity of the nose, and that the Veteran reported a history of both nasal trauma and nasal obstruction. Surgery to correct the septal deviation was indicated from the presence of nasal obstruction with chronic ear infections; in this regard, the examiner explained that the eustachian tube, which connects the middle ear to the nasal cavity, can become chronically blocked from nasal obstruction, causing the ear infection to be chronic and difficult to treat. The examiner noted that, despite Dr. P.Y.'s assertion that the Veteran awoke after his septoplasty "shocked to find that his ears were not touched" and surprised to find that he had had sinus surgery, there was "clear documentation" that there were clear and documented examination findings of septal deviation and nasal obstruction; there was clear documentation of external nasal deformity prior to the surgery; and the Veteran clearly consented to the surgery, which was listed as septoplasty with possible turbinate resection, appropriately described in layman's terms on the consent form as "repair of the inside and outside of the nose," and the consent was appropriately witnessed. The examiner therefore determined that there was no evidence of wrongful surgery, inappropriate surgery, inappropriate medical care or disability resulting from the surgery which did not pre-exist the surgery. The examiner further concluded that there was no additional disability as a result of the surgery documented or present in the objective medical records. Indeed, review of VA treatment records from the period on appeal does not show that the Veteran has complained of or been diagnosed with chronic rhinitis, disfigurement of the nose, frequent nasal and sinus infections, or pain of the nose. Overall, after careful review of the evidence of record, the Board finds that compensation pursuant to 38 C.F.R. § 1151 for residuals of a deviated nasal septum is not warranted. First, despite Dr. P.Y.'s notation that the Veteran has chronic rhinitis, disfigurement of the nose itself, frequent nasal and sinus infections, and pain of the nose as a result of the surgery in question, to which the Veteran clearly consented, there is no evidence of such conditions, or any other additional disability related to the surgery, during the period on appeal. Indeed, the November 2013 VA examiner determined, after review of the record, that there was no additional disability as a result of the surgery documented or present in the objective medical records. Even assuming that the Veteran meets the threshold criteria of a current disability, the evidence does not show carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. Therefore, his claim must be denied. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. 3. Entitlement to increased disability ratings for bilateral hearing loss The Veteran seeks increased ratings for his service-connected bilateral hearing loss, currently assigned a noncompensable (0 percent) rating prior to February 25, 2020 and a 10 percent rating thereafter. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86 (a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86 (b). The Veteran was afforded a VA examination in connection with his claim in August 2013. The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 30 30 50 55 41 98 LEFT 45 60 70 65 60 80 Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level IV in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level IV for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Veteran was afforded another VA examination in February 2020. The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 50 55 60 51 84 LEFT 70 75 75 80 75 76 Applying the results to Table VI, the findings yield a numeric designation of Level II in the right ear and Level V in the left ear. Entering the resulting bilateral numeric designation of Level II for the right ear and Level V for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 10 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was shown in the left ear. Applying the results to Table VIA yields Level VI in the left ear. Entering the resulting bilateral numeric designation of Level II for the right ear and Level VI for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 10 percent disability rating under Diagnostic Code 6100. Here, application of Tables VI and VIA yield the same disability rating. Based on the evidence above, increased ratings for the Veteran's bilateral hearing loss are not warranted. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran's reports that he has difficulty hearing his wife, and also that he needs to watch a person speaking slowly to be able to hear them. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable disability rating prior to February 25, 2020 and in excess of 10 percent thereafter for bilateral hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a disability rating in excess of 20 percent for a lumbosacral strain The Veteran seeks a higher rating for his service-connected lumbar spine disability, for which he has been in receipt of a 20 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5237 for the entire period on appeal. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore not be reflected on range of motion testing. 38 C.F.R. § 4.45 requires that consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Turning to the evidence, the Board observes that the Veteran was afforded a VA back conditions examination in connection with his claim in August 2013. He reported back pain on a daily basis, with pain in the lumbosacral area and associated stiffness. He reported that pain was aggravated by prolonged standing and sitting, and that he could not tolerate walking more than 100 feet. He reported flare-ups impacting the function of the lumbar spine, and described the impact as limiting walking and requiring him to take frequent breaks when sitting at his desk. Initial range of motion testing revealed forward flexion to 40 degrees, with objective evidence of painful motion beginning at 30 degrees; and extension to 10 degrees, with objective evidence of painful motion beginning at 5 degrees. The Veteran was able to perform repetitive use testing with three repetitions, after which range of motion testing showed forward flexion to 40 degrees and extension to 10 degrees. The examiner indicated that the Veteran had functional loss, functional impairment, and/or additional limitation of range of motion of the lumbar spine after repetitive use, with contributing factors of less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. The Veteran had localized tenderness or pain to palpation at the lumbosacral junction. The examiner also indicated that the Veteran had guarding or muscle spasm of the lumbar spine that did not result in abnormal gait or spinal contour. The examiner found that the Veteran's lumbar spine condition impacted his ability to work in that the Veteran required frequent breaks due to his inability to sit for long periods of time. The examiner noted that the Veteran reported additional limitations in all planes of range of motion due to flares, but he did not specify how much. Nevertheless, the examiner wrote that limitations were due to pain and not weakness, fatigue, or incoordination. The Veteran was afforded another VA back conditions examination in connection with his claim in March 2020. He reported that his lumbar spine condition had worsened since onset, with current symptoms of stiffness, throbbing pain, and numbness/tingling in both lower extremities. He reported taking ibuprofen to treat his pain. He reported flare-ups involving symptoms of stiffness, throbbing pain, and numbness/tingling in both lower extremities. He reported functional impairment when sitting for long periods of time. Initial range of motion testing showed forward flexion to 45 degrees and extension to 20 degrees, with pain noted on examination of all planes of range of motion causing functional loss, though the examiner did not indicate at which point objective evidence of pain set in. There was objective evidence of localized tenderness or pain on palpation over the lumbar region to lumbar strain and bilateral lower extremity radiculopathy. There was evidence of pain with weight bearing. The Veteran was able to perform repetitive use testing with three repetitions, with no additional loss of function or range of motion after three repetitions. The Veteran was not examined after repeated use over time or flare-ups, but the examiner noted that pain, weakness, and lack of endurance caused functional loss with both. However, the examiner estimated that range of motion would be the same as initial range of motion. There was no guarding or muscle spasm of the lumbar spine. Additional contributing factors of disability included disturbance of locomotion and interference with sitting. There was no ankylosis of the spine, nor was there intravertebral disc syndrome (IVDS). The examiner indicated that the Veteran required constant use of a cane due to his bilateral hip and lumbar spine disabilities. There was no objective evidence of pain on non-weight bearing, and passive range of motion testing was the same as active range of motion. VA treatment records show the Veteran has been treated for chronic lumbar pain throughout the period on appeal. Multiple treatment notes throughout the period document lumbar pain with any range of motion, but particularly flexion. Lumbar spine range of motion was noted to be decreased by 50 to 75 percent throughout the period. The Veteran was observed to be uncomfortable with lower back pain, ambulating with a cane and an antalgic gait. Overall, after careful review of the record and resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports awarding a 40 percent disability rating for his lumbosacral strain for the entire period on appeal. The July 2013 VA examination showed forward flexion to 40 degrees, but there was objective evidence of painful motion beginning at 30 degrees. VA treatment records from throughout the period on appeal show the Veteran consistently reported near constant back pain, that he appeared uncomfortable with lower back pain, that he walked with an antalgic gait and required constant use of a cane, and that he experienced decreased range of motion in the lumbar spine by as much as 75 percent. The March 2020 VA examination report showed forward flexion to 45 degrees on initial range of motion testing. The Veteran reported experiencing flare-ups of stiffness and throbbing pain, and pain, weakness, and lack of endurance were noted to significantly limit functional ability with flare-ups, but the examiner estimated that forward flexion during a flare up would still be 45 degrees. Nevertheless, the examination report indicates that the Veteran required constant use of a cane due in part to his lumbar spine disability, and that his disability caused functional impairment with activities of daily living such as dressing, eating, and bathing. Having reviewed the foregoing, the Board finds the next higher 40 percent disability rating is warranted for the Veteran's service-connected lumbosacral strain. As indicated during the July 2013 VA examination, the Veteran manifested forward flexion limited to 30 degrees when accounting for pain on use, weakness, and fatigueother forms of recognized functional loss. See DeLuca v. Brown, supra; 38 C.F.R. §§ 4.45, 4.59. Similarly, VA treatment records indicate the Veteran's range of motion was limited by upwards of 75 percent during much of the period on appeal. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria are met to substantiate a 40 percent evaluation for his lumbosacral strain for the entire period on appeal. However, the Board finds that the preponderance of the evidence is against a rating in excess of 40 percent. The Board acknowledges the Veteran's lay reports of symptoms including stiffness; however, the Veteran was consistently found to not have ankylosis on examination, and there is no mention of ankylosis in VA treatment records. Further, the Veteran has not asserted, and the evidence does not show, that he has experienced the functional equivalent of ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Board notes that the Veteran has already been awarded service connection for left and right lower extremity sciatica associated with lumbosacral strain, and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 40 percent for the Veteran's service-connected lumbosacral strain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to a disability rating in excess of 10 percent for limitation of flexion associated with trochanteric bursitis of the right hip 6. Entitlement to a disability rating in excess of 10 percent for limitation of flexion associated with trochanteric bursitis of the left hip 7. Entitlement to a disability rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the right hip 8. Entitlement to a disability rating in excess of 10 percent for limitation of extension associated with trochanteric bursitis of the left hip The Veteran seeks higher ratings for limitation of flexion associated with trochanteric bursitis of the right and left hips, each currently assigned a noncompensable (0 percent) rating under 38 C.F.R. § 4.71a, Diagnostic Code 5252. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. The Veteran also seeks higher ratings for limitation of extension associated with trochanteric bursitis of the right and left hips, each currently assigned a maximum 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5251. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Here, because the Veteran is in receipt of the maximum rating available under Diagnostic Code 5251 (10 percent), he cannot receive a higher rating under that code. Turning to the evidence, the Board notes that the Veteran was afforded a VA examination in connection with his claim in July 2013. The Veteran reported daily hip pain aggravated by prolonged standing and sitting. He reported that he could not tolerate walking more than 100 feet, though he could walk while leaning on a cart during grocery shopping. He reported flare-ups that limited walking and required him to take frequent breaks when sitting at his desk. Initial range of motion measurements showed right hip flexion to 65 degrees, with objective evidence of painful motion beginning at 30 degrees. Right hip extension was to 5 degrees, with objective evidence of painful motion beginning at 5 degrees. Left hip flexion was to 65 degrees, with objective evidence of painful motion beginning at 30 degrees. Left hip extension was to 5 degrees, with objective evidence of painful motion beginning at 5 degrees. Range of motion testing results were the same after repetitive use testing of each leg. There was no ankylosis of either hip joint, and no malunion or nonunion of either femur, flail hip joint, or leg length discrepancy. The Veteran did not require use of any assistive devices. He reported additional limitations of range of motion of both hips in all planes due to flare-ups, but he did not specify how much. Limitations were due to pain and not weakness, fatigue, or incoordination. The Veteran was most recently afforded a VA examination in March 2020. He reported that his bilateral hip disability had worsened since onset and involved current symptoms of soreness, stiffness, and dull/aching pain throughout the day, which he treated with ibuprofen as needed. He reported flare-ups, during which he experiences soreness, stiffness, and dull/aching pain throughout the day. He also reported functional impairment when sitting for long periods of time. Initial range of motion measurements showed right hip flexion to 60 degrees and extension to 10 degrees. Pain was noted on range of motion of flexion, extension, abduction, adduction, external rotation, and internal rotation, and it caused functional loss. There was evidence of pain with weight bearing. Left hip flexion was to 60 degrees and extension was to 10 degrees. The Veteran was able to perform repetitive use with at least three repetitions of each hip, with no additional loss of function. The Veteran was not examined after repeated use over time or flare-ups, but the examiner noted that pain, weakness, and lack of endurance caused functional loss with both. However, the examiner estimated that range of motion would be the same as initial range of motion. There was no ankylosis. The examiner noted a leg length discrepancyspecifically, the Veteran's right lower extremity was found to be one inch shorter than the left lower extremity. The examiner indicated that the Veteran used a cane constantly due to bilateral trochanteric bursitis and lumbar strain. His bilateral hip disability impacted his ability to work in that he had functional impairment when sitting for long periods of time. The Veteran also reported functional impairments with activities of daily living such as dressing, eating, and bathing. There was no objective evidence of pain on non-weightbearing in either hip, and passive range of motion was the same as active range of motion bilaterally. Overall, after careful review of the record, the Board finds that increased ratings are not warranted for the Veteran's bilateral hip disabilities based on limitation of extension or limitation of flexion. As previously discussed, the Veteran is already in receipt of the highest schedular rating for limitation of extension associated with his trochanteric bursitis of the left and right hips. As he is in receipt of the highest schedular rating for limitation of extension of the thigh, there is no basis to award a higher rating. Moreover, the Veteran's extension was limited at most to 5 degrees, which is the disability level contemplated by a 10 percent rating. No argument has been made to identify other symptoms caused by limitation of extension. As the Veteran is already in receipt of the maximum schedular disability rating, the appeal for higher ratings based on limitation of extension is denied. The Board also finds that compensable disability ratings are not warranted for limitation of flexion associated with the Veteran's trochanteric bursitis of the left and right hips. The objective medical evidence of record indicates that the Veteran's bilateral hip flexion was consistently in excess of 45 degrees. During his July 2013 VA examination, the Veteran exhibited forward flexion to 65 degrees in both the right and left leg. During the August 2020 VA examination, the Veteran exhibited forward flexion to 60 degrees in each hip, even accounting for his reports of pain, weakness, and lack of endurance during flare-ups and after repeated use over time. The Board acknowledges the lay and medical reports of hip pain. However, the record does not include evidence of any specific degree of additional limitation of motion due to pain beyond that described in the medical evidence above. The totality of the evidence preponderates against finding that the criteria for higher ratings were more nearly approximated based on these findings. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for compensable ratings for limitation of flexion associated with his trochanteric bursitis of the left and right hips. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Although the Board regrets the delay, the remaining issues on appeal must be remanded for additional development. 1. Entitlement to service connection for residuals of a TBI The Veteran was afforded a VA TBI examination in July 2013. He reported that in June 1968, he was parachuting out of an airplane and hit his head on the back of a plane, knocking him unconscious. He reported that the first thing he remembered was waking up in the hospital. The examiner noted that review of STRs showed the Veteran vomited before exiting the plane and had a syncopal episode. STRs indicated he woke up entangled in his chute and was noted to have a headache, though skull x-rays were normal. The Veteran reported chronic daily headaches ever since the incident. Nevertheless, the examiner determined that the Veteran did not currently have, nor had he ever had a TBI or residuals of a TBI. In an accompanying opinion, the examiner wrote that there was insufficient evidence for TBI in the Veteran's STRs. The examiner explained that although the Veteran was noted to have vomiting before exiting the plane and a syncopal episode, there was no mention of head trauma in the incident. The Board notes that the Veteran is competent to report the circumstances of an in-service head injury, and there is no reason to doubt the credibility of his statements that he hit his head when jumping out of a plane in June 1968. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Further, the absence of documentation of a specific trauma or disability in his STRs does not alone negate the credibility of his statements concerning that disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Here, the Veteran's lay statements concerning the circumstances of his in-service head injury are generally corroborated by documentation from June 1968 in his STRs. Further, in an October 2012 report of consultation, private chiropractor P.Y. opined that the Veteran has multiple current TBI symptoms that could be causally related to injuries sustained when he injured his head jumping out of an aircraft during service. Because the July 2013 VA examiner based his negative opinion primarily on the lack of mention of head trauma in the Veteran's STRs, and because he failed to consider Dr. P.Y.'s opinion that the Veteran has current TBI symptoms that could be causally related to an in-service head injury that occurred when jumping from an aircraft, the Board finds the examination report and opinion to be inadequate for rating purposes, and remand for a new examination is warranted. In finding that further development is necessary to adjudicate the claim, the Board has considered Dr. P.Y.'s private medical opinion submitted by the Veteran and acknowledges the U.S. Court of Appeals for Veterans Claims (Court) decision in Mariano v. Principi, 17 Vet. App. 305 (2003). In this regard, the Board notes that although Mariano states that it "would not be permissible for VA to undertake such additional development if a purpose was to obtain evidence against an appellant's case," the Court has held that VA may undertake the development of additional evidence if, as here, it is necessary to render an informed decision on the claim. See Douglas v. Shinseki, 23 Vet. App. 19 (2009) (distinguishing Mariano, 17 Vet App. at 312). In this case, the Board acknowledges that the Veteran provided a private positive nexus opinion from Dr. P.Y. concerning the nature and etiology of his claimed TBI residuals. While informative, his opinion is largely conclusory in that he did not provide a detailed rationale for his opinion. Nevertheless, while an insufficient basis for granting service connection at this time, the opinion indicates that an additional VA examination and opinions are warranted. 2. Entitlement to a TDIU and to SMC, including based on the need for aid and attendance The Board finds that the claims for a TDIU and SMC, including based on the need for aid and attendance, are inextricably intertwined with the claim of entitlement to service connection for an acquired psychiatric disability, which was granted herein. The assignment of a rating and effective date for the acquired psychiatric disability claim granted herein will affect the Veteran's combined schedular rating and will therefore directly impact the TDIU and SMC claims. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Schedule the Veteran for an additional VA examination to determine the nature and etiology of his claimed TBI residuals. The claims folder should be made available to the examiner for review before the examination. The examiner should express an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran currently has a diagnosis of TBI, or any other current residuals, related to a June 1968 incident in which the Veteran states he struck his head when jumping from an aircraft. The opinion should reflect consideration of the Veteran's contentions that he struck his head and was rendered unconscious. The opinion should also reflect consideration of contemporaneous STRs documenting vomiting and a syncopal episode related to jumping from an aircraft, as well as the October 2012 private report from chiropractor P.Y., who opined that the Veteran has current symptoms of a TBI that are causally related to the claimed in-service head injury. A complete rationale must be offered for all opinions expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. The examiner must identify and explain the medical basis or bases for each opinion, with identification of the evidence of record. 2. Then, readjudicate the claims on appeal in light of all additional evidence received. If any benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. T. Raftery, Counsel 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.