Citation Nr: 21068213 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-12 382 DATE: November 9, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for degenerative disc disease of the thoracolumbar spine with scoliosis is denied. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine is denied. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the right hip is denied. Entitlement to an initial rating in excess of 10 percent for aspherical femoral head of the left hip is denied. REMANDED Entitlement to a compensable initial rating for left ear hearing loss is remanded. Entitlement to a compensable initial rating in excess of 10 percent for pansinusitis with headaches is remanded. Entitlement to a compensable initial rating for hypertension is remanded. Entitlement to a compensable initial rating for rosacea is remanded. FINDINGS OF FACT 1. The Veteran's degenerative disc disease (DDD) of the thoracolumbar spine with scoliosis has not manifested as forward flexion of the thoracolumbar spine 30 degrees or less, ankylosis of the entire spine, or incapacitating episodes. 2. The Veteran's DDD of the cervical spine has not manifested with forward flexion of the cervical spine 30 degrees or less, the combined range of motion of the cervical spine less than 170 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. 3. During the entire rating period on appeal, the Veteran's degenerative joint disease (DJD) of the right hip has not manifested by limitation of extension to 5 degrees, limitation of flexion to 30 degrees, limitation of adduction with inability to cross legs, or limitation of rotation with inability to toe-out more than 15 degrees of the right leg. 4. During the entire rating period on appeal, the Veteran's aspherical femoral head of the left hip has not manifested by limitation of extension to 5 degrees, limitation of flexion to 30 degrees, limitation of adduction with inability to cross legs, or limitation of rotation with inability to toe-out more than 15 degrees of the left leg. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for DDD of the thoracolumbar spine with scoliosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Codes 5242-5243. 2. The criteria for an initial rating in excess of 10 percent for DDD of the cervical have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5242. 3. The criteria for an initial rating in excess of 10 percent for DJD of the right hip have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252. 4. The criteria for an initial rating in excess of 10 percent for aspherical femoral head of the left hip have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1997 to April 2001, June 2004 to November 2005, November 2006 to June 2007, January 2008 to February 2009, April 2009 to March 2011, and October 2011 to November 2014. The Veteran served in Iraq and Afghanistan and is the recipient of numerous awards and decorations including the Purple Heart and Combat Action Badge. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. In June 2019, the Board remanded the matter for further development and the case has been returned for appellate consideration. Increased Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran's disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, a "staged" rating is warranted if the evidence demonstrates distinct periods when a service-connected disability exhibits diverse symptoms meeting the criteria for different ratings, irrespective of whether an initial or established rating. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the standard working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. 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 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."). The Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). 1. Entitlement to an initial rating in excess of 20 percent for DDD of the thoracolumbar spine with scoliosis. 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. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, DCs 5235-5242. 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). Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. at Note (5). Additionally, if there is evidence of IVDS, Diagnostic Code 5243 provides it is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25 (VA's Combined Ratings Table). The Formula for Rating intervertebral disc syndrome (IVDS) Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note (1) to Diagnostic Code 5243 explains that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The rating criteria for IVDS were amended, effective February 7, 2021. See 85 Fed. Reg. 76453 (February 7, 2021) (codified at 38 C.F.R. § 4.71a). The revised criteria provide that a rating under DC 5243 for IVDS is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that DC 5242 be assigned for all other disc diagnoses. When amended regulations expressly state an effective date and do not include any provision for retroactive applicability, application of the revised regulations prior to the stated effective date is precluded. 38 U.S.C. § 5110(g); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997); VAOPGCPREC 3-2000. Therefore, as the amendment discussed above has a specified effective date without provision for retroactive application, the amendment may not be applied prior to its effective date. As of the effective date, February 7, 2021, the Board must apply whichever version of the rating criteria is more favorable to the Veteran. The Veteran's thoracolumbar spine disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5243. In the assignment of diagnostic codes, hyphenated numbers may be used. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. In the selection of code numbers, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. Here, Diagnostic Code 5243 sets forth the criteria for rating IVDS and Diagnostic Code 5242 sets forth the criteria for degenerative arthritis of the spine. Effective February 7, 2021, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, Diagnostic Code 5242, were amended. However, the amendment changed only the title of the regulation from "degenerative arthritis of the spine" to "degenerative arthritis, degenerative disc disease other than [IVDS]," the latter to account for situations when there is not disc herniation with compression and/or irritation of the adjacent nerve root to warrant rating the disability, instead, under Diagnostic Code 5243. No substantive changes were made to the General Rating Formula so including to Diagnostic Code 5242, in terms of assessing, as an example, range of motion. The Veteran's thoracolumbar spine disability has been evaluated as 20 percent disabling from November 4, 2014. The question for the Board, therefore, is whether his disability picture more nearly approximated the criteria for a higher rating. In June 2014, the Veteran was afforded a VA back conditions examination, during which he reported back pain being treated with medication, with flare-ups of limited extension of the back. Initial range of motion testing (ROM) was all normal and revealed forward flexion of 90 degrees or greater, with painful motion starting at 70 degrees; extension of 25 degrees, with painful motion starting at 20 degrees; right and left lateral flexion of 30 or greater degrees, with painful motion starting at 25 degrees; and right and left lateral rotation of 30 degrees or greater. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or range of motion. There was no muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour. Muscle strength was normal, and there was no muscle atrophy. Deep tendon reflexes and sensory examinations were also normal. Straight-leg raising test was negative, bilaterally. There was no ankylosis or signs or symptoms due to radiculopathy. It was indicated that the Veteran had IVDS but had no incapacitating episodes over the last 12 months. He did not use assistive devices. As to the functional impact on the Veteran's ability to perform occupational task, the examiner indicated that the Veteran's back condition did not impact his ability to work. VA treatment records show physical therapy for low back pain. During an August 2019 treatment, forward bending revealed significant scoliotic hump on the right and backward bending and side-bending and rotation produced pain. A November 2019 Back Conditions Disability Benefits Questionnaire (DBQ) shows the Veteran's report of sharp pains in the low back pain, currently treated with physical therapy and chiropractic care. He reported flare-ups in the morning and evening relieved by rest and responding to NSAIDs. Functional impairment was less range of motion (ROM) than normal. Initial ROM testing revealed forward flexion of 80 degrees; extension of 20 degrees; right and left lateral flexion of 20 degrees; and right and left lateral rotation of 30 degrees. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no change in RO after repetitive testing. The examiner also noted that pain, weakness, fatigability, or incoordination did not significantly limited functional ability with repeated use over a period of time or during a flare-up. There was no guarding or muscle spasms of the thoracolumbar spine resulting in abnormal gait or abnormal spinal contour. With regard to functional loss, the examiner noted that "the Veteran is extremely careful not to re-injure his back although it sometimes happens anyway. He exercises a significant amount to try to ensure minimum injuries and minimum pain when injury comes." The examiner further noted that during the flare-ups, the Veteran was mobile, though with pain, and functional as he tried to stay active. Muscle strength was normal, and there was no muscle atrophy. Deep tendon reflexes and sensory examinations were also normal. Straight-leg raising test was negative, bilaterally. There was no ankylosis. The Veteran did not have any signs or symptoms due to radiculopathy or other neurological abnormalities. The examiner indicated that the Veteran did not have IVDS. There was no pain noted on active or repetitive use testing, in weight-bearing or non weight-bearing resulting in functional loss or additional limitation of ROM. Passive ROM testing for the back was not medically appropriate. As to the functional impact on the Veteran's ability to perform occupational task, the examiner indicated that the Veteran's back condition did not impact his ability to work. After careful consideration of the medical and lay evidence of record, the Board concludes that, an initial rating in excess of 20 percent for the Veteran's thoracolumbar spine disability is not warranted. The preponderance of the evidence is against finding that the Veteran's thoracolumbar spine disability manifested as forward flexion of the thoracolumbar spine 30 degrees or less, ankylosis of the entire thoracolumbar spine, or incapacitating episodes. During the entire rating period, physical examination revealed forward flexion of 80 degrees or greater. As for incapacitating episodes due to IVDS, the Board notes that the medical evidence establishes that the Veteran has not suffered from IVDS resulting in any incapacitating episodes. There is no evidence of record that a physician has prescribed any period of bed rest to treat the Veteran's IVDS or any other aspect of his back disability. The Veteran has not contended otherwise. Consequently, the Board finds that the Veteran's thoracolumbar spine disability has not been manifested as incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months to warrant a higher disability rating under the criteria for IVDS. The Board notes that the change to Diagnostic Code 5243 effective February 7, 2021 states that the criteria should be applied for intervertebral disc syndrome only when there is disc herniation with compression and/or irritation of the adjacent nerve root. As the evidence does not reflect that the Veteran suffers intervertebral disc syndrome/lumbosacral disc herniation, the revised criteria is not applicable. In addition to the schedular criteria, the Board has considered functional loss due to flare-ups of pain, weakness, fatiguability, incoordination, pain on movement, and lack of endurance for each period under consideration. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The probative evidence, both medial and lay, establishes that the Veteran has reported increased pain in the morning and evening. However, as noted above, range of motion testing has revealed forward flexion of 80 degrees or greater. Consequently, the Board finds that the preponderance of the evidence is against finding that the Veteran has been so limited by the factors noted in DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59 as to constitute forward flexion of the thoracolumbar spine 30 degrees or less or ankylosis of the entire thoracolumbar spine. VA examiners indicated that ankylosis is not present. Even considering DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59, ankylosis was not nearly approximated. The Veteran has not contended otherwise. Consequently, the Board finds that, throughout the period on appeal, the Veteran's back disability did not manifest as forward flexion of the thoracolumbar spine 30 degrees or less, ankylosis of the entire thoracolumbar spine, or incapacitating episodes such that a rating in excess of 20 percent is warranted. The Board has also considered whether separate neurological ratings are warranted in this case. However, the record does not show any neurologic or radicular abnormalities in connection to the thoracolumbar spine disability. 2. Entitlement to an initial rating in excess of 10 percent for DDD of the cervical spine. The Veteran's cervical spine disability is currently rated under Code 5242. Cervical spine disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. As noted above, there were extensive amendments to the rating schedule governing the musculoskeletal system, effective February 7, 2021. See 85 Fed Reg. 76453 (Nov. 30, 2020). However, the amendments do not impact the criteria applicable here. Under the General Rating Formula for Diseases or Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 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 an 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 cervical spine greater than 15 degrees but not greater than 30 degrees; or, combined range of motion of the cervical spine is not greater than 170 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 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Normal ranges of motion of the cervical spine are flexion from 0 to 45 degrees, extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, and lateral rotation from 0 to 80 degrees. 38 C.F.R. § 4.71, Plate V. In June 2014, the Veteran was afforded a VA neck conditions examination, during which he reported neck pain for which he received no treatment. He had flare-ups consisting of a decrease in motion from turning side or side. Initial range of motion (ROM) testing was all normal and revealed forward flexion of 45 degrees or greater, with no objective evidence of painful motion; extension of 45 degrees or greater, with no objective evidence of painful motion; right lateral flexion of 45 or greater degrees, with painful motion starting at 45 degrees or greater; left lateral flexion of 45 degrees or greater, with no objective evidence of painful motion; and right lateral rotation of 60 degrees or greater, with no objective evidence of painful motion; and left lateral rotation of 80 degrees or greater, with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or range of motion. There was no muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour. Muscle strength was normal, and there was no muscle atrophy. Deep tendon reflexes and sensory examinations were also normal. There was no ankylosis or signs or symptoms due to radiculopathy. It was indicated that the Veteran did not have IVDS resulting in incapacitating episodes over the last 12 months. He did not use assistive devices. As to the functional impact on the Veteran's ability to perform occupational task, the examiner indicated that the Veteran's back condition did not impact his ability to work. In January 2018, the Veteran was afforded another VA examination. The Veteran was diagnosed with cervical degenerative disc disease with radiculopathy. He described pain and stiffness in the posterior neck that increased with any movement of the head or after sleeping. Initial ROM was as follows: forward flexion ended at 45 degrees, extension ended at 45 degrees, right lateral flexion ended at 30 degrees, left lateral flexion ended at 40 degrees, right lateral rotation ended at 60 degrees, and left lateral rotation ended at 70 degrees. ROM itself contributed to a functional loss. Pain was noted on examination that caused a functional loss. There was evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing that did not cause additional loss of function or ROM. Pain, fatigue, weakness, lack of endurance, or incoordination did not significantly limit functional ability with repeated use over a period of time and flare-ups. The Veteran did not have guarding or muscle spasm of the cervical spine. The Veteran had a normal muscle strength testing. Reflex examination and sensory examinations were normal except for hypoactive reflex in the left biceps and decreased sensation to light touch in both forearms and hand/fingers. The examiner noted that the Veteran had moderate bilateral radiculopathy in the upper and middle radicular groups. He did not have ankylosis of the spine. The examiner indicated that the Veteran had IVDS of the cervical spine, but it did not result in any episodes of bed rest. The examiner remarked that there was objective evidence of pain on passive ROM of the neck. There was objective evidence of pain on non-weightbearing testing of the neck. The examiner opined that the Veteran's neck disability did not impact his ability to work. An August 2019 VA physical therapy evaluation report reflects that the Veteran's complaint of neck pain going into the spine and radicular pain when sleeping. He stated his neck bothered him throughout the day with sitting for twenty minutes, standing, and driving. His cervical forward bending, backward bending, and side bending was restricted, and rotation was 45 degrees, bilaterally. In November 2019, the Veteran was afforded a VA examination. He was diagnosed with degenerative disc disease of the cervical spine. The Veteran reported that he had daily neck pain and headaches that seemed to originate from the neck. He underwent physical therapy and chiropractic care for his condition. He reported that he had flare-ups of pain in the morning and later in the day, relieved partially by NSAIDs. He had a functional loss/impairment described as less ROM than normal in the cervical spine. Initial ROM was as follows: forward flexion ended at 45 degrees, extension ended at 45 degrees, bilateral lateral flexion ended at 20 degrees, and bilateral lateral rotation ended at 60 degrees. The Veteran's ROM itself contributed to a functional loss. Pain was noted on the examination but did not result in functional loss. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing with no additional loss of function or ROM. Pain, fatigue, weakness, lack of endurance, or incoordination did not significantly limit functional ability with repeated use over a period of time and flare-ups. The Veteran did not have guarding or muscle spasm of the cervical spine. The Veteran had normal muscle strength and reflex testing. He did not have muscle atrophy. Sensory examination was also normal. There were no signs of symptoms of radiculopathy or other neurological abnormalities. The examiner indicated that there was no ankylosis of the spine. The Veteran did not have IVDS of the cervical spine. The Veteran's neck condition did not impact his ability to work. The examiner noted that there was no objective evidence of pain when the neck was used in non-weightbearing. Passive ROM testing could not be performed as it was not medically appropriate. The evidence of record does not reflect cervical spine forward flexion of 30 degrees or less and does not otherwise reflect a combined range of motion of the cervical spine not greater than 170 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. Even considering additional functional loss and impairment during flare-ups and periods of repeated use, the evidence does not show that such impairment would be akin to forward flexion of 30 degrees or less. During the VA examinations, the Veteran reported flares-ups, and the examiner determined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or during a flare-up. Further, there is no evidence of intervertebral disc syndrome to warrant application of the formula for rating intervertebral disc syndrome resulting any episodes of bed rest. As such, an initial rating in excess of 10 percent is not warranted at any time during the entire rating period on appeal. 3. Entitlement to an initial rating in excess of 10 percent for DJD of the right hip. 4. Entitlement to an initial rating in excess of 10 percent for aspherical femoral head of the left hip. In April 2015, the RO issued a rating decision that granted service connection for right hip DJD and for aspherical femoral head of the left hip with noncompensable initial ratings under Diagnostic Codes 5252-5003 and 5252, respectively, effective November 4, 2014. In a June 2020 rating decision, the RO increased the initial rating for right hip DJD from noncompensable to 10 percent under Diagnostic Code 5252-5003 from November 4, 2014 to November 15, 2019. From November 16, 2019, a 10 percent rating was assigned under Diagnostic Code 5003-5251 but noncompensable under Diagnostic Code 5252-5003. Likewise, the initial rating for left hip aspherical femoral head was increased from noncompensable to 10 percent disabling from November 4, 2014 to November 15, 2019. From November 16, 2019, the disability was evaluated as 10 percent under Diagnostic Code 5251 but as noncompensable under Diagnostic Code 5252. Limitation of motion of the hip or thigh is rated under Diagnostic Codes 5251, 5252, and 5253. The Veteran's left and right hip disabilities were each rated at 10 percent prior to November 16, 2019 under Diagnostic Code 5252 for limited flexion. From November 16, 2019, the bilateral hip disabilities are rated as 10 percent disabling for limited extension under Diagnostic Code 5251. However, he is not in receipt of a rating under Diagnostic Code 5253 for limited abduction. Under Diagnostic Code 5251, a maximum 10 percent disability rating is warranted where there is limitation of extension of the thigh to 5 degrees. A 10 percent rating is the maximum statutorily allowable for limitation of extension. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Under Diagnostic Code 5252, a 10 percent disability rating is assigned for flexion of the thigh limited to 45 degrees. For the next higher rating, a 20 percent rating, there must be limitation of flexion to 30 degrees. Limitation of thigh flexion to 20 degrees warrants a 30 percent rating, and limitation of flexion to 10 degrees warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Under Diagnostic Code 5253, a 10 percent disability rating is assigned for limitation of thigh rotation, with an inability to toe-out (external rotation) in excess of 15 degrees, or where there is limitation of adduction such that one cannot cross legs. A 20 percent disability rating is warranted for limitation of thigh abduction, where motion is lost beyond 10 degrees. A 20 percent rating is the maximum under this Diagnostic Code for limited rotation. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Normal ranges of motion of the hip include hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.7, Plate II. The criteria for musculoskeletal disabilities in 38 C.F.R. § 4.71a were amended, effective February 7, 2021, and the "new" schedular criteria are applicable as of that date. 85 Fed. Reg. 76453 (Nov. 30, 2020). However, the Board notes that Diagnostic Codes 5250-5254 for the hip and thigh were not amended. The Veteran underwent a VA examination in June 2014. The diagnoses were bilateral aspherical femoral heads and right hip mild degenerative osteoarthritis with possibly impingement syndrome. He reported bilateral hip pain with no flare-ups. The Veteran had bilateral hip flexion to 125 degrees or greater and extension to greater than 5 degrees. His hip abduction was not lost beyond 10 degrees and hip adduction was not so limited as to prevent the Veteran's legs from crossing, bilaterally. The Veteran's rotation was not limited such that he could not toe-out more than 15 degrees. His internal rotation of bilateral hips was to 40 degrees with no pain and external rotation of bilateral hips was to 60 degrees with no pain. The Veteran was able to perform repetitive-use, and there was no additional loss of function or ROM after three repetitions. The Veteran had normal muscle strength. The examiner indicated that there was no hip ankylosis, malunion or nonunion of femur, flail hip joint or leg length discrepancy. The examiner found that the Veteran's hip conditions did not impact his ability to work. The Veteran was afforded another VA hip examination in November 2019. The diagnoses were degenerative joint disease of the right hip and aspherical femoral head of the left hip. He reported numbness and sharp pains in both hips most days with flare-ups in the mornings, which subsided with medications. Flare-ups involved pain in both hips nearly every in the mornings and evenings. Functional loss included limited ability to squat or kneel with current ROM. The examiner reported that the Veteran had bilateral hip flexion to 100 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 20 degrees, external rotation to 40 degrees, and internal rotation to 20 degrees. Adduction was not so limited as to prevent the Veteran's legs from crossing. The abnormal ROM itself contributed to a functional loss and ROM interfered with effective squatting and kneeling. Pain was noted on examination but did not cause functional loss. There was no evidence of pain with weight bearing and no objective evidence of crepitus. The Veteran was able to perform repetitive-use and there was no additional loss of function or ROM after three repetitions. Pain, fatigue, weakness, lack of endurance, or incoordination did not significantly limit functional ability with repeated use over a period of time and flare-ups. Additional contributing factors of disability was less movement than normal with mild limits in ROM. The Veteran had normal muscle strength and did not have muscle atrophy. The examiner indicated that there was no hip ankylosis. The Veteran did not have malunion or nonunion of femur, flail hip joint, or leg length discrepancy. The examiner found that the Veteran's hip conditions impacted his ability to work because he was limited in ability to effectively squat or kneel. The examiner noted that there was no objective evidence of pain when the hip was used in non-weightbearing. Passive ROM was same as active ROM. After reviewing the evidence, the Board finds that initial ratings in excess of 10 percent are not warranted for limited extension associated with the Veteran's right or left hip disability for the entire rating period on appeal because the maximum compensable rating based on limited extension of the thigh is 10 percent when extension is limited to 5 degrees. The Board finds that the 10 percent initial ratings were based on limited hip extension and symptoms causing functional loss of the hips, without meeting the objective criteria for the minimal compensable rating for hip flexion under DC 5252. As mentioned above, a 10 percent rating is warranted for flexion limited to 45 degrees. The June 2014 VA examination showed flexion to 125 degrees or greater and the November 2019 VA examination showed flexion to 100 degrees, meaning the criteria for a 10 percent rating was not met. However, the Veteran had functional loss caused by pain, so the minimum compensable ratings, or 10 percent, were assigned. In order to warrant a 20 percent rating, flexion limited to 30 degrees must be shown. However, none of the VA examinations showed flexion limited to 30 degrees. Therefore, a separate rating for limited flexion is not warranted for either hip as the Veteran's bilateral hip flexion has been greater than 100 degrees, meaning the motion of the bilateral hips is not so limited in flexion as to warrant the minimum compensable rating under DC 5252. Regarding the Veteran's limited adduction and rotation, the November 2019 VA examiner specifically documented pain in external and internal rotation and indicated it did not cause functional loss. There is no competent evidence indicating painful movement resulting in functional loss of adduction, or rotation. Additionally, in order to receive the minimum 10 percent rating under Diagnostic Code 5253, there must be evidence of limitation of thigh adduction, where the Veteran cannot cross legs or toe-out more than 15 degrees. The examination report shows that the Veteran's abduction was to 20 degrees and external rotation was to 40 degrees. Therefore, a separate compensable rating is not warranted for left or right hip disability under this diagnostic code. As the preponderance of the evidence is against the claims for increased ratings, there is no doubt to be resolved, and initial ratings greater than those currently assigned for the Veteran's disabilities are not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND 1. Entitlement to a compensable initial rating for left ear hearing loss is remanded. 2. Entitlement to an initial rating in excess of 10 percent for pansinusitis with headaches is remanded. 3. Entitlement to a compensable initial rating for hypertension is remanded. 4. Entitlement to a compensable initial rating for rosacea is remanded. VA's duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). This includes providing a new medical examination when a veteran asserts or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). The Veteran was provided VA examinations for his service-connected left ear hearing loss, pansinusitis with headaches, hypertension, and rosacea in June 2014, over 7 years ago. Accordingly, more contemporaneous VA examinations are required to provide a current picture of the Veteran's service-connected disabilities at issue on appeal. 38 C.F.R. §§ 3.326, 3.327. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records for the Veteran, dated from November 2019 to the present. All records and/or responses received should be associated with the claims file. 2. Schedule the Veteran for a VA audiological examination to determine the current severity of his service-connected left ear hearing loss. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. Specifically, the findings of pure tone decibel loss at 1000, 2000, 3000 and 4000 Hertz must be numerically reported, and speech recognition must be derived using the Maryland CNC Test. The examiner must fully describe the functional effects caused by the Veteran's hearing disability. The claims file and a copy of this remand must be made available to the examiner and reviewed in conjunction with the examination. 3. Schedule the Veteran for an appropriate examination to determine the severity of his service-connected pansinusitis with headaches. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. Any indicated diagnostic tests and studies must be accomplished. All pertinent symptomatology and findings must be reported in detail. 4. The Veteran must be afforded the appropriate VA examination to determine the current nature and severity of his service-connected hypertension. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. The examiner must specifically indicate whether the Veteran's service-connected hypertension is manifested by diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. It must also be noted if the Veteran is taking medication to control his service-connected hypertension. 5. The Veteran should be scheduled for a VA skin examination to assess the current level of severity of the Veteran's rosacea. A complete copy of the claims file must be made available to the examiner, including a copy of this remand. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner should offer an assessment of all pertinent symptomatology and findings, level of severity, and functional impairment associated with his rosacea, to include the percentage of the body affected by the disability and treatment used for treatment for this disability. 6. After completing the above development, and any other development deemed necessary, readjudicate the claims on appeal. If any benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. J. In, 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.