Citation Nr: 21069925 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 17-32 220 DATE: November 22, 2021 ORDER Service connection for a disability manifested by right leg pain, to include as secondary to lumbosacral strain and degenerative arthritis, is denied. Service connection for a disability manifested by left leg pain, to include as secondary to lumbosacral strain and degenerative arthritis, is denied. Entitlement to a rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. Entitlement to a rating in excess of 30 percent for migraine headaches for the period from September 12, 2013, to April 3, 2017, is denied. Entitlement to a rating in excess of 50 percent for migraine headaches for the period beginning April 4, 2017, is denied. Entitlement to a compensable rating for lumbosacral strain and degenerative arthritis for the period from September 12, 2013, to December 13, 2019, is denied. Entitlement to a rating in excess of 40 percent rating for lumbosacral strain and degenerative arthritis for the period beginning December 14, 2019, is denied. REMANDED The claim for a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The most probative evidence of record weighs against a conclusion that the Veteran has a disability manifested by right or left leg pain due to service. 2. The most probative evidence of record weighs against a conclusion that the Veteran has a disability manifested by right or left leg pain that is proximately due to or a result of service-connected lumbosacral strain and degenerative arthritis, to include with consideration of aggravation. 3. PTSD does not result in total occupational and social impairment. 4. For the period from September 12, 2013, to April 3, 2017, migraine headaches did not result in very frequent completely prostrating and prolonged attacks that were productive of severe economic inadaptability. 5. The VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (Ratings Schedule) does not provide for a rating in excess of 50 percent for migraine headaches. 6. For the period from September 12, 2013, to December 13, 2019, lumbosacral strain and degenerative arthritis did not result in forward flexion of the thoracolumbar spine being limited to no greater than 85 degrees, 65 degrees or 30 degrees or less; a combined range of motion of the thoracolumbar spine not greater than 235 or 120 degrees; muscle spasm, guarding, or localized tenderness; a vertebral body fracture with loss of 50 percent or more of the height; favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes of intervertebral disc syndrome (IVDS). 7. For the period beginning December 14, 2019, lumbosacral strain and degenerative arthritis for the period has not resulted in unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes of IVDS having a total duration of at least six weeks during a twelve-month period. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability manifested by right or left leg pain, to include as secondary to lumbosacral strain and degenerative arthritis, are not met. 38 U.S.C. §§ 1110, 1131, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2021). 2. The criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2021). 3. The criteria for a rating in excess of 30 percent for migraine headaches for the period from September 12, 2013, to April 3, 2017, are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107, 5110(a) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8100 (2021). 4. A rating in excess of 50 percent for migraine headaches for the period beginning April 4, 2017, cannot be assigned as a matter of law. 38 U.S.C. § 1155, 5103, 5103A, 5107, 5110(a) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8100 (2021). 5. The criteria for a compensable rating for lumbosacral strain and degenerative arthritis for the period from September 12, 2013, to December 13, 2019, are not met. 38 U.S.C. §§ 1155, 5003, 5103, 5103A, 5107, 5110(a) (2012); 38 C.F.R. §§ 3.400, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2021). 6. The criteria for a rating in excess of 40 percent for lumbosacral strain and degenerative arthritis for the period beginning December 14, 2019, are not met. 38 U.S.C. §§ 1155, 5003, 5103, 5103A, 5107, 5110(a) (2012); 38 C.F.R. §§ 3.400, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1995. This appeal was remanded by the Board of Veterans' Appeals (Board) in March 2019 and is now ready for appellate review of the claims adjudicated below. As development conducted pursuant to this remand resulted in a grant of service connection for a vision disability, urinary disability, and disabilities manifested by bilateral foot pain and left shoulder pain, the appeal with respect to the claims for service connection for these disabilities has been satisfied. I. Service Connection Claims A. Legal Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U.S. Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). A disability which is proximately due to or the result of a service-connected disease shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability has aggravated a nonservice-connected disability. 38 C.F.R. § 3.310(b). B. Analysis The service treatment reports (STRs) reflect treatment for pain to the back of the right knee in January 1977. No significant objective findings were identified and the impression was a contusion of the left knee. The Veteran complained about right knee pain giving away in February 1978 and inflammation in the right knee was diagnosed at that time and on a March 1978 STR. He ambulated with the assistance of crutches during this period. An October 1988 STR reflects complaints of a pulled hamstring with leg pain and swelling and an impression of a strained muscle. The STRs do not otherwise reflect a disability manifested by left or right leg pain and an examination conducted proximate to separation from service in February 1995 was silent for such disability. A medical history collected at that time was positive for leg cramps, with the Veteran describing such when he goes diving that subside after a while. The examiner remarked that there were no complications or sequalae associated with leg cramping at that time. Following separation from service, the first VA general medical examination afforded the Veteran in October 2003 did not reflect any complaints or findings relating to a disability manifested by right or left leg pain. A December 2019 VA examination conducted to address the claims for service connection for a disability manifested by right or left leg pain pursuant to the March 2019 Board remand directives reflected the Veteran reporting a history of bilateral leg pain radiating from the back since 1990 due to many years of work as a mechanic in the military. The radiated pain was said to be of the shooting variety from the back down to below the knees. The pain was said to be intermittent and to usually occur once a month. The examination of the peripheral nerves of the lower extremities showed no abnormalities and the examiner concluded as follows: While the [V]eteran is claiming radiculopathy symptoms (bilateral leg pain), there is no objective evidence to support a diagnosis of radiculopathy at this time. In rendering otherwise positive medical opinions with respect to claims for service connection for a bilateral foot disability, urinary disability, and a left shoulder disability, the examiner commented as follows with respect to the claim for service connection for a disability manifested by right or left leg pain: [T]here is no objective evidence to support a diagnosis of radiculopathy or a peripheral nerve condition (claimed as right and left leg pain) at this time. There is otherwise no positive opinion of record that contradicts the negative conclusions set forth above, and the Board finds these opinions to be definitive as to the matters of whether the Veteran has a current disability manifested as right or left leg pain that is due to service or the service-connected lumbar spine disability, to include with consideration of aggravation. To the extent the assertions of the Veteran and his representative are advanced in an attempt to establish that he has a disability manifested as right or left leg pain as a result of service or the service-connected lumbar spine disability, such complex medical matters are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is not shown to have the appropriate training and expertise, he is not competent to render a persuasive opinion as to such matters. While the Veteran is competent to describe any lay observable symptoms associated with a disability manifested as right or left leg pain since service, the undersigned finds the lack of any competent evidence indicating that the Veteran has a current disability associated with a condition manifested as right or left leg pain to service to be more probative than any lay assertions made in connection with the claims for service connection for these disabilities and that these facts weigh against a finding of continuity of relevant symptoms associated with these conditions since service. Given all of the above, the Board finds that the preponderance of the evidence is against the claims for service connection for a disability manifested as right or left leg pain. As such, these claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. II. Increased Rating Claims A. General Legal Criteria Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Court has since held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The effective date of an increased rating will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. B. PTSD 1. Rating Criteria The General Rating Formula for Mental Disorders provide for a noncompensable rating for a formally diagnosed mental condition manifested by symptoms that are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent for psychiatric disorders is warranted if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A rating of 30 percent is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran's own occupation or name. C.F.R. § 4.130. The symptoms recited in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. 2. Analysis Service connection for PTSD was granted by a December 2014 rating decision at a disability rating of 70 percent. This rating has been continued until the present time. Pertinent evidence in determining the proper rating to be assigned for the service connected PTSD includes reports from a May 2014 VA examination in which the examiner, in checklist fashion corresponding to the General Rating Formula for Mental Disorders listed at 38 C.F.R. § 4.130 as set forth above, selected "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation" as the degree of occupational and social impairment due to the Veteran's PTSD. Such would warrant a 30 percent rating under the General Rating Formula. Symptoms of PTSD listed on the reports from this examination were depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, an inability to establish and maintain effective relationships, and suicidal ideation. At that time, the Veteran was not receiving psychiatric treatment and the examiner noted that he required continued and intense outpatient treatment. At the most recent VA examination to assess the severity of the Veteran's PTSD conducted in December 2019 pursuant to the March 2019 remand directives, the examiner, in checklist fashion corresponding to the General Rating Formula, selected "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood" as the degree of occupational and social impairment due to the Veteran's PTSD. Such would warrant a 70 percent rating under the General Rating Formula. The reports from this exanimation noted that the Veteran has been involved in a group PTSD therapy program at a VA clinic for the prior six months and he stated that the sessions are the best type of therapy for him. He reported that he feels validated by the other Veterans' experiences during such sessions, and that in turn, it helps him become more in touch with himself. Symptoms of PTSD listed on the reports from this examination were depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or worklike setting, an inability to establish and maintain effective relationships, and suicidal ideation. Upon examination, the Veteran displayed a down mood and flat affect and his thought processes were spontaneous and tangential but redirected. Review of the VA mental hygiene clinical reports of record, dated at the time of this writing through January 2020, do not reflect clinical findings that differ in significant degree from those set forth above. A January 2020 VA mental hygiene clinical report indicated that the Veteran was maintaining a relationship with his wife, who he had recently married, and her daughter. He denied suicidal or homicidal ideation at that time and it was noted that the Veteran was compliant with the medication prescribed for his PTSD and that he was committed to continuing his therapy sessions. It was noted that the Veteran did not have any symptoms of depression or psychosis and the mental status examination showed the Veteran to have an appropriate affect, fair insight, and to be cognitively intact. The VA examinations set forth abovein addition to not selecting the degree of degree of occupational and social impairment ("total") due to the Veteran's PTSD associated with a 100 percent ratingalso listed the symptoms of PTSD in checklist fashion, and the examiners specifically did not select any of the symptoms contemplated by a 100 percent rating under the General Rating Formula for Mental Disorders. While the undersigned recognizes that such criteria serve as examples of the type and degree of the symptoms or effects that would justify a 100 percent rating as explained in Mauerhan, the Board finds that the criteria for a rating in excess of 70 percent for PTSD are not met. Again, emphasizing that such are listed as mere examples, the Board makes this determination because the assessment of psychiatric impairment at the above VA psychiatric examinations and the VA mental hygiene clinic reports shows, at worst, the impairment warranting a 70 percent rating, and do not reflected the "total" occupational and social impairment required for a 100 percent rating. As support for this decision, the fact that the Veteran has recently married and is maintaining a relationship with his wife and her daughter; that he is compliant with his medications and is regularly attending therapy sessions; and was shown at the January 2020 VA mental hygiene visit to not have any symptoms of depression or psychosis and to have an appropriate affect, fair insight, and to be cognitively intact upon mental status examination all weight against a conclusion that the Veteran has a total impairment due to his PTSD. C. Migraine Headaches 1. Rating Criteria Migraine headaches resulting in characteristic prostrating attacks averaging one in 2 months over a period of several months warrant a 10 percent rating. 38 C.F.R. § 4.124a, DC 8100. Migraine headaches manifested by characteristic prostrating attacks occurring on an average once a month warrant a 30 percent disability. Id. The maximum 50 percent disability rating is warranted under DC 8100 when migraine headaches are very frequently completely prostrating and prolonged with attacks productive of severe economic inadaptability. Id. The rating criteria do not define "prostrating;" nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes DC 8100 verbatim but does not specifically address the matter of what is a prostrating attack.) By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p.1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." 2. Analysis Service connection has been granted for migraine headaches at disability rating of 30 percent from September 12, 2013, and 50 percent from April 4, 2017. As such, the matters now for appellate consideration with respect to the compensation to be assigned for migraine headaches are whether a rating in excess of 30 percent for such may be as assigned for the period from September 12, 2013, to April 3, 2017, and whether a rating in excess of 50 percent for this disability may be assigned for the period beginning April 4, 2017. AB v. Brown, 6 Vet. App. 35 (1993). A rating in excess of 30 percent for migraine headaches for the period from September 12, 2013, to April 3, 2017, would require evidence during this period of migraine headaches that were very frequently completely prostrating and prolonged with attacks productive of severe economic inadaptability. 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.400, 4.124a, DC 8100. In this regard, a May 2014 VA examination to assess the severity of the Veteran's migraine headaches, in checklist fashion as to the frequency of prostrating headaches, selected the occurrence of such headaches once a month and not "[m]ore frequently than once per month." The examiner also checked "No" with respect to whether the Veteran had "very frequent prostrating and prolonged attacks of migraine headache pain[.]" The examiner also noted that the Veteran's headaches did not impact his ability to work. Review of the remaining clinical evidence for the period from September 12, 2013, to April 3, 2017, does not reflect any evidence that the Veteran's headaches were very frequently completely prostrating and prolonged with attacks productive of severe economic inadaptability. As such, a rating in excess of 30 percent for migraine headaches for the period from September 12, 2013, to April 3, 2017, is not warranted. Id. With respect to a rating in excess of 50 percent for migraine headaches for the beginning April 4, 2017, as a rating in excess of 50 percent is not available under the rating criteria codified at 38 C.F.R. § 4.124a, DC 8100, a rating in excess of 50 percent for migraine headaches for the period beginning April 4, 2017, cannot not be assigned as a matter of law. D. Lumbosacral Strain and Degenerative Arthritis 1. Rating Criteria For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2006). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Traumatic arthritis is rated as for degenerative arthritis. DC 5010. The General Rating Formula for Diseases and Injuries of the Spine provides that for DCs 5235 to 5243, a rating of 100 percent is warranted when there is unfavorable ankylosis of the entire spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted when there is unfavorable ankylosis of the cervical spine, forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 30 percent is warranted for forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees, a combined range of motion of the cervical spine that is not greater than 170 degrees, or if the spine disability is manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent rating if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. The General Formula also includes the following notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is 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) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. IVDS (preoperatively or postoperatively) may be evaluated 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 evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating IVDS Based on Incapacitating Episodes provides for a 60 percent rating when there are incapacitating episodes of IVDS having a total duration of at least six weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes of IVDS having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 20 percent rating is warranted when there are incapacitating episodes of IVDS having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 10 percent rating is warranted when there are incapacitating episodes of IVDS having a total duration of at least one week, but less than two weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method results in the higher evaluation. 2. Analysis Service connection has been granted for lumbosacral strain and degenerative arthritis under DC 5237 (lumbosacral or cervical sprain) at a noncompensable rating effective from September 12, 2013, and 40 percent effective from December 14, 2019. As such, the matters for appellate consideration with respect to the compensation to be assigned for the service connect lumbar spine disability are whether a 40 percent rating may be assigned for such for the period from September 12, 2013, to December 13, 2019, and whether a rating in excess of 40 percent may be assigned for the period beginning December 14, 2019. AB v. Brown, supra. Such ratings may be assigned under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS, whichever method results in the higher evaluation. In point of fact, the 40 percent rating for the service connected lumbosacral spine disability was assigned effective from a December 14, 2019 VA examination conducted pursuant to the March 2019 Board remand that demonstrated limitation of lumbar flexion (with consideration of additional limitation of motion due to pain and weakness) to 30 degrees, thus warranting a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine on the basis of there being forward flexion of the thoracolumbar spine to 30 degrees or less. Reviewing the evidence for the period from September 12, 2013, to December 13, 2019, no clinical evidence during this period demonstrated forward flexion of the thoracolumbar spine to 30 degrees or less. In this regard, a May 2014 VA examination to assess the severity of the service-connected lumbar spine disability showed full flexion to 90 degrees, to include after repetitive motion. There is otherwise no clinical evidence for the period from September 12, 2013, to December 13, 2019, of there being forward flexion of the thoracolumbar spine to 30 degrees or less. A 40 percent rating for the service-connected lumbosacral spine disability may also have been assigned for the period from September 12, 2013, to December 13, 2019, if there was evidence during this period of favorable ankylosis of the entire thoracolumbar spine or incapacitating episodes of IVDS having a total duration of at least four weeks but less than six weeks during a twelve month period. However, there is no clinical evidence during this period that demonstrates these findings. In this regard, the aforementioned May 2014 VA examination revealed no IVDS, nor did it reveal any thoracolumbar ankylosis, much less favorable ankylosis involving the entire thoracolumbar spine. As such, a 40 percent rating cannot be assigned for the service-connected lumbosacral spine disability for the period from September 12, 2013, to December 13, 2019. 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.400, 4.71a, DC 5237. As for entitlement to 10 percent or 20 percent ratings for the period from September 12, 2013, to December 13, 2019 (a 30 percent rating is not available for disability of the lumbar spine), because there was full lumbar flexion at the March 2014 VA examination and as there is otherwise no evidence for the period from September 12, 2013, to December 13, 2019, that the limitation of lumbar flexion required for 10 percent (no greater than 85 degrees) or 30 percent rating (no greater than 60 degrees) ratings, a compensable rating cannot be assigned during this period on the basis of limitation of lumbar flexion. As for entitlement to a 10 or 20 percent for the period from September 12, 2013, to December 13, 2019, on the basis of combined loss of thoracolumbar spine motion, there was no loss of motion on any direction of the spine at the March 2014 VA examination, and as there is otherwise no evidence during the appeal period prior to December 14, 2019, that the combined limitation thoracolumbar spine motion required for a 10 percent (no greater than 235 degrees) or 30 percent rating (no greater than 120 degrees), a compensable rating cannot be assigned for the period from September 12, 2013, to December 13, 2019, on the basis of combined limitation of lumbar motion. As for entitlement to a 10 or 20 percent rating for the period from September 12, 2013, to December 13, 2019, on the basis of muscle spasm, guarding, localized tenderness, or a vertebral body fracture, the March 2014 VA examination did not reveal any of these findings, nor is there any evidence of such during this period. As such, a compensable rating cannot be assigned for the period from September 12, 2013, to December 13, 2019, on the basis of muscle spasm, guarding, localized tenderness, or a vertebral body fracture. Finally with respect to 10 or 20 percent ratings for the period from September 12, 2013, to December 13, 2019, on the basis of incapacitating episodes of IVDS, the March 2014 VA examination did not reveal any IVDS, and there is otherwise no evidence during this period that the Veteran had the incapacitating episodes of IVDS in the frequencies warranted for a 10 percent (a total duration of at least one week, but less than two weeks during a 12 month period) or 30 percent rating (a total duration of at least two weeks, but less than four weeks during a 12 month period) Therefore, a compensable rating cannot be assigned for the period from September 12, 2013, to December 13, 2019, basis of IVDS. Given all of the above, a compensable rating for the service-connected lumbar spine disability cannot be assigned for the period from September 12, 2013, to December 13, 2019. Id. Turning now to whether a rating in excess of 40 percent may be assigned for the service-connected lumbar spine disability for the period beginning December 14, 2019, such would require unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes of IVDS having a total duration of at least six weeks during a twelve-month period. The aforementioned December 2019 VA examination demonstrated no ankylosis in the lumbar spine and no IVDS, and there is otherwise no evidence for the period beginning December 14, 2019, demonstrating the degree of ankylosis required for a rating in excess of 40 percent rating or incapacitating episodes of IVDS in the frequency required for such a rating. As such, a rating in excess of 40 percent for lumbosacral strain and degenerative arthritis for the period beginning December 14, 2019, cannot be assigned. Id. With respect to the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016), the December 2019 VA examiner noted that there was pain in the lumbar spine on non-weight bearing and that active and passive motion were the same. As such, and as the 40 percent rating assigned rating for degenerative arthritis of the lumbar spine for the period beginning December 14, 2019, is the maximum assignable rating based on limitation of motion of the thoracolumbar spine, increased compensation pursuant to Correia is not warranted. As for the findings with respect to flare-ups required by Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Veteran at the March 2014 VA examination in his own words described flare-ups every two to three months which cause problems with lifting and bending. At the December 2019 VA examination, the Veteran in his own words described flare-ups of pain in the lumbar spine during cold and rainy weather. The examination was said to be neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. In short, the undersigned has considered the Veteran's complaints of fare-ups but finds any impairment resulting therefrom to be adequately compensated by the ratings that have been assigned for degenerative arthritis of the lumbar spine. Finally, with regard to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. §§ 4.40, 4.45 and the holdings in DeLuca and Mitchell, the reports from the examinations discussed above document consideration of these principles, to include repetitive motion. In particular, the March 2014 VA examination found no additional loss of lumbar spine motion with repetitive motion and noted that there were no contributing factors of weakness, fatigability, incoordination, or pain during flare-ups or repeated use over time that could additionally limit lumbar spine functioning. The December 2019 VA examination also showed no additional loss of motion with repetitive motion. This examination did note that pain and weakness resulted in some additional loss of motion in the lumbar spine measured to 30 degrees of forward flexion and 5 degrees of flexion and rotation to each side. As set forth above, it was this additional loss of motion to 30 degrees due to pain and weakness that was the basis for the assigment of the 40 percent rating, and there is otherwise no clinical evidence indicating that any additional compensation would be warranted for the service-connected lumbar spine disability with consideration of the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. §§ 4.40, 4.45 and the holdings in DeLuca and Mitchell. E. Final Considerations In making the above rating determinations, the undersigned observes that she has carefully considered the Veteran's contentions with respect to the nature of the service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these manifestations. However, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected manifestations at issue. As such, while the undersigned accepts the Veteran's testimony with regard to the matters he is competent to address, she places more probative weight upon the competent medical evidence with regard to the specialized evaluation of functional impairment; namely, the assessments of the severity of disability due to the service connected for PTSD, migraine headaches, and lumbosacral strain and degenerative arthritis. Finally, and noting again that the determination that a rating in excess of 50 percent rating for migraine headaches cannot be assigned for the period beginning April 4, 2017 is based on the operation of law, in making the negative rating determinations above, the undersigned has considered the doctrine of reasonable doubt but finds that the preponderance of the evidence is against the assignment of increased compensation for these disabilities. As such, increased ratings for PTSD, migraine headaches, and lumbosacral strain and degenerative arthritis may not be granted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert. REMAND The audiometric findings from the December 2019 examination requested by the March 2019 Board remand would warrant a compensable rating for the service-connected bilateral hearing loss with application of either Table VIA or VII codified at 38 C.F.R. § 4.85. However, the audiologist who conducted this examination found the Veteran's responses on audiometric testing to be inconsistent and unreliable. She also indicated that the use of the speech discrimination score is not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc., thus indicating the need to use Table VIA codified at 38 C.F.R. § 4.85 to evaluate the Veteran's hearing impairment based solely on puretone threshold averages. As the record before the Board does not at this time include a reliable measurement of the Veteran's current hearing impairment, the undersigned finds that another attempt must be made to obtain reliable audiometric results so as to fulfill the duty to assist the Veteran. Therefore, this case is remanded for the following development: Schedule the Veteran for a VA examination, if possible by a different clinician than the one that conducted the December 2019 VA audiometric examination, to determine the current severity of his bilateral hearing loss. The examiner should conduct audiometric testing and report the resulting auditory thresholds, in decibels, for the frequencies of 1000, 2000, 3000, and 4000 Hertz. A Maryland CNC Test should also be administered to obtain speech recognition scores, and if it is again determined that these scores are not appropriate for ratings purposes because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc., such should be so stated. The examiner is specifically requested to describe the functional effects caused by the Veteran's bilateral hearing loss. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Andrew Ahlberg, 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.