Citation Nr: 21006721 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 16-19 272 DATE: February 5, 2021 ORDER Entitlement to service connection for a bilateral hearing loss disability is denied. Entitlement to an initial rating higher than 10 percent for left ankle sprain is denied. Entitlement to an initial rating higher than 10 percent for right heel strain from September 1, 2012 to April 15, 2016 is denied. Entitlement to an initial rating higher than 10 percent for left heel strain from September 1, 2012 to April 15, 2016 is denied. Entitlement to a rating higher than 50 percent for bilateral plantar fasciitis with heel strain since April 15, 2016 is denied. Entitlement to an initial compensable rating for gastroesophageal reflux disease (GERD) from September 1, 2012 to October 7, 2019 is denied. Entitlement to an initial 10 percent rating, but no higher, for GERD since October 7, 2019 is granted. REMANDED Entitlement to an initial rating higher than 10 percent for lumbar strain is remanded. Entitlement to an initial compensable rating for mucus retention cysts in the maxillary sinus is remanded. Entitlement to an initial rating higher than 10 percent for traumatic brain injury (TBI) is remanded. Entitlement to an initial compensable rating for left leg condition is remanded. Entitlement to an initial rating higher than 10 percent for left knee sprain is remanded. FINDINGS OF FACT 1. A bilateral hearing loss disability according to VA regulations has not been shown by the record. 2. Left ankle sprain is not manifested by marked limitation of motion. 3. From September 1, 2012 to April 15, 2016, right heel strain was not manifested by a moderately severe disability. 4. From September 1, 2012 to April 15, 2016, left heel strain was not manifested by a moderately severe disability. 5. Since April 15, 2016, bilateral plantar fasciitis with heel strain is assigned a 50 percent rating, which is the maximum schedular rating available for the disability. 6. From September 1, 2012 to October 7, 2019, GERD was manifested by reflux. 7. Since October 7, 2019, GERD is characterized by dysphagia, pyrosis and regurgitation of less severity than the rating criteria for a 30 percent evaluation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2020). 2. The criteria for a rating higher than 10 percent for left ankle sprain have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2020). 3. The criteria for an initial rating higher than 10 percent rating for left heel strain from September 1, 2012 to April 15, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5284 (2020). 4. The criteria for an initial rating higher than 10 percent for right heel strain from September 1, 2012 to April 15, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5284 (2020). 5. The criteria for a rating higher than 50 percent for bilateral plantar fasciitis with heel strain since April 15, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.59, 4.7, 4.71a, Diagnostic Codes 5276-5284 (2020). 6. From September 1, 2012 to October 7, 2019, the criteria for a compensable rating for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1 , 4.2, 4.3, 4.7, 4.10, 4.20, 4.114, Diagnostic Code 7346 (2020). 7. Since October 7, 2019, the criteria for a 10 percent rating, but no higher, for GERD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.114, Diagnostic Code 7346 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Marine Corp from November 1991 to August 2012. Initially, the Board notes that in his March 2019 Board hearing the Veteran expressed that his service-connected disabilities impacted his ability to maintain employment. Thus, a claim of entitlement to a total disability evaluation based on individual unemployability due to service-connected disorders was raised by the record and thus a component of the increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In May 2019, however, the Veteran requested that his claim for TDIU be withdrawn as he found employment. Accordingly, the claim has been withdrawn and is no longer before the Board. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as sensorineural hearing loss, may be presumed to be service-connected if manifested to a degree of 10 percent disabling or more within one year after separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran appeals the denial of service connection for a bilateral hearing loss disability. After review of the record, the Board finds against the claim for service connection for a bilateral hearing loss disability. To that end, in this case, basic entitlement to disability compensation derives from 38 U.S.C. § 1131. The statute provides for compensation, beginning with the words: “For disability resulting from personal injury suffered of disease contracted in the line of duty....” 38 U.S.C. § 1131. Thus, in order for a veteran to qualify for entitlement to compensation under those statutes, the Veteran must prove the existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Here, there is no credible showing of a bilateral hearing loss disability for VA purposes at the time of filing or anytime during this appeal. In this regard, the evidence is devoid of a showing of auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz 40 decibels or greater; or auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 26 decibels or greater; or speech recognition score using the Maryland CNC Test shown to be less than 94 percent for the right ear. See 38 C.F.R. § 3.385. While the Veteran complains of loss of hearing, the May 2013 and October 2018 VA examinations disclosed essentially normal hearing. While the October 2018 VA examination noted that the use of the word recognition score (Maryland CNC) was not appropriate due to language difficulties, cognitive problems, etc, the May 2013 VA examination disclosed speech recognition scores of 98 percent for the right and left ear. Implicit in the claim is the Veteran’s belief that he has a bilateral hearing loss disability. The Board notes, however, that a bilateral hearing loss disability as defined by VA regulations has not been shown by the service treatment records, VA medical records and examinations, and/or private medical records. The existence of a hearing loss disability is determined by very specific testing. The VA examinations discloses hearing acuity that does not reach the level of disability for the left and/or right ear. Accordingly, service connection for a bilateral hearing loss disability is denied. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal concerning an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the ‘staging’ of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127; see also 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 normal 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Entitlement to an initial rating higher than 10 percent for left ankle sprain The Veteran appeals the denial of an initial rating higher than 10 percent for left ankle sprain. The Veteran’s disability is rated under Diagnostic Code 5271. DC 5271 assigns a 10 percent evaluation for moderate limitation of motion of the ankle, and a 20 percent evaluation is assigned for marked limitation of motion. The Board notes that the terms “moderate” and “marked” in the criteria are not defined in the rating schedule. Therefore, rather than applying a mechanical formula, VA must evaluate all the evidence to the end that decisions are equitable and just. 38 C.F.R. § 4.6. With regard to the criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5271, normal dorsiflexion of the ankle is from 0 degrees to 20 degrees. Normal plantar flexion is from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Based on the evidence of record, the Board finds that the claim for an increased rating must be denied. To that end, the August 2013 VA examination disclosed a diagnosis of mild left ankle sprain. At that time, the Veteran reported that he had left ankle pain all of the time. He denied flare ups. Examination revealed left ankle plantar flexion was to 40 degrees with no objective evidence of painful motion and dorsiflexion (extension) was 20 degree or greater with no objective evidence of painful motion. There was no additional loss of function or range of motion following repetitive use testing. There was a showing, however, of functional loss which included less movement than normal after repetitive testing. The ankle had normal muscle strength, and there was no showing of joint instability and/or ankylosis. In March 2014, the Veteran reported that he had left ankle swelling and limited range of motion. The Veteran was afforded another VA examination in June 2017. Lateral collateral ligament sprain (chronic/recurrent) was diagnosed. The Veteran denied flare ups of the ankle but he reported limited use of the ankle, i.e. sports or prolonged standing. Examination revealed left ankle plantar flexion was to 45 degrees and dorsiflexion (extension) was 20 degree. There was pain noted on examination but it did not result in/cause functional loss. There was pain with weightbearing. There was no additional loss of function or range of motion following repetitive use testing. The left ankle had normal muscle strength, no atrophy and there was no showing of joint instability and/or ankylosis. Pain left lateral ankle with active and passive motion with and without weightbearing was noted. During the October 2019 VA examination, the Veteran reported constant pain and stiffness. The Veteran denied ankle flare ups. Examination revealed left ankle plantar flexion was to 20 degrees and dorsiflexion (extension) was 10 degrees. No pain was noted on examination and range of motion itself did not contribute to functional loss. There was no evidence of pain with weight bearing. There was no additional loss of function or range of motion following repetitive use testing. It was noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The left ankle had normal muscle strength, no atrophy and there was no showing of joint instability and/or ankylosis. During the April 2020 VA examination, a diagnosis was rendered of mild left ankle sprain, resolved. It was noted that the Veteran felt pain with prolonged standing, and popping. He had difficulty walking and left ankle swelling. The Veteran denied flares ups of the left ankle. Examination revealed left ankle plantar flexion was to 45 degrees and dorsiflexion (extension) was 20 degree. There was no pain on examination. There was also no pain with weight bearing. There was no additional loss of function or range of motion following repetitive use testing. It was noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The left ankle had normal muscle strength, no atrophy and there was no showing of joint instability and/or ankylosis. There was no objective evidence of pain on non-weight bearing. The VA examiner noted that, though the Veteran complains of a left ankle injury and the record notes that in 1972 he had a left ankle sprain, examination of the left ankle was normal indicating that the original left ankle sprain has resolved. He noted that there was no evidence of an ongoing left ankle sprain, and that the Veteran’s symptoms of difficulty walking are not due to his left ankle, but rather, to his bilateral plantar fasciitis. The VA examinations disclose left ankle plantar flexion has been no worse than 20 degrees and dorsiflexion (extension) no worse than 10 degrees. The Board is mindful of the Veteran's complaints of left ankle pain and swelling, but the evidence of record is devoid of a showing of marked limitation of motion. Rather, the Veteran denies left ankle flare up and there is no showing of ankle instability. To the extent that the Veteran reports difficulty walking and prolonged standing, the Board notes the VA examiner stated that the Veteran’s difficulty walking was not due to his left ankle but rather to his bilateral plantar fasciitis. Lastly, despite his left ankle pain, the Board notes that the majority of examinations show that the Veteran retains left ankle plantar dorsiflexion to at least 40 degrees and plantar flexion to 20 degrees. Even when considering 38 C.F.R. §§ 4.40, 4.45, 4.59; and DeLuca, supra, 8 Vet. App. 202, the functional equivalent of marked limitation of motion is not shown. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board has considered whether a higher rating by analogy is available through another other diagnostic code that considers similar symptoms, but has found none. In this case, the Board finds no other provision upon which to assign a rating higher than 10 percent disabling for left ankle sprain. Moreover, the Veteran has not reported other symptoms not contemplated by these rating criteria. Accordingly, the claim for a rating higher than 10 percent disabling for left ankle sprain is denied. Entitlement to an initial rating higher than 10 percent for left and right heel strain from September 1, 2012 to April 15, 2016, and a rating higher than 50 percent for bilateral plantar fasciitis with heel strain from April 15, 2016 The Veteran appeals the denial of an initial rating higher than 10 percent for right heel strain from September 1, 2012 to April 15, 2016, an initial rating higher than 10 percent for left heel strain from September 1, 2012 to April 15, 2016 and a rating higher than 50 percent for bilateral plantar fasciitis with heel strain from April 15, 2016. From September 1, 2012 to April 15, 2016, the Veteran’s left and right heel strain disability is rated under Diagnostic Code 5284 which evaluates foot injuries. Under this Code, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries and a 30 percent rating is assigned for severe foot injuries. After review of the record, the Board finds against a rating higher than 10 percent for the service connected right and left heel strain from September 1, 2012 to April 15, 2016 as a moderately severe foot injury is not shown during this time. To that end, the May 2013 VA examination disclosed a diagnosis of heel strain with an onset of 2011. No other foot conditions were found. At that time, the Veteran reported heel pain with long standing and walking. In March 2014, the Veteran reported that he could not put pressure on his heels without pain. While the Veteran reported heel pain during this time, he reported such with long standing and walking. He denied flare-ups that impact the function of the foot and examinations of the heel during with time were generally normal. At most, the Board finds that the evidence showed a moderate disability. Regarding the Veteran’s complaints of painful motion, the Board notes that the 10 percent rating contemplates periarticular pathology productive of painful motion. 38 C.F.R. § 4.59. In reaching this conclusion, the Board has considered the requirements of 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The Board finds, however, that the more probative evidence is devoid of a showing of a moderately severe foot disability as to warrant the next higher evaluation during this period of time. The Board acknowledges the Veteran's assertions to include his reports of pain. The Veteran is competent to report his symptoms and has presented credible testimony. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has also considered the lay statements of record which discuss the Veteran's functional limitations. The Board finds, however, that neither the lay or medical evidence demonstrates that the criteria for a 20 percent evaluation have been met. The most probative evidence is that prepared by neutral skilled professionals, and such evidence demonstrates that no more than a 10 percent evaluation is warranted during this period of time. Accordingly, a rating higher than 10 percent for left and/or right heel strain September 1, 2012 to April 15, 2016 is denied. The Board also finds against the claim for a rating higher than 50 percent for bilateral plantar fasciitis with heel strain since April 15, 2016. As of April 15, 2016, the Veteran’s bilateral plantar fasciitis with heel strain is rated under DCs 5284-5276. Under Diagnostic Code 5276, a 10 percent rating is warranted for moderate pes planus with the weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet, bilateral or unilateral. Severe pes planus manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, warrants the assignment of a 20 percent rating if unilateral and 30 percent rating if bilateral. Pronounced pes planus manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances warrants the assignment of a 30 percent rating if unilateral and 50 percent rating if bilateral. The Board notes that, since April 15, 2016, the Veteran has been granted a 50 percent rating for his disability which is the maximum under DC 5276 and above the maximum 30 percent rating permitted under DC 5284. The Board recognizes the Veteran’s assertion that his disabling warrants a higher evaluation; however, 50 percent is the maximum rating available for bilateral plantar fasciitis with heel strain since April 15, 2016 under DCs 5276-5284. The Board further notes that it cannot factually ascertain from the lay and medical evidence that bilateral plantar fasciitis was clinically present at any specific time prior to the VA clinic evaluation on April 15, 2016. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board has considered whether a higher rating by analogy is available through another other diagnostic code that considers similar symptoms, but has found none. In this case, the Board finds no other provision upon which to assign a rating higher than 50 percent disabling for bilateral plantar fasciitis with heel strain. Moreover, the Veteran has not reported other symptoms not contemplated by these rating criteria. Accordingly, the claim for a rating higher than 50 percent disabling for bilateral plantar fasciitis with heel strain since April 15, 2016 is denied. Entitlement to an initial compensable rating for GERD The Veteran appeals the denial of an initial compensable rating for gastroesophageal reflux disease. The Veteran’s disability is rated under DC 7346. Under Diagnostic Code 7346, a 10 percent rating is warranted where there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. During the August 2013 VA examination, the Veteran was diagnosed with GERD with an onset of four years prior. The Veteran reported that he got reflux about once a week but it was noted that he was not on a treatment plan that included continuous medication. His only symptom was reflux. During the October 2019 VA examination, it was noted that the Veteran had GERD symptoms to include pyrosis, regurgitation and dysphagia. It was noted he complained of intermittent pyrosis, regurgitation and nausea. In an October 2019 outpatient treatment report, it was noted that the Veteran was evaluated for irregular bowel movements and GERD/abdominal bloating. The Veteran reported small bowel movement every few days with occasional red blood and mucus in the stools with associated abdominal bloating. He had reflux symptoms but no dysphagia. His weight was stable. After review of the evidence, the Board finds against a compensable rating for GERD from September 1, 2012 to October 7, 2019. To that end, during this period of time the Veteran’s GERD was manifested by symptoms of at most reflux, two or more of the symptoms for the 30 percent evaluation of less severity was not shown during this time. The Board acknowledges the Veteran’s assertions that his disability is more severe than evaluated to include his reports of regurgitation. The Veteran is competent to report his symptoms and presented credible testimony. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds, however, that neither the lay or medical evidence demonstrates that the criteria for a compensable rating for GERD are met from September 1, 2012 to October 7, 2019. The more probative evidence is that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned rating is warranted and no more. The Board has considered whether any other diagnostic codes would allow for a higher disability rating during this period of time but has found none. As of October 7, 2019, however, the evidence shows that the Veteran’s GERD symptoms include intermittent pyrosis, regurgitation and dysphagia. Thus, the Veteran has two or more of the symptoms of less severity than the rating criteria for a 30 percent evaluation. Therefore, the Veteran is entitled to a disability rating of 10 percent since October 7, 2019. A higher 30 percent rating is not warranted, however, as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health has not been shown. At most, the Veteran has exhibited GERD symptoms of intermittent dysphagia, pyrosis, regurgitation and nausea. There is also no showing of substernal or arm or shoulder pain, productive of considerable impairment of health, that is caused by, or due to, GERD. Accordingly, a rating of 10 percent, but no higher, for GERD is warranted as of October 7, 2019. The Board further notes that it cannot factually ascertain from the lay and medical evidence that GERD symptoms other than reflux were clinically present at any specific time prior to October 7, 2019. REASONS FOR REMAND The Veteran appeals the denial of an initial rating higher than 10 percent for lumbar strain. In relation to his claim, the Veteran was last afforded a VA examination in April 2019. During the VA examination, the VA examiner noted that pain and lack of endurance significantly limited functional ability with repeated use over a period of time. The examiner was unable to describe the limitation in terms of range of motion. The examiner, however, indicated that there was no change in range of motion after three repetitions with flexion, extension, right lateral and rotation, and that the Veteran was only able to perform one left lateral and rotation and then he had to sit down because he stated that he was in too much pain to continue. Even though the examiner noted that there was no change in range of motion after three repetitions with flexion, extension, right lateral and rotation, the examiner did not address whether there was loss of range of motion after repeated use over time. Rather, the examiner addressed whether there was motion loss after observed repetitive use which is separate and distinct from repeated use over time. As such, the record is still unclear as to the extent of range of motion loss after repeated use over time. In light of the holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017) and the criteria set forth in Diagnostic Code 5237, the Board finds that another examination on this matter is needed. The Veteran appeals the denial of an initial compensable rating for mucus retention cysts in the maxillary sinus. The Veteran’s disability is evaluated under 38 C.F.R. § 4.97, Diagnostic Codes 6599-6513. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional Diagnostic Code to identify the basis for the rating. 38 C.F.R. § 4.27. DC 6599 represents an unlisted disability requiring rating by analogy to one of the disorders rated under the code. DC 6513 evaluates chronic maxillary sinusitis. During the May 2013 VA examination, the examiner found that the Veteran did not have a sinus, throat, nose, larynx and/or pharynx condition. The examiner stated that the Veteran denied having sinusitis and/or sinusitis symptoms, and it was noted that he was not taking medication for such. In March 2014, the Veteran reported constant restriction of his airways caused by his condition. During the October 2019 VA examination, the Veteran was diagnosed with mucus retention cysts in the maxillary sinus. The Veteran complained of occasional rhinitis, nasal dyspnea and congestion. Although the Veteran’s disability is rated under the criteria for chronic maxillary sinusitis, he reports symptoms that include green snot in the mornings with blood and constant restriction of his airways. He also complains of occasional rhinitis. As he reports nasal obstruction, the Board finds that consideration by analogy of DC 6523 (rhinitis) may be warranted. Accordingly, the Board finds that another VA examination is warranted to determine the current severity of the Veteran’s disability. The Veteran appeals the denial of an initial rating higher than 10 percent for traumatic brain injury. In the August 2020 rating code sheet, the Veteran is shown to have a rating of 70 percent disabling under Diagnostic Code 9434 for major depressive disorder and traumatic brain injury with residuals of brain infections, effective September 1, 2012. The same code sheet also shows a rating of 10 percent for TBI with residuals of brain infections under Diagnostic Code 8045, effective September 1, 2012 to May 7, 2019. It seems that for the period from September 1, 2012 to May 7, 2019 the Veteran’s TBI has been rated under DC 8045 as 10 percent and rated under DC 9434 as combined with the major depressive disorder. Consequently, two separate ratings for the same disability are in effect for period of time from September 1, 2012 to May 7, 2019. The Board also finds that clarification is needed regarding the claims for an initial compensable rating for left leg condition and an initial rating higher than 10 percent for left knee sprain. To that end, in the August 2020 rating code sheet, the Veteran is shown to be service-connected for left knee sprain rated as 10 percent under DC 5260 and a left leg condition rated as 0 percent under DCs 5299-5260. Historically, the Veteran’s left knee sprain was rated under DC 5257 while the Veteran’s left leg condition was rated under DC 5260. The rating code sheet is conflicting and clarification on this matter is needed for proper adjudication of the claims. The Board cannot adequately adjudicate the claims on appeal without clarification as to the correct ratings assigned and/or the effective dates assigned. As there are conflicting ratings assigned for the Veteran’s TBI and left knee disabilities, a remand is required in order for the RO to provide clarification as to the ratings assigned, the diagnostic code under which those ratings are assigned, and the date ranges that each rating is effective. The matters are REMANDED for the following action: 1. Associate with the claims folder updated VA treatment records. 2. Review the record to provide clarification as to the ratings assigned to the Veteran’s TBI, left knee strain and left leg condition. Specifically, the rating code sheet must clarify the period of time that each rating is effective and the diagnostic code under which rating is assigned. 3. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected lumbar spine disability. Access to the electronic claims file must be made available to the examiner for review. In accordance with the latest worksheets for rating the lumbar spine, the examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints and the nature and extent of his disability. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017), the examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repeated use over time, and if so, the examiner must estimate range of motion during flares or repeated use. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. Also, in order to comply with the Court’s decision in Correia v. McDonald,28 Vet. App. 158 (2016), the VA examination must include range of motion testing in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. The degree at which pain begins must be documented. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The VA examiner should provide a complete rationale for any opinions provided. 4. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected mucus retention cysts in the maxillary sinus. Access to electronic record must be made available to the examiner for review. In accordance with the latest worksheets for rating the sinus disorders and rhinitis, the examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints and the nature and extent of his disability. The examiner should consider the Veteran’s descriptions of green snot in the mornings with blood, constant restriction of his airways, occasional rhinitis and nasal obstruction. 5. Upon completion of the above requested development and any additional development deemed appropriate, the AOJ must readjudicate the issues. All applicable laws and regulations should be considered. If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S. Willie 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.