Citation Nr: 21027096 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 14-03 584 DATE: May 4, 2021 ORDER Entitlement to service connection for shin splints is denied. Entitlement to an initial rating in excess of 20 percent for left shoulder tendonitis is denied. Entitlement to an initial rating in excess of 10 percent for left elbow degenerative joint disease (DJD) with scar is denied. Entitlement to an initial rating in excess of 10 percent for right hip bursitis with snapping syndrome is denied. Entitlement to an initial separate compensable, for right hip limitation of flexion associated with right hip bursitis with snapping syndrome is denied. REMANDED Entitlement to service connection for chronic sinusitis is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a respiratory condition, to include chronic obstructive pulmonary disorder (COPD) or chronic bronchitis, to include as due to Gulf War exposures is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for neurological symptoms including tingling and numbness in the bilateral lower extremities and right upper extremity is remanded. Entitlement to service connection for chronic fatigue is remanded. Entitlement to a total disability individual unemployability rating (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that shin splints began during active service or are otherwise related to an in-service injury or disease. 2. For the entire period on appeal, tendonitis of the left shoulder results in no more than painful limitation of motion at the shoulder level. 3. For the entire period on appeal, the Veteran's left elbow disability was manifested by only flexion limited to 135 degrees with pain, as well as functional loss with less movement than normal and pain on movement. 4. For the entire period on appeal, the Veteran's right hip limitation of rotation causes some painful and limited motion, but does not result in limitation of abduction such that motion is lost beyond 10 degrees. 5. Throughout the entire appeal period, the Veteran's service-connected right hip limited flexion was manifested by no worse than limitation of flexion to 90 degrees, even with pain; flexion of the left hip limited to 45 degrees or less, objective evidence of ankylosis of the left hip, flail hip joint or impairment of the femur have not been demonstrated. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for shin splints have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to a rating in excess of 20 percent for left shoulder tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5024-5201. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5024-5201). 3. The criteria for entitlement to an initial rating in excess of 10 percent for service-connected DJD of the left elbow with scar, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, DCs 5010. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5010). 4. The criteria for a disability rating in excess of 20 percent for right hip bursitis with snapping syndrome have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5019-5253. 5. The criteria for an initial compensable rating for impaired flexion due to right hip limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5019-5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1989 to January 1997 and from December 2003 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated May 2009, July 2009, February 2011, and March 2011 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a September 2012 Decision Review Officer Hearing. Thereafter he was scheduled for a hearing before the Board in April 2015. However, he did not appear for that hearing, and he has not requested that it be rescheduled or provided good cause for not appearing. Under these circumstances, his hearing request is deemed to have been withdrawn. 38 C.F.R. § 20.704(d). The Board remanded the issues on appeal in July 2015 and May 2018 for additional development. While pending return to the Board, in May 2015, the RO increased the Veteran's rating from 10 to 20 percent disabling for the left shoulder disability. In July 2020, the RO also granted a separate noncompensable rating for right hip limitation of flexion. These grants were made effective from August 26, 2008. The Veteran has continued his appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that the Veteran submitted a VA Form 21-22a, Appointment of Individual as Claimant's Representative, in favor of an unaccredited attorney in October 2015. The Board notified the Veteran in November 2020 correspondence that in order to represent him, his representative had to be accredited to represent claimants before VA. The correspondence also explained the options that he could pursue if he wished to be represented in his appeal. Significantly, the letter informed him that if he did not respond to the letter within 30 days with respect to his choice of representation, the Board would assume that he wished to proceed pro se. To date, the Veteran has not responded to the 2020 correspondence. The Board will thus assume that he wishes to represent himself in this appeal. Finally, as will be addressed in the remand portion of this decision, the issue of entitlement to a TDIU has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, this issue is listed above. Service Connection Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In order to establish entitlement to service connection for any disability on a direct basis, the record must contain competent evidence of (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that manifest "during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War" or to a degree of 10 percent or more before December 31, 2021. 38 U.S.C. § 1117; see 38 C.F.R. § 3.317 (a); 81 Fed. Reg. 71,382-84(Oct. 17, 2016) (extending the presumptive period for compensation for Gulf War veterans from December 31, 2016 to December 31, 2021). A qualifying chronic disability is as a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multi-symptom illness such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317 (a)(2)(i). A "medically unexplained chronic multi-symptom illness" has been defined as a "diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 C.F.R. § 3.317 a )(2)(ii). "Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained." Id. Along with the three examples of a medically unexplained chronic multi-symptom illness provided by section 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multi-symptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117 (g); 38 C.F.R. § 3.317(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49(1990). 1. Entitlement to service connection for shin splints. The Veteran seeks service connection for shin splints. He reports the condition began in 1991. Following consideration of the evidence entitlement to service connection is denied. Current diagnosis is established by way of an April 2013 VA examination report. Service treatment records are negative for diagnosis of shin splints. However, records confirm treatment for right knee pain. Pain was diagnosed as due to a right tibial stress fracture following road marching. The Veteran is also competent to report shin pain. Given the above, the first and second elements of Shedden are met. What remains is nexus. In April 2013, a VA examiner opined that the Veteran's diagnosed shin splints were not etiologically related to service. As rationale, the examiner first explained that shin splints are typically self-limited therefore not a condition usually associated with ongoing impairment/chronic residuals. The examiner then clarified that service treatment records are negative for evidence of chronic residuals. Additionally, the examiner noted that earlier and more recent diagnostic testing was negative for shin splits or other abnormalities. As a result, of the above, the examiner opined it less likely than not that the Veteran suffered from chronic shin splints etiologically related to service. The Board finds this opinion to be highly probative and there is no competent positive evidence to the contrary. In that regard, the record is also negative for treatment medical records post VA examination which document shin splints. The Board finds this collective evidence to be the most probative of record, and entitlement to service connection is not warranted. In rendering the above determination, the Board has considered the Veteran's lay assertions correlating his condition to service. However, to the extent the Veteran is diagnosing shin splints and correlating them to service, his claims are non-competent lay evidence. In that regard, not all questions of nexus are subject to non-expert opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay witnesses are competent to report that which they have observed with their own senses. Layno v. Brown, 6 Vet. App. 465, 469(1994). But here, while noting symptoms such as leg pain is within the Veteran's lay expertise, the diagnosing of said pain to specifically shin splints is not. Such a diagnosis is distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau v. Nicholson, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310(2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002). In any event, the Veteran's statements are outweighed by the probative and competent evidence of record. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increase Rating 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."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. A veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1. Where, as here, a veteran timely appealed the rating initially assigned for the service-connected disability, VA must consider whether a veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. Left Shoulder The Veteran is currently in receipt of a 20 percent rating under DC 5024-5201 effective August 26, 2008. As briefly aforementioned, the final rule, which amends portions of the schedule that addresses the musculoskeletal system, went into effect, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463(Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5201, 5024). The hyphenated DC in this case indicates that tendonitis under DC 5024, is the service-connected disorder, and limitation of motion of the arm, under DC 5201, is a residual condition. Under the aforementioned final rule, the note to the DC 5024 provides that diseases under DCs 5013 through 5024 to be evaluated based on limitation of motion of affected parts. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a), DC 5024. Under both the prior and the amended version of DC 5201, limitation of motion of the arm at the shoulder level (flexion and/or abduction limited to 90 degrees) is rated 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees) is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. The Veteran is right-hand dominant, and as such the criteria for a minor shoulder apply. 2. Entitlement to a rating in excess of 20 percent left shoulder tendonitis is denied. The Veteran seeks a rating in excess of 20 percent for his service-connected left shoulder disability. He generally asserts that his rating does not reflect the current severity of his disability. The claim stems from the initial grant of service connection, as a result, the period on appeal is from the date of service-connection, August 26, 2008 forward. Following consideration of the record, entitlement to a rating in excess of 20 percent is denied. Turning to the claims file, a March 2009 VA general examination confirms the Veteran as right hand dominant. He reported having decreased motion of the shoulder with some pain, weakness, and stiffness. There was no swelling, heat, redness, giving way or locking. The pain was reported as intermittent. Treatment was listed as rest and ibuprofen. Flareups were caused by cutting firewood or any rotating movement such as swimming. Flare ups were alleviated with over the counter medication and rest. Pain was moderate, with varying frequency and duration. Functional impairment during flare up was needing to stop and rest. The examiner found no limitations on occupation, but trouble with the tasks of cutting firewood or swimming. Physical examination of the shoulder revealed no obvious deformity, no tenderness to palpation. Range of motion (ROM) testing to the shoulder was: flexion to 160 degrees, abduction to 140 degrees, internal rotation to 80 degrees, external rotation to 80 degrees. There was discomfort at the end points of ROM, but no loss of motion with repetition. On April 2011 VA general examination, the Veteran reported no change in his condition. There was pain, weakness, and decreased speed of joint motion. Examination was negative for deformity, giving way, instability, incoordination, dislocation, locking, effusions, and inflammation. Flare ups were present, moderate in severity occurring weekly and for hours. Flare ups were precipitated by push-ups and overhead activities and alleviated by rest and medication. Flare ups required the Veteran to stop his activity. Physical examination revealed the shoulder was positive for tenderness with flexion is 0 to 150 degrees, abduction 0 to 135 degrees, and rotation was 0 to 70. Examination was negative for pain. The examiner opined that the occupational impact of the Veteran's disability was difficulty reaching and pain, resulting in moderate impairment of chores, exercise and recreation. On September 2012 DRO Hearing, the Veteran reported worsening in his shoulder. However, he reported being able to lift his arm to shoulder level straight out to his side. On October 2019 VA shoulder examination, the Veteran reported experiencing occasional sharp pain when lifting greater than 20 pounds over his head. He denied flares ups and reported not having a primary care physician or seeing a medical provider since 2016. Functional loss or functional impairment were noted as sharp pain when lifting greater than 20 pounds over head. ROM was flexion and abduction 0 to 170, and rotations to 90. There was no pain with weight bearing, or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Pain was present in flexion and abduction. There was no change following repetition. Examination was deemed medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Muscle strength was normal with no atrophy or ankylosis. Examination was positive for left shoulder rotator cuff conditions generally, but testing was negative. Examination was negative for instability, dislocation, or labral pathology, and clavicle, scapula, acromioclavicular joint or sternoclavicular joint conditions or conditions or impairments of the humerus. There were no assistive devices. There was no change between active and passive ROM testing. Functional impact was confirmed. Treatment medical records do not reflect worse symptomatology than discussed above. Upon consideration of the evidence, the Board finds that a rating in excess of 20 percent for the left shoulder condition is not warranted. At no point during the pendency of the appeal has the left shoulder exhibited range of motion limited to below shoulder level, which would be necessary to warrant a rating greater than the assigned 20 percent rating in fact, his flexion was, at worst, to 150 degrees, abduction to 135 degrees, and internal and external rotation to 70 degrees. Furthermore, he consistently manifested normal muscle strength, with no evidence of ankylosis, muscle atrophy, or shoulder instability. An adequate discussion of functional loss includes consideration of manifest functional loss during flare-ups. See Mitchell, 25 Vet. App. 32. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38 C.F.R. § 3.344 (a) and 38 C.F.R. § 4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. In that regard, the Board finds the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. There are no reports of exacerbation or flare-ups that are quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38 C.F.R. § 3.344 (a) regarding stabilization of ratings. To the contrary, the Veteran's most recent VA examination was negative for reports of flare ups. In addition, when previously describing his flare ups the Veteran reported they were associated with activities requiring overexertion and repeated rotation. To that end, he did not associate his flare ups with regular consistent movements, instead, he reported them as occurring following infrequent activities which are known to be strenuous such as chopping wood, swimming, and doing push-ups. Importantly, although his reports are credible, the current rating schedule contemplates symptoms such as pain or limitation of the motion, and his reports do not equate to the severity and consistency sufficient to warrant a higher rating. Furthermore, the Veteran was able to perform repetitive use testing, with no additional loss of function or range of motion. As such, a higher rating is not warranted. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, supra. Thus, the preponderance of the evidence is against a finding that the Veteran had more limitation of motion in his shoulder than that noted above. In reaching this conclusion, the Board, again, acknowledges the Veteran's competent lay reports of symptoms and that there was, at times, functional loss due to pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran's service-connected disability has been provided by VA medical professionals who have examined him. The medical findings adequately address the criteria under which the disability is evaluated and clearly demonstrate that the degree of impairment over the period at issue. As stated, even considering the Veteran's lay reports of symptoms, the record is devoid of competent evidence, supporting his conditions more nearly approximating a rating in excess of 20 percent. The Board accords these medical professional findings greater weight than the Veteran's complaints as to symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Therefore, the claim for rating in excess of 20 percent for the left shoulder disability must, for the above reasons, be denied. The Board also considered whether a separate shoulder rating was appropriate in this case. DC 5200 considers ankylosis, which has not been shown here. There is also no indication of immobility, even with reported pain, such that the Veteran's ROM could be functionally equivalent to a finding of ankylosis. Additionally, DC 5202 applies to impairment of the humerus and scapulohumeral joint, and DC 5203 applies to malunion, non-union, or dislocation of the clavicle or scapula, none of which has been shown in the medical evidence of record for the Veteran's service-connected left shoulder disability. Separate ratings under these codes is not warranted. In summary, the Board finds disability rating in excess of 20 percent for the Veteran's service-connected left shoulder disability is not warranted throughout the appeal period. As the evidence preponderates against the claim, the benefit of the doubt rule has no application. Left Elbow Prior to February 7, 2021, DC 5010 directs that traumatic arthritis substantiated by x-ray findings should be rated as degenerative arthritis under DC 5003. 38 C.F.R. § 4.71a. Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent rating, and x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, warrants a 20 percent rating. Id. The 10 percent and 20 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id. at Note 1. From February 7, 2021, DC 5010 referred to post-traumatic arthritis: to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25. 3. Entitlement to a rating in excess of 10 percent for left elbow DJD with scar is denied. The Veteran seeks a higher disability rating for his service-connected left elbow disability. He claims that his current rating does not reflect the current severity. The claims stem from the initial grant of service connection, as a result, the period on appeal is from the date of service-connection, August 26, 2008 forward. Throughout the period on appeal, the Veteran has been rated under DC 5010. Following consideration of the record, entitlement to a rating in excess of 10 percent is denied. March 2009 VA general examination confirms the Veteran as right hand dominant. Elbow pain was reported as coming and going with stiffness, no weakness, heat, redness, giving away or locking. Elbow pain and flare ups were associated with overexertion such as wrenching or pipefitting as work. Examination was negative for dislocations, subluxations, constitutional symptoms, assistive devices, or prosthesis. Pain was moderate, with varying frequency and duration. Functional impairment, because of pain, resulted in the Veteran needing to stop and rest. The Veteran reported increased pain at work due to wrenching but no other limitations and no limitations on daily activities. Physical examination of the elbow revealed no tenderness to palpation or pain with ROM. There was a scar on the posterolateral aspect of the elbow from prior surgery. The scar was 5 cm x less than 1 cm. There was no elevation, depression or cheloid formation, and no adherence to the underlying skin. The scar was nontender, with no evidence of skin breakdown or tissue loss. ROM was flexion to 140, extension to 0, pronation to 80, and supination to 85 degrees. On September 2012 DRO Hearing, the Veteran reported worsening in his elbow with locking up and precluding straightening. He reported that once his elbow pops, he can straighten it. He denied problems extending his elbow and instead confirmed full extension. He also reported experiencing associated numbness into his hands at times when pulling objects. On October 2019 VA elbow examination revealed the Veteran reporting constant achy joint pain in the left elbow. He reported pain with twisting motions, lifting greater than 20 pounds and pulling action. He denied any scar pain and flare ups. He reported taking over the counter medication. ROM was flexion 0 to 135, extension 0 to 135, supination 0 to 85, and pronation to 80. Pain was present in flexion. There was no objective evidence of localized tenderness or pain on palpation or crepitus. There was no change following repetition. The examination was deemed medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Muscle strength was normal, with no atrophy, and no ankylosis. Residuals of arthroscopic surgery was achy pain. A left elbow scar was present and 8.0 cm x width 0.1 cm with no indication of pain or other symptoms. No assistive devices were used. Functional impact was mild pain with reaching over head, twisting, or pulling. There was no change between active and passive ROM testing. Treatment medical records do not reflect symptomatology worse than reflected above. After careful review, the Board finds that the most probative evidence of record does not reach the level of equipoise as to whether a rating in excess of 10 percent may be assigned for DJD of the left elbow. From the outset, the Veteran has already been assigned the highest possible disability rating under DC 5010 throughout the appeal period, as the left elbow is a single major joint. 38 C.F.R. § 4.45 (f). Thus, a higher disability rating is not applicable for the Veteran's left elbow disability respecting DC 5010, and the Board will no longer discuss this code. See 38 C.F.R. § 4.71a, DC 5010. Additionally, based upon the evidence of record, the Board finds the Veteran's service-connected left elbow disability is manifested by limitation of ROM that is consistently noncompensable, including because of functional loss due to pain. As to numerical testing results, the VA examination findings are found to be persuasive and consistent with the overall evidence of record. These examinations reflected flexion at worse to 135 degrees, and extension always to 0. Of note, on final VA examination the Veteran had full ROM. Given the above, there is no evidence of compensable limitation of motion; therefore, no higher rating is warranted for the service-connected elbow disability. The Board has considered the manifestation of functional loss during flare-ups. See Mitchell, 25 Vet. App. 32. However, the degree of disability specified is considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. There are no reports of exacerbation or flare-ups that are quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38C.F.R. §3.344 (a) regarding stabilization of ratings. As stated, the Veteran's 2019 VA examination was negative for reports of flare ups. Even when considering his earlier reports of flare ups in 2009 there is no indication that they were of the consistency or severity to warrant an increase rating. His reported increased pain with wrenching or pipefitting was noted to resolve with rest and no other limitation or impairment was reported or documented. He also did not report losing work. That said, while the Veteran has reported occasional elbow pain and painful flare-ups, there is no indication from the record that he has more limitation of motion than that shown discussed during his VA examinations of record. Such additional limitation that he experiences due to pain, weakness, fatigability, lack of endurance, or incoordination on repetition was accounted for by the VA examiner when determining the Veteran's ROM and was further considered by the Board. 38 C.F.R. § 4.40, 4.45. Thus, the preponderance of the evidence is against a finding that the Veteran had more limitation of motion in his elbow. The Board again acknowledges the Veteran's competent lay reports of symptoms and that there was, at times, functional loss due to pain. See Jandreau, supra. However, he is not competent to identify a specific level of disability. Such competent evidence has been provided by way of examiner and clinician evidence. This evidence, which is considered more probative, does not support that the elbow condition more nearly approximating a rating in excess of 10 percent. See Cartwright, supra. Therefore, the claims for ratings in excess of 10 percent for the left elbow must, for the above reasons, be denied. The Board has also considered whether higher disability ratings are warranted under an alternative diagnostic code relating to disabilities of the elbow and forearm. See, Esteban, supra. 6 Vet. App. 259, 261-62 (1994). However, the evidence of record does not show evidence of, or equivalent to ankylosis, forearm flexion limited to 90 degrees, extension limited to 75 degrees, forearm flexion limited to 100 degrees and extension to 45 degrees, joint fracture, nonunion of the radius and ulna, impairment of the radius or ulna, or impairment of supination and pronation. See 38 C.F.R. § 4.71a, DC 5205, 5206, 5207, 5208, 5209, 5210, 5211, 5212 and 5213. With specific regard to ankylosis, the Board notes that although the Veteran reported his elbow locking on 2012 DRO hearing, he denied locking on examinations. Treatment records are also negative for reports supporting immobility akin to his testimony or a specific finding of ankylosis. Rather, as evidenced above, the Veteran has largely maintained almost complete ROM throughout the appeal. Accordingly, higher disabilities ratings are not warranted under an alternative diagnostic code. Lastly, the Board has also considered whether the Veteran is entitled to a separate rating for his left elbow scar. VA examination reports a single lateral scar on the left elbow. During the pendency of the appeal, the scar ranged from 4-8 centimeters by 0.1 centimeter. The scar was characterized as well-healed, non-tender, non-keloidal, and there is no indication of interference with the elbow joint. As there is no evidence that the scars were painful/tender, unstable, deep, nonlinear, covered an area of 144 square inches or more, or limited function of the left foot in any way, a separate, compensable rating for the left foot scars cannot be assigned. See 38 C.F.R. § 4.118, DCs 7801-7805. Consequently, a rating in excess of 10 percent for the Veteran's left elbow disability is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Right Hip The Veteran is currently in receipt of two separate ratings for the right hip a 10 percent rating under DC 5019-5253 and a noncompensable rating under 5019-5252, both from August 26, 2008 forward. As briefly aforementioned, the final rule, which amends portions of the schedule that addresses the musculoskeletal system, went into effect, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463(Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5201, 5024). The regulation changes do not affect the Veteran's DCs. DC 5019 addresses bursitis and indicates that evaluation under the limitation of motion codes for the applicable joints, including the applicable DCs for arthritis, is appropriate. DC 5251, a maximum 10 percent disability evaluation is warranted where there is limitation of extension of the thigh to 5 degrees. 38 C.F.R. § 4.71a, DC 5251. Under DC 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, DC 5252. Under DC 5253, a 10 percent rating is warranted for limitation of rotation of affected leg, cannot toe out more than 15 degrees. A 10 percent rating is also warranted for limitation of adduction, cannot cross legs. A maximum 20 percent rating is warranted for limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. Normal ranges of motion of the hip are hip flexion from 0 degrees to 125 degrees and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. 4. Entitlement to an initial rating in excess of 10 percent for right hip bursitis with snapping syndrome is denied. 5. Entitlement to a separate compensable rating for right hip limitation of flexion is denied. The Veteran seeks a higher disability rating for his service-connected right hip disabilities. The claims stem from the initial grant of service connection, as a result, the period on appeal is from the date of service-connection, August 26, 2008 forward. The Veteran is in receipt of a 10 percent rating under DC 5019-5253 and a noncompensable rating under 5019-5252 for the entire period on appeal. Increase ratings are not warranted. Turning to the claims file, on March 2009 VA general examination the Veteran reported intermittent right hip pain as well as experiencing the sensation that his hip popped in and out. He denied weakness, stiffness, swelling, heat, redness, giving way or locking. He reported no treatments for his conditions. He reported right hip flare ups after a jog or if he sleeps or lays on his right side. Flare was alleviated by changing positions and time. There were no functional limitations. The Veteran denied using assistive devices or having surgeries, dislocations, recurrent subluxation, constitutional symptoms, or prothesis. He reported experiencing intermittent pain daily with walking. He reported his ability to walk was limited to about half a mile. He reported an inability to sleep on his right side and avoiding jogging. There were no other limitations and no occupational limitations. Physical examination of the hip revealed no obvious deformity. There was tenderness to palpation over the lateral aspect of the hip and there was popping or snapping sensation noted with the ROM testing. The Veteran was able to cross his legs and could toe out greater than 15 degrees. ROM was flexion to 110, extension to 20 degrees, and abduction to 40 degrees. There was discomfort at the end points of movement, but no loss of ROM with repetition. On April 2011 VA general examination, the Veteran reported increased pain with jogging and being able to walk without pain. His condition was noted as stable with only over the counter medication. Examination was negative for deformity, dislocation, subluxation, locking, effusions, inflammation, giving way, weakness, decreased speed of joint motion, and incoordination. Examination was positive for stiffness, pain, and clicking with walking upstairs and on inclines. Joint flare ups were present moderate in severity and occurring weekly for hours. Flare ups were precipitated by jogging, prolonged standing, and squatting. The Veteran was noted to be able to stand for 30 minutes and walk for one to two miles. No assistive devices were not used. The hip was positive for guarding. ROM was right flexion 0 to 90, extension 0 to 30, abduction 0 to 35. The Veteran was able to cross his right leg over his left and toes can out greater than 15 degrees. There was no change follow repetition. Veteran reported being unemployed for one to two years. He reported being "laid off" approximately a year and a half prior to examination. The examiner noted functional impact of pain on his occupational activities, with moderate impairment on chores, shopping, exercise, and recreation. He had mild impairment of travel and prevention of sports. On September 2012 DRO Hearing, the Veteran reported worsening in his hip with pain traveling into his back. On April 2013 VA examination, the Veteran reported that "once and a while" he experienced sharp pain in the hip that is provoked by prolonged walking and kneeling. He reported using nothing to treat pain and denied flares. ROM was flexion to 100, extension was greater than 5, abduction was not lost beyond 10 degrees or limited such that he could not cross his legs. Rotation was not limited such that he could not toe-out more than 15 degrees. There was no objective evidence of painful motion. There was no change following repetition. Functional loss and/or functional impairment of the hip and thigh were noted as less movement than normal. There was no pain on palpitation. Strength was normal, there was no ankylosis, or malunion or nonunion of the femur, flail hip joint or leg length discrepancy. No assistive devices, hip replacements, or arthritis were noted. No functional impact was associated with the Veteran's hip. On October 2019 VA examination, the Veteran reported his right hip clicks and pops when walking up/down-stairs. He also reported achy pain with twisting, walking up/down-stairs of greater than one floor and climbing up/down ladders greater than two to three times. He denied flare ups. Functional loss or impairment was defined as pain with twisting, walking up/down-stairs greater than one floor and climbing up/down ladders greater than two to three times. ROM was flexion 0 to 90 degrees, extension 0 to 30 degrees, abduction 0 to 40 degrees, and adduction 0 to 25 degrees. The Veteran's adduction was not severe enough that he could not cross his legs. External Rotation was 0 to 45 and internal rotation was 0 to 40 degrees. Pain was present in flexion, abduction, external rotation. Pain was noted to cause functional loss. No change following repetition. The examination was deemed medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength was normal, with no atrophy or ankylosis. He did not have assistive devices or degenerative arthritis. Functional impairment was mild pain with twisting, walking up/down-stairs greater than one floor and climbing up/down ladders greater than two to three times. There was no change between active and passive ROM or weightbearing and non-weight bearing. Treatment medical records do not reflect worse symptomatology than discussed above. Regarding the Veteran's hip limitation of rotation, under DC 5253. The Board notes that the medical evidence of record does not show that the Veteran's hip has limited abduction where motion is lost beyond 10 degrees, as warranted for a 20 percent disability rating. The VA examination shows abduction to at worst 35 degrees, to include with pain. Treatment medical records do not contain evidence of symptomatology worse than noted on examination. As will be discussed below, even taking into account the functional loss factors contemplated by DeLuca and 38 C.F.R. §§ 4.40 and 4.45, there exists no basis for a higher rating under DC 5253 for the hip. Thus, the Board concludes that the Veteran's hip disability does not warrant a rating in excess of 10 percent. Upon review of the record, the Board finds that during the entire period on appeal, an initial compensable disability rating is not warranted for the Veteran's left hip limited flexion nor is an initial rating in excess of 10 percent warranted for the left hip degenerative joint disease. Even considering the Veteran's subjective complaints of pain and other symptoms described in DeLuca, there is no evidence of flexion limited to 45 degrees at any time during the appeal period such that a higher compensable rating would be warranted pursuant to Diagnostic Code 5252 for the Veteran's left hip limited flexion. Thompson v. McDonald, 815 F.3d 781, 786 (Fed. Cir. 2016) (holding that provision describing functional loss due to disability of the musculoskeletal system does not supersede requirements for a higher rating specified in the Rating Schedule). In this regard, flexion of the left hip was limited to 90 degrees at worst, as shown by VA hip examinations. Accordingly, an initial compensable rating is not warranted for the Veteran's right hip limited flexion throughout the entire period on appeal. The Board has considered manifested functional loss during flare ups per Mitchell. 25 Vet. App. 32. As stated, flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38C.F.R. §3.344 (a) and 38C.F.R. §4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. Here, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. There are no reports of exacerbation or flare-ups that are quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38 C.F.R. § 3.344 (a) regarding stabilization of ratings. Instead, the Veteran's most recent VA examination was negative for reports of flare ups. In addition, when considering his reported previous flare ups there is no indication that they were of the consistency or severity to warrant an increase rating. In that regard, although the Veteran reported at times experiencing flares while simply sleeping on his right side, his flares were more typically associated with prolonged walking, jogging, and squatting. Nevertheless, none of the Veteran's reported flares were of the severity to preclude functionality, require the use of assistive devices, consistent medication, or treatment. Moreover, as reflected above, the record is negative for reports of flare ups, or estimation of flare impact, that amount to disability sufficient to warranted even a compensable rating let alone a rating in excess of the current 10 percent ratings. The claims file is also negative for consistent findings warranting increase ratings. While the Veteran has reported occasional hip pain and painful flare-ups, there is no indication from the record that he has more limitation of motion than that shown at his VA examinations of record during flare-ups. The additional limitation that he experiences due to pain, weakness, fatigability, lack of endurance, or incoordination on repetition was accounted for by the VA examiner when determining the Veteran's ROM and was further considered by the Board. 38 C.F.R. § 4.40, 4.45. Thus, the preponderance of the evidence is against a finding that the Veteran had more limitation of motion in his hip than that noted above. In reaching this conclusion, the Board, again, acknowledges the Veteran's competent lay reports of symptoms and that there was, at times, functional loss due to pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence has been provided by VA medical professionals who have examined him. The medical findings adequately address the criteria under which the disability is evaluated and clearly demonstrate that the degree of impairment over the period at issue. As stated, even considering the Veteran's lay reports of symptoms, the record is devoid of competent evidence, supporting his conditions more nearly approximating a rating in excess of 10 percent for abduction or a compensable rating for flexion. The Board accords these medical professional findings greater weight than the Veteran's complaints as to symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Therefore, the claims for ratings in excess of 10 percent for the right hip abduction or a compensable rating for flexion must, for the above reasons, be denied. The Board has also considered whether a rating could be assigned under alternate DCs for rating disabilities of the Veteran's hip disabilities. The claims file is negative for evidence of ankylosis, compensable limitation of extension, flail joint, or femur impairment. As a result, ratings under DCs 5250, 5251, 5254, and 5255 are not applicable. With specific regard to ankylosis, the Board also emphasizes that the claims file, including both examination and treatment records is negative for an indication that the Veteran's symptoms have been equivalent to ankylosis. To the contrary, throughout the period on appeal the Veteran has maintained mobility with no reports or evidence to the contrary. In sum, a rating in excess of 10 percent for the Veteran's service-connected limitation of rotation of the right hip and an initial compensable rating for limitation of flexion are denied. REASONS FOR REMAND 6. Entitlement to service connection for chronic sinusitis. The Veteran was afforded a VA examination opinion in October 2019. In brief, the examiner opined against the Veteran suffering from a condition that was etiologically related to service. However, this opinion was partially predicated on the record lacking documented evidence of sinusitis since 2010. Importantly, the examiner failed to address an April 2013 VA examination wherein the Veteran was diagnosed with acute sinusitis. In addition, the examiner failed to address the relevance of the Veteran's assertions of suffering from on-going sinus symptomatology since service, notwithstanding the lack of treatment medical documentation. Given the above, a remand for an addendum opinion is required. 7. Entitlement to service connection for bilateral hearing loss. The Veteran was most recently afforded a VA examination in March 2013. The 2013 examination was negative for hearing loss as defined by 38 C.F.R. § 3.385. Thereafter, in January 2014, the Veteran reported having hearing loss for VA purposes and requested a new VA examination. The Veteran has not been afforded said new VA examination. Additionally, the claims file is negative for audiologic testing results which speak to the current severity of his condition or document VA compensable hearing loss. Given the record, and the lack of contemporaneous audiometric testing a remand is required for VA examination. 8. Entitlement to service connection for a respiratory condition. The Veteran asserts suffering from a respiratory condition resulting in shortness of breath. He asserts his respiratory condition is the result of environmental exposures he received while deployed to the Persian Gulf. Most recently, in June 2020, a VA examiner opined that the etiology of the Veteran's shortness of breath was "unknown" but "possibly" caused by his history of anxiety and/or his former use of tobacco and alcohol. The examiner also found that the Veteran's respiratory conditions were unrelated to his Persian Gulf service as the record lacked "evidence [that the] Veteran was exposed to any known environmental contamination in the military." The Board finds the examiner's opinion inadequate. First, the examination opinion remains unclear whether the Veteran's shortness of breath constitutes a disability that is separate and distinct from his history of anxiety. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Such an opinion is particularly important as the Veteran is service connected for PTSD with associated anxiety. As a result, it is critical that an examiner opine whether his symptoms could be either etiologically related to his PTSD or a part of it. Second, the examiner provided a conclusory opinion that the Veteran was not exposed to environmental containments while in service. The examiner did not rationalize this finding against the Veteran's conceded Persian Gulf service or service records. Such an opinion is required as in May 2018, the Board granted service connection for IBS presumptively under 3.317. The basis of the grant was the Veteran's conceded exposure to environmental containments while deployed. Given the above inadequacies, an addendum opinion is required. 9. Entitlement to service connection for a low back condition. 10. Entitlement to service connection for fibromyalgia. 11. Entitlement to service connection for neurological symptoms including tingling and numbness in the bilateral lower extremities and right upper extremity. With specific regard to direct service connection, an October 2019 VA examiner opined that the Veteran's currently diagnosed spine disabilities are unrelated to service. As rationale, the examiner noted that STRs were negative for complaints or treatment for a low back condition. This opinion is inadequate as it does not address the Veteran's reports of in-service back pain or his noted report of back pain on a post-deployment examination. A remand to address the question of direct service connection is required. The Veteran seeks service connection for fibromyalgia and a disability resulting in upper and lower extremity neurological symptoms as due to his service in the Persian Gulf and environmental contaminant exposure therein. As stated above, Persian Gulf service is conceded. In April 2013, the Veteran was afforded a Gulf War examination. The Veteran asserts that the examiner failed to adequately access whether he suffers from fibromyalgia and neurological symptoms. The Board agrees. Review of the examination report is silent consideration or elicitation of the Veteran's symptoms associated with claimed fibromyalgia and/or his neurological symptoms. In turn, the examination report is negative for a determination as to whether the Veteran's claimed symptoms were indicative of fibromyalgia or a neurological disability, associated with another diagnosis, or were a part of a multi-symptom undiagnosed illness. Given the Veteran's reports of symptomatology and his conceded Persian Gulf service, a VA examination opinion as to current diagnosis is warranted. 12. Entitlement to service connection for chronic fatigue. The Veteran seeks service connection for claimed chronic fatigue. In October 2010 VA examiner opined that the Veteran's fatigue is in part due to insomnia and a mental disorder. As stated, the Veteran is service connected for PTSD. However, no opinion has been obtained as to the nature and etiology of the Veteran's insomnia, and what, if any relationship, it shares with his service-connected PTSD. As the record is suggestive of a correlation between the conditions a remand is required. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). While on remand, the examiner should also verify that the Veteran's insomnia is a separate and distinct condition and not a symptom of a psychiatric disorder. On remand all outstanding treatment medical records must be obtained and associated with the claims file. 13. Entitlement to a TDIU. VA examination reports throughout the appeal reflect that the Veteran's service-connected musculoskeletal and psychiatric disabilities impact his ability to work. Specifically, 2009 examination records document the Veteran having to change employment because of repeat verbal altercations with coworkers and superiors. Moreover, as discussed above, the Veteran's combined musculoskeletal disabilities decrease the kind of dexterity and stamina which are required for his work in plumbing. The Board considers the claim of TDIU raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Currently, the claims file contains conflicting evidence as to the Veteran's level of employment throughout the period on appeal. In that regard, records vacillate between the Veteran reporting employment and unemployment. Given the conflicting evidence of record, a remand for further development to obtain the Veteran's employment history records is required. The matters are REMANDED for the following action: 1. Obtain all outstanding treatment medical records and associate them with the claims file. 2. Provide the Veteran VA Form 21-8940 and request he provide details regarding his employment history and education. An appropriate period of time should be allowed for response. 3. Forward the claims file to appropriate clinician to obtain an addendum opinion on whether sinusitis is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as telehealth interview is acceptable. (a.) Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the sinusitis began in or is otherwise caused by the Veteran's active service, to include exposures while in-service. (b.) The examiner should specifically address the Veteran's DRO hearing testimony and any other lay statements regarding the onset of sinusitis symptoms during active duty service, and their persistence since service. The examiner may not disregard the Veteran's reported history of symptoms of sinusitis solely on the basis that they are not recorded in contemporaneous medical treatment records. The examiner should address any other pertinent evidence of record. (c.) Note, an October 2019 VA examiner opined against service-connection, however, this opinion was partially predicated on the record lacking documented evidence of sinusitis since 2010. The examiner failed to address an April 2013 VA examination wherein the Veteran was diagnosed with acute sinusitis. Any opinion obtained must address this diagnosis. (d.) Note in-service exposure to environmental contaminants during Southwest Asian service has been conceded. (e.) All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Schedule the Veteran for a VA examination with an audiologist to determine whether he has a current bilateral hearing loss disability as defined by 38 C.F.R. § 3.385. (a.) Provide the Veteran's electronic claims file and a complete copy of this remand to the designated audiologist for review. Following a review of the claims file and examination, the audiologist should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any current hearing loss disability had its onset in service, manifested to a compensable degree within one year of separation from service, or is otherwise related to the Veteran's military noise exposure. A medical rationale must be provided for all opinions expressed. (b.) Note, the Veteran is service connected for tinnitus. This grant was predicated on repeat in-service noise exposure. 5. Forward the claims file to appropriate clinician to obtain an addendum opinion in Veteran's reported lung/respiratory disorder. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as telehealth interview is acceptable. The examiner is asked to address the following: (a.) Please clarify all disabilities related to the Veteran's reported lung/respiratory disorder, to include dyspnea and/or shortness of breath on exertion. The examiner should note that symptoms manifesting in functional impairment constitutes a disability for VA purposes, even if such cannot be attributed to a formal diagnosis. If the Veteran's lung/respiratory symptoms cannot be attributed to a known diagnostic entity, the examiner must provide an opinion as to whether any such symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to his service in Southwest Asia. (b.) If the examiner makes a diagnosis of a separate and distinct respiratory condition, is it at least as likely as not that the respiratory condition had its onset in or is otherwise etiologically related to active service, to include exposure to containments while serving in the Persian Gulf? (c.) Is it at least as likely as not that a respiratory disorder was proximately caused by the Veteran's PTSD any of his service-connected disabilities? (d.) Is it at least as likely as not that a respiratory disorder underwent any incremental increase in disability regardless of its permanence, due to the Veteran's PTSD or medications for any of his service-connected disabilities? (e.) Note, the October 2019 VA examiner indicated that the Veteran's sensation of shortness of breath might be related to his psychiatric disability. (f.) Note in-service exposure to environmental contaminants during Southwest Asian service has been conceded. (g.) The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. 6. Forward the claims file to appropriate clinician to obtain an addendum opinion on whether low back disability is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as telehealth interview is acceptable. (a.) Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the low back began in or is otherwise caused by the Veteran's active service. (b.) Note, an October 2019 VA examiner opined against service-connection, however, this opinion is inadequate as it does not address the Veteran's reports of in-service back pain or his report of back pain on a post-deployment examination in February 2005. (c.) The examiner should specifically address the Veteran's DRO testimony and any other lay statements regarding the onset of low back symptoms during active duty service, and their persistence since service. The examiner may not disregard the Veteran's reported history of symptoms of low back solely on the basis that they are not recorded in contemporaneous medical treatment records. The examiner should address any other pertinent evidence of record. (d.) All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 7. Schedule the Veteran for an examination by an examiner with sufficient expertise to conduct Gulf War examinations to determine the nature and etiology of the Veteran's claimed (i) fibromyalgia and (ii) right upper and bilateral lower extremity neuropathy. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. (a.) Based on a review of the file the examiner should diagnose all current disabilities. (b.) The examiner should then determine whether it is at least as likely as not (50 percent probability or greater) that any such diagnosed disabilities are related to the Veteran's service. (c.) If the Veteran's symptoms cannot be attributed to a known clinical diagnosis, the examiner must indicate whether it is at least as likely as not (50 percent probability or greater) that the Veteran's symptoms are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness etiologically related to his service in Southwest Asia. 8. Obtain VA examination opinion regarding the Veteran's insomnia disorder diagnosis. If the examiner determines that an examination is necessary, the AOJ should schedule one for the Veteran. (a.) The examiner is asked to clarify whether the Veteran's insomnia disorder is a separate and distinct disability from his service-connected PTSD. (b.) If a separate and distinct insomnia disability is confirmed, the examiner must opinion whether this diagnosis was at least as likely as not incurred in or caused by service, or incrementally increased by any of the Veteran's service-connected disabilities, to include PTSD. The examiner must address: (Continued on the next page) (c.) The significance of October 2010 VA examination findings suggesting that the Veteran's fatigue stems from both insomnia and a mental disorder. In so doing, the examiner must address whether the conditions are intertwined or separate. This examination report also appears to list insomnia as a separate disability, any finding to the contrary must be rationalized against this notion. (d.) The examiner should also address whether any sleep impairment associated with his psychiatric disability could have masked his separately diagnosed insomnia. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Burroughs, 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.