Citation Nr: 21027946 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 16-07 774 DATE: May 7, 2021 ORDER An initial rating of 100 percent for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing payment of monetary benefits. An initial rating of 50 percent, but not higher, for low back sprain, is granted. REMANDED Entitlement to an initial rating in excess 30 percent for pes planus, bilateral feet, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period, the Veteran's PTSD was manifested by symptoms resulting in total occupational and social impairment. 2. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period, the Veteran's service-connected low back sprain is primarily productive of lumbar spine degenerative joint disease, thoracolumbar spondylosis with painful or no motion, forward flexion of the thoracolumbar spine at worst to 0 degrees, a combined range of motion of the thoracolumbar spine at worst to 0 degrees, which approximates unfavorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. The criteria for an initial maximum rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2020). 2. The criteria for an initial rating of 50 percent, but not higher, for low back sprain have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2020) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from June 1990 to January 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2014 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In his February 2016 appeal to the Board, the Veteran requested a hearing. However, upon notification that the hearing was scheduled for March 2020, the Veteran withdrew his hearing request. In July 2020, the Board remanded the instant claims for further development, to include obtaining outstanding treatment records and providing the Veteran with new VA examinations to ascertain the current severity of each of the service-connected disabilities. The Veteran was afforded VA PTSD, back, and foot conditions examinations in February and March 2021, and the examination reports have been associated with the electronic claims file and reviewed. The Board finds substantial compliance with its July 2020 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Subsequent to the February and March 2021 VA examinations, the Veteran's PTSD and low back sprain increased rating claims were readjudicated by the AOJ in a March 2021 Supplemental Statement of the Case (SSOC) and returned to the Board for further appellate consideration. However, the SSOC does not address the Veteran's claim for an increased rating for bilateral pes planus. Instead, the AOJ issued a separate rating decision denying an increase and proposing severance of the rating. See Rating Decision dated March 11, 2021. The Board is unable to determine from the March 2021 rating decision whether the AOJ correctly applied the applicable legal criteria for severance. 38 C.F.R. § 19.29 (2020). Therefore, the Veteran's claim for an increased rating for bilateral pes planus must be remanded. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its finding[s] of fact and conclusion[s] of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings Applicable Law and Regulations Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his or her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where a veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant bears the burden of presenting and supporting his or her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). PTSD The AOJ has assigned an initial 70 percent disability rating for the Veteran's PTSD under Diagnostic Code (DC) 9411 based on occupational and social impairment, with deficiencies in most areas. 38 C.F.R. § 4.130, DC 9411; Rating Decision dated March 11, 2014. The Veteran claims that a higher rating is warranted. Rating Criteria Under the General Rating Formula for Mental Disorders, a noncompensable rating is warranted where a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria for a psychiatric disability demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the General Rating Formula for Mental Disorders are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Mauerhan, stated that the symptoms listed in VA's General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Mauerhan, 16 Vet. App. at 442. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, the Veteran's claim for service connection was submitted in April 2013, and his claim for an increased rating was certified to the Board in March 2017, and as such, only DSM-5 applies. Analysis For the reasons set forth below, the Board finds that a disability rating of 100 percent is warranted for the Veteran's PTSD for the entire initial rating period. Turning to the evidence of record, the Veteran's outpatient treatment records reflect that he has consistently endorsed audio and visual hallucinations throughout the entire initial rating period. For example, in May 2013, the Veteran described hearing voices telling him to hurt himself. See VA psychology outpatient note dated May 15, 2013. In September 2014, the Veteran reported hearing "multiple unfamiliar voices saying that they are going to kill him and peripheral visions as if someone is watching him," despite being compliant with his medication regimen. See VA psychiatry outpatient note dated September 19, 2014. Notably, a VA psychologist noted during a December 2014 outpatient appointment that the Veteran experienced an audio hallucination during the treatment session. See VA psychology outpatient note dated December 30, 2014. In March 2015, the Veteran said he had been experiencing fewer visual hallucinations, and he could recognize that they are not real. He said the audio hallucinations occurred mainly when he was outdoors at night smoking." See VA psychology outpatient note dated March 18, 2015. In September 2015, it was noted that the Veteran was responding to internal stimuli thought to be an audio hallucination during the treatment session. See VA psychology note dated October 1, 2015. However, in October 2015, the Veteran said the hallucinations had diminished back to a "typical level." See VA psychology outpatient note dated October 15, 2015. During an April 2016 VA appointment, the Veteran said he experienced audio/visual hallucinations "about two or three times a week" but said, "I block them out." See VA psychiatry outpatient note dated April 27, 2016. The Veteran endorsed hallucinations in August 2016, described as seeing friends wearing turbans, and he said he was aware at the time that it was a hallucination. He reported compliance with the prescribed mental health medication regimen. See VA psychology outpatient note dated August 25, 2016. Subsequent VA treatment notes reflect the Veteran's endorsement of audio and/or visual hallucinations. See VA psychology notes dated October 19, 2017, March 22, 2018; see also VA psychiatry notes dated September 26, 2018, November 13, 2019, and July 8, 2020. During the pendency of the Veteran's claim, he was afforded two VA PTSD examinations. In September 2013, the VA examiner recorded diagnoses of PTSD and bipolar disorder, unspecified, adding that it was not possible to differentiate which symptoms are attributable to each diagnosis. The examiner noted that the Veteran endorsed a sense that past traumatic events were reoccurring, including illusions and hallucinations. The examiner concluded that the Veteran's psychiatric disorders resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See VA PTSD examination report dated September 6, 2013. In February 2021, a VA examiner recorded a diagnosis of PTSD. On examination, the Veteran reported no hallucinations or delusions. The examiner identified symptoms that included difficulty adapting to stressful circumstances, including work or a worklike setting. The examiner concluded that the Veteran's psychiatric disorders resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See VA PTSD examination report dated February 11, 2021. Upon review of all the evidence of record, both lay and medical, the Board finds that the Veteran's PTSD more nearly approximates symptoms resulting in total occupational and social impairment. As discussed above, the Veteran's treatment records and the VA examinations show that the Veteran's PTSD has manifested symptoms of depressed mood, suicidal ideation, anxiety, suspiciousness, chronic sleep impairment, memory difficulties, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. See 38 C.F.R. § 4.130, Diagnostic Code 9411. He has been found to have consistently endorsed persistent hallucinations, which are specifically contemplated by the 100 percent rating criteria. Id. Although the February 2021 VA examiner noted that the Veteran denied hallucinations and delusions, the examiner's notation is not inconsistent with the treatment records, which reveal that at times the Veteran has denied hallucinations generally or denied experiencing hallucinations during appointments. See, e.g., VA mental health note dated May 3, 2013; VA psychiatry notes dated September 29, 2016, January 18, 2017, and February 7, 2018. Nevertheless, the treatment records show that the Veteran has consistently endorsed audio/visual hallucinations throughout the rating period. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 100 percent for PTSD is warranted for the entire initial rating period. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Low Back Sprain The AOJ has assigned an initial 40 percent disability rating for the Veteran's low back sprain under DC 5237 for lumbosacral strain on the basis of forward flexion of the thoracolumbar spine 30 degrees or less, combined range of motion of the thoracolumbar spine not greater than 120 degrees, guarding and muscle spasm not resulting in abnormal gait or abnormal spinal contour, and painful motion. 38 C.F.R. § 4.71a, DC 5237; Rating Decision dated March 11, 2014. The Veteran claims that a higher rating is warranted. Rating Criteria 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 (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria."). It is the intention to recognize actual 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. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Note (6) provides that DC 5242 for degenerative arthritis of the spine can also be rated under DC 5003. Id. Intervertebral disc syndrome (IVDS) can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). Under the IVDS Formula, a 40 percent is warranted for incapacitating episodes with a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, IVDS Formula. For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). The Board recognizes that the criteria for Rating Musculoskeletal System was amended effective February 7, 2021. However, with regard to the General Rating Formula for Diseases and Injuries of the Spine, as relevant here, the criteria under DC 5237 were not amended, and the criteria for degenerative (DC 5003) and post-traumatic arthritis (DC 5010) continue post-amendment to be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints. 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, Diagnostic Codes 5235-5243). Analysis For the reasons set forth below, the Board finds that a disability rating of 50 percent, but not higher, is warranted for the Veteran's low back sprain for the entire initial rating period. Turning to the evidence of record, VA treatment notes dated May 2013 reflect that the Veteran was prescribed pain medications that included Diclofenac twice a day and Hydrocodone up to four times a day as needed. In September 2013, the Veteran underwent a VA thoracolumbar spine examination. The diagnosis was low back sprain. The Veteran reported that he was in an emergency room the previous week due to back pain. On examination, ROM testing of the lumbar spine revealed flexion to 30 degrees; extension to 10 degrees; right lateral flexion to 20 degrees, left lateral flexion to 20 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. The combined ROM was 120 degrees. Pain was objectively indicated in all planes of motion and following repetitive motion. There was no additional limitation of motion after three repetitions. The Veteran endorsed flare-ups, described as occurring upon "any exertion." The Veteran was negative for localized tenderness or pain to palpation of the thoracolumbar spine; however, the examiner observed guarding and/or muscle spasm, which did not result in abnormal gait or spinal contour. Reflex, sensory, and muscle strength testing were normal, bilaterally, and the Veteran was negative for muscle atrophy. Straight-leg tests were normal, bilaterally, and there were no radicular symptoms indicated. He was negative for ankylosis. The examiner noted that imaging studies of the Veteran's thoracolumbar spine were negative for arthritis, IVDS, and any other significant diagnostic testing findings. Lastly, the examiner opined that the Veteran's back disability did not impact his ability to work. See VA thoracolumbar spine examination report dated September 26, 2013. In a statement submitted with his June 2014 Notice of Disagreement, the Veteran said he experienced back pain while sitting and standing. In a statement submitted with the Veteran's February 2016 appeal to the Board (VA Form 9), he said his wife must assist him getting in and out of bed and with bathing due to his back condition. He described back spasm so severe that he asked family members to hit him in the back to try to obtain relief from the spasm, which causes more pain. He said he was unable to lift anything weighing over 10-15 pounds without causing severe back pain or triggering a spasm. The Veteran said back spasms can disable him two to three weeks at a time. See Appeal to Board of Veterans' Appeals received February 22, 2016. December 2015 VA treatment notes show that the Veteran reported twisted his low back while doing push-ups and sit-ups during a workout, and he had been experiencing low back spasms on and off since then. A muscle strain was suspected. The recommended treatment included engaging in only light activities for two to three days, avoiding prolonged sitting, lifting, or jumping until the pain resolved, using a heating pad, and taking his usual pain medication. A June 2016 lumbar spine x-ray revealed no significant interval change in the minimal spondylosis or suggestion for minimal degenerative disc disease at the L3-L4 vertebrae. The Veteran underwent a spine MRI in July 2016, which showed minimal degenerative change, including minimal left lateral bulge, at the L4-L5 vertebrae. VA treatment records dated September 2016 reflect that the Veteran's prescription pain medication included Diclofenac twice a day and Hydrocodone up to four times a day. In January 2017, the Veteran provided renewed consent for long-term VA opiod treatment of low back pain, e.g., Hydrocodone. During a March 2017 VA outpatient appointment, the Veteran reported continuing chronic low back pain, and said his medications helped reduce the pain. VA treatment records dated March 2017 show that the Veteran's pain medication regimen continued to include Diclofenac twice a day and Hydrocodone up to four times a day as needed. In February 2021, the Veteran underwent a VA thoracolumbar spine examination. The diagnosis was lumbosacral strain and degenerative arthritis. The examiner also noted that the Veteran's low back sprain had progressed to degenerative joint disease and back weakness secondary to lack of use. The Veteran reported that he is unable to lift more than 25 pounds due to his low back sprain, and he endorsed low back spasms when sleeping on his side. The Veteran was taking Methocarbamol, Diclofenac, and Hydrocodone several times per day. On examination, active ROM testing of the lumbar spine revealed flexion to 30 degrees; extension to 15 degrees; right lateral flexion to 10 degrees, left lateral flexion to 25 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 30 degrees. The combined active ROM was 135 degrees. Pain was objectively indicated during forward and left lateral rotation, and the Veteran said he "cannot move much" because of the pain. Passive ROM testing of the lumbar spine revealed flexion to 25 degrees; extension to 20 degrees; right lateral flexion to 15 degrees, left lateral flexion to 15 degrees; and lateral rotation to 30 degrees, bilaterally. The combined passive ROM was 135 degrees. Pain was objectively indicated during extension and right lateral rotation. The examiner noted that there was evidence of pain that caused functional loss, specifically, the Veteran had to stop because of severe pain. There was objective evidence of moderate tenderness on palpation at the midthoracic paraspinals and right rhomboid due to the Veteran's lumbar strain and DJD. ROM testing after repetitive use testing revealed flexion to 25 degrees; extension to 15 degrees; right lateral flexion to 15 degrees, left lateral flexion to 30 degrees; and lateral rotation to 30 degrees, bilaterally. The combined ROM following repetitive use testing was 145 degrees. Functional loss due to pain was noted. ROM testing after repeated use over time revealed flexion to 15 degrees; extension to 5 degrees; right lateral flexion to 5 degrees, left lateral flexion to 10 degrees; right lateral rotation to 10 degrees; and left lateral rotation to 15 degrees. The combined ROM following repetitive use testing was 60 degrees. The examiner indicated that the Veteran was not examined during a flare-up but stated that the Veteran's description of flare-ups suggested that pain significantly limited functional ability during flare-ups, and recorded "0" (zero degrees) for ROM in all planes, indicating no range of motion during flare-ups. The Veteran was negative bilaterally for muscle spasm, atrophy, and guarding associated with his low back sprain. The examiner noted localized tenderness at the midthoracic paraspinal and right rhomboid that did not result in abnormal gait or abnormal spinal contour. Muscle strength testing was normal, bilaterally, except for right hip flexion, which indicated active movement against some resistance (4/5). Sensory testing was normal, bilaterally, except for reduced sensation in the right plantar arch area. The examiner noted a history of a gunshot wound to the Veteran's right foot. The Veteran was negative for radiculopathy, ankylosis, and IVDS. The examiner noted generalized weakness of the Veteran's back muscles, and that the Veteran leans forward while walking and is forming a kyphosis secondary to upper back pain. No imaging studies were obtained in conjunction with the VA examination, although the VA examiner noted the findings of the July 2016 MRI. See VA thoracolumbar spine examination report dated March 1, 2021. Upon on review of all the evidence of record, both lay and medical, the Board finds that the Veteran's low back sprain symptomatology more nearly approximates symptoms of unfavorable ankylosis of the entire thoracolumbar spine, which warrants a 50 percent rating. While there is no evidence of a clinical diagnosis of ankylosis of the thoracolumbar spine, the Court recently held that the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis, ie., functional loss consistent with that contemplated by ankylosis. Chavis v. McDonough, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660, at *23-25 (April 16, 2021). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland's Illustrated Medical Dictionary (28th ed. 1994) at 86). As outlined in Note (5) of the rating formula, fixation of a spinal segment in neutral position (zero degrees) indicates favorable ankylosis. Here, the Veteran's ability to extend or flex during flare ups was estimated by the February 2021 VA examiner to be "0" (zero degrees) in all planes, effectively the functional equivalent of ankylosis. 38 C.F.R. §§ 4.71a, Note (5). While the September 2013 VA examiner did not provide an estimate of the Veteran's ROM during flare ups, the 2013 examination report reflects that the Veteran experienced flare ups upon "any exertion" and the Veteran reported at that time that he had recently been treated in an emergency room for back symptoms. Additionally, VA treatment records show that the Veteran, throughout the rating period, has experienced severely limited flexion combined with the need to take prescribed medications for pain and swelling daily, including the opiod Hydrocodone. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating if 50 percent for low back sprain, but not higher, is warranted for the entire initial rating period. 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59; Chavis, supra. A higher rating of 100 percent is not warranted as the record contains no competent evidence indicating unfavorable ankylosis of the entire spine. 38 C.F.R. §§ 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Moreover, a higher rating is not warranted based on incapacitating episodes of IVDS, as there is no evidence of IVDS or incapacitating episodes requiring bed rest prescribed by a physician at any point during the period on appeal. See 38 C.F.R. § 4.71a, IVDS Formula, at Note (1). The Board also considers whether a higher, separate rating is warranted for the neurological impairment associated with the Veteran's service-connected low back disorder. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Board acknowledges that the Veteran has reported numbness and burning in his bilateral feet during the rating period on appeal. However, these symptoms have been attributed to diabetic neuropathy of the lower extremities and not to the lumbar spine disability. See, e.g., VA podiatry consultations dated November 6, 2013 and August 10, 2015. While the August 2015 VA podiatry note reflects a podiatrist's notation of "chronic low back pain / radiculopathy," his ultimate diagnosis did not include radiculopathy. See VA podiatry note dated August 10, 2015. Moreover, no other treatment records during the rating period on appeal reference radiculopathy associated with the Veteran's low back disorder, and, notably, the September 2013 and February 2021 VA thoracolumbar spine examinations reflect that the Veteran was negative for radiculopathy. The medical evidence consistently shows negative findings for radicular pain or other neurological symptoms related to the Veteran's low back sprain. In the absence of evidence of neurologic symptoms related to the Veteran's lumbar spine disability, the Board finds that separate rating for neurological abnormalities is not warranted. Accordingly, for the reasons set forth above, a rating of 50 percent, but not higher, is granted for the Veteran's service-connected low back sprain. See 38 U.S.C. § 5107(b); 38C.F.R. §§ 4.3, 4.7; Gilbert, supra. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). REASONS FOR REMAND Although the Board regrets the additional delay, remand is necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38C.F.R. § 3.159(c) (2020). Bilateral Pes Planus The March 2021 SSOC does not address the Veteran's claim for an increased rating for bilateral pes planus. The AOJ issued a separate rating decision denying an increased rating and proposing severance of the rating altogether in order to combine the evaluation of pes planus symptoms with those of the service-connected residuals of a gunshot wound, concluding its prior assignment of a separate 30 percent rating for bilateral pes planus in 2014 was clearly and unmistakably erroneous because "these issues are the same." See Rating Decision dated March 11, 2021 at pg. 2. VA regulations provide the Veteran with 60 days to present additional evidence to the contrary. 38 C.F.R. § 3.105(d). It is not clear from the March 2021 rating decision whether the AOJ's prior assignment of a separate rating for bilateral pes planus in March 2014 was clearly and unmistakably erroneous, the threshold requirement for severance. 38 C.F.R. § 3.105(d). The 2014 rating decision granting service connection found that the Veteran's bilateral pes planus was a distinct disability secondary to the service-connected residuals of a right foot gunshot wound. The March 2021 rating decision proposing severance characterizes the Veteran's gunshot residuals as "a muscle condition" and his bilateral pes planus as a "foot condition," yet concluded that they are the same disability. See Rating Decision dated March 11, 2021 at pg. 2. VA regulations provide that a change in diagnosis may be accepted as a basis for severance if the examining physician or other proper medical authority "certifies that, in light of all accumulated evidence, the diagnosis upon which service connection was predicated is clearly erroneous." 38 C.F.R. § 3.105(d). Here, a VA examiner, a physician, recently confirmed the Veteran's diagnosis of bilateral pes planus. See VA foot conditions examination dated March 1, 2021. Accordingly, the issue of entitlement to an initial rating in excess 30 percent for bilateral pes planus is remanded for readjudication to include issuance of a SSOC that clearly and adequately addresses the Veteran's claim for an increased rating and severance pursuant to applicable VA regulations. 38 C.F.R. § 19.29. The matters are REMANDED for the following action: 1. Implement the Board's decisions herein granting a maximum 100 percent rating for PTSD and a 50 percent rating for low back sprain. 2. Thereafter, readjudicate the remanded claim. If the benefits sought on appeal are not granted in full, issue a Supplemental Statement of the Case, and in doing so, adequately address the Veteran's claim for an increased rating for pes planus and any impact that the March 2021 rating decision has on the rating. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, Associate 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.