Citation Nr: 21028822 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-27 557A DATE: May 12, 2021 ORDER Service connection for bilateral hearing loss is denied. Service connection for a disability manifested by gastrointestinal symptoms, as a qualifying chronic disability under 38 C.F.R. § 3.317 is denied. Service connection for a disability manifested by left hip symptoms, as a qualifying chronic disability under 38 C.F.R. § 3.317 is denied. Service connection for a disability manifested by right hip symptoms, to include as a qualifying chronic disability under 38 C.F.R. § 3.317 is denied. For the period from April 16, 2013, a disability rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. A disability rating in excess of 10 percent for degenerative disc disease, cervical spine, is denied. A disability rating in excess of 10 percent for retropatellar pain syndrome, left knee, is denied. A disability rating in excess of 10 percent for retropatellar pain syndrome, right knee, is denied. A disability rating in excess of 10 percent for thoracic scoliosis is denied. REMANDED A compensable disability rating for sinusitis is remanded. A compensable disability rating for allergic rhinitis is remanded. A disability rating in excess of 30 percent for asthma is remanded. FINDINGS OF FACT 1. Bilateral hearing loss is not shown for VA disability purposes. 2. The Veteran had active military service in the Southwest Asia Theater of operations during the Persian Gulf War. 3. A gastrointestinal disability, to include gastrointestinal signs or symptoms, has not been shown. 4. A left hip disability, to include joint pain, has not been shown. 5. The Veteran's disability of the right hip is a congenital defect and a preponderance of the evidence is against finding that the Veteran sustained superimposed disability to the right hip during service. 6. From April 16, 2013, PTSD is manifested by symptoms resulting in occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood due to such symptoms as difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. 7. Throughout the rating period on appeal, degenerative disc disease of the cervical spine has been manifested by normal forward flexion, albeit with pain, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 8. Throughout the rating period on appeal, left knee retropatellar pain syndrome has not been manifested by flexion limited to 30 degrees, with normal extension, and with no objective findings of instability. 9. Throughout the rating period on appeal, right knee retropatellar pain syndrome has not been manifested by flexion limited to 30 degrees, with normal extension, and with no objective findings of instability. 10. Throughout the rating period on appeal, thoracic scoliosis has not been manifested by forward flexion of 60 degrees or less, nor ankylosis of the entire thoracolumbar spine; there is no showing of incapacitating episodes having a total duration of at least 2 weeks. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.385. 2. The criteria for a gastrointestinal disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for a left hip disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.317. 4. The criteria for a right hip disability have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.303, 4.9, 4.57. 5. For the period from April 16, 2013, the criteria for a disability rating of 70 percent, but no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 6. The criteria for a rating in excess of 10 percent for degenerative disc disease, cervical spine, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 7. The criteria for a disability rating in excess of 10 percent for retropatellar pain syndrome, left knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Part 4, Diagnostic Code 5260. 8. The criteria for a disability rating in excess of 10 percent for retropatellar pain syndrome, right knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Part 4, Diagnostic Code 5260. 9. The criteria for a disability rating in excess of 10 percent for thoracic scoliosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237, 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1997 to April 2013, to include service in Southwest Asia theater of operations. He also had subsequent service in the Army Reserves. See 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(d). These matters came to the Board of Veterans' Appeals (Board) from a February 2014 Department of Veterans Affairs (VA) rating decision from a Regional Office (RO) which denied service connection for bilateral hearing loss, a gastrointestinal disability, and disabilities of the hips; and, granted service connection for PTSD (50%); degenerative disc disease, cervical spine (0%); retropatellar pain syndrome, left knee (0%); retropatellar pain syndrome, right knee (0%); thoracic scoliosis (0%); sinusitis (0%); allergic rhinitis (0%); and, asthma (30%), all effective April 16, 2013. In October 2018, the issues were remanded for further development. In an October 2020 rating decision, a 70 per disability rating was assigned for PTSD, effective August 5, 2015, and separate 10 percent disability ratings were assigned to the cervical spine, left knee, right knee, and thoracic spine disabilities, effective April 16, 2013. Service connection was granted for a right shoulder disability which constituted a full grant of benefit sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). A total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities was granted effective August 8, 2015. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The Veteran claims entitlement to service connection for a gastrointestinal disability and a left hip disability as due to an undiagnosed illness due to environmental exposures while serving in the Persian Gulf. He asserts that his claimed disability is part of a constellation of symptoms, specifically gastrointestinal signs or symptoms or joint pain, as due to an illness as described under 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(a)(2); see also 75 Fed. Reg. 61995-97 (2010); see also 76 Fed. Reg. 41696-98 (July 15, 2011). Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became 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 during the presumptive period prescribed by the Secretary. The period within which such disabilities must become manifest to a compensable degree in order for entitlement to compensation to be established is December 31, 2021. 38 C.F.R. § 3.317(a)(1)(i). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a),(b). The term "objective indications of a qualifying chronic disability" include both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(3). Bilateral hearing loss Hearing loss is considered to be a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition thresholds using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Furthermore, clinical hearing loss is shown where the auditory thresholds exceed 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In this case, the Veteran contends that he has current hearing loss as a result of exposure to loud noise during service. Service treatment records do not reflect findings of hearing loss. A February 2014 VA audiological examination reflects normal hearing for VA purposes, to include a 100 percent speech discrimination score in the right ear and 96 percent in the left ear. Per such findings, hearing loss is not shown. No other audiometric results are of record. As detailed above, service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. For the purposes of applying the laws administered by VA, the thresholds for normal hearing are between 0 and 20 decibels, and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Specifically, none of the auditory thresholds in any of frequencies from 500 through 4000 Hertz reach 40 decibels. None of the auditory thresholds for at least three of the frequencies (500, 1000, 2000, 3000, or 4000 Hertz) are 26 decibels or greater. With regard to the speech recognition scores for both ears, it was 100 percent in the right ear and 96 percent in the left ear. Consequently, in this case, the Veteran's hearing is within normal limits for VA purposes. 38 C.F.R. § 3.385. In this regard, Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). In other words, in the absence of proof of present disability, in this case impaired hearing in the right or left ears per § 3.385, there can be no valid claim. The post-service examination shows that the Veteran does not have hearing loss in either ear as defined by § 3.385. As there is no probative evidence of a hearing loss disability, as defined by the applicable regulation, the claim of service connection for hearing loss must be denied. As a disability is not shown, the first element of a service connection claim has not been met, and thus it is not necessary to discuss an etiological relationship to service. The Board acknowledges the statements from the Veteran with respect to his noise exposure experienced during service. While the Board finds these assertions credible, the fact remains that he does not have a hearing loss disability for VA purposes. As the preponderance of the evidence is against the claim of service connection for hearing loss, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107. Gastrointestinal disability Service treatment records do not reflect any complaints of or treatment for a gastrointestinal disability or associated symptoms. A February 2013 C&P General examination reflects that the examiner checked the box for an intestinal condition. 04/03/2013 C&P Exam at 2. A February 2013 C&P Intestinal Conditions exam reflects the Veteran's report that in 2000 he developed frequent bowel movements of 3 to 4 per day exacerbated by certain foods. Id. at 68-72. He complained of episodic pain before bowel movements. He has not required any treatment and no condition has been identified. The examiner checked the 'Yes' box with regard to whether the Veteran has signs or symptoms attributable to any non-surgical non-infectious intestinal conditions, indicating frequent bowel movements with pain. The examiner commented that the Veteran has non-specific symptoms, no condition has been identified, and no treatment has been required. In December 2019, the Veteran underwent a C&P examination, wherein he reported a date of onset of 2000 of occasional loud bowel movements and occasional pain with constipation if he does not go 2-3 times a day in the bathroom. The examiner checked the 'No' box for signs or symptoms due to any stomach or duodenum conditions and signs or symptoms attributable to any non-surgical non-infectious intestinal conditions. The examiner found no objective evidence of the claimed gastrointestinal condition, to include irritable bowel syndrome or any disability manifested by gastrointestinal symptoms, including frequent bowel movements and abdominal pain at this time. The examiner opined that there is no diagnosis for any stomach or intestine, therefore arose during service or is otherwise related to service, to include his service in the Persian Gulf. The examiner commented that there are no significant symptoms of any gastrointestinal condition. Inasmuch as the C&P examinations show that the Veteran does not have a disability of a gastrointestinal disability, service connection must be denied. The examiners have indicated that he does not have significant symptoms of a gastrointestinal condition and he does not undergo treatment. Moreover, the examination findings in this case precludes the consideration of an undiagnosed or medically unexplained chronic multi-symptom illness because the findings here are not significant rather than unexplained. In short, the Veteran is not shown to have a chronic gastrointestinal disability, nor gastrointestinal signs or symptoms, unexplained or otherwise, and the requirements for service connection are therefore not met. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In so finding, the Board acknowledges that the Veteran is competent to report his observable symptomatology. However, he lacks the medical expertise to conclude that such symptoms are manifestations of a gastrointestinal disability, to include a chronic multi-symptom illness. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the claim must be denied. Hips A December 2009 service treatment record reflects a history of hip problems. 09/28/2012 STR-Medical at 37. In April 2012, the Veteran complained of left hip pain, described as insidious onset of left hip pain. 09/28/2012 STR-Medical at 37. A May 2012 service treatment record reflects complaints of left hip pain. There was tenderness on palpation of the iliotibial band/tensor fascia lata and tenderness on palpation of the gluteus maximus and gluteus medius muscle. Id. at 31. An x-ray examination reflects an unremarkable left hip. The right hip demonstrated a well-circumscribed 17-millimeter blastic area in the proximal femur which most likely represents a bone island. 09/28/2012 STR-Medical at 11. An October 2012 service treatment record reflects hip joint pain. 09/28/2012 STR-Medical at 1. A February 2013 C&P examination reflects the Veteran's complaints of bilateral hip pain that began in 2008 from no specific injury; he complained of pain with exercising and leg lifting activities and a popping sensation. 04/03/2013 C&P Exam at 5. On physical examination, a condition or pain was not found. A December 2019 C&P examination reflects the Veteran's report of bilateral occasional hip pain. A diagnosis of bone blastic area in proximal femur on right was diagnosed, and the examiner explained that the May 2012 x-ray examination reflects a well-circumscribed 17-millimeter blastic area in the proximal femur which most likely represents a benign bone island. There was no objective evidence of a left hip condition. With regard to the left hip, the examiner characterized it as an undiagnosed illness. The examiner opined that there is no diagnosis of a left hip condition and thus it less likely than not arose during service or is otherwise related to service, to include his service in the Persian Gulf. In an October 2020 addendum opinion, the examiner stated that the Veteran does not have an undiagnosed illness due to Southwest Asian service and there is no objective evidence of a left hip diagnosis. With regard to the right hip, the examiner characterized it as a diagnosable but medically unexplained chronic multi-symptoms illness of unknown etiology. The examiner opined that his right hip disability less likely than not arose during service or is otherwise related to service, to include his service in the Persian Gulf. The examiner noted that the Veteran reported the onset of occasional right hip pain in 1998 when he was in service. During the years the Veteran reported that the condition stayed about the same. The examiner explained that bone islands are well known in the international literature and have insignificant medical meaning and are typically asymptomatic. If the bone island had a functional impact on the joint in terms of impairment or pain, that symptoms should have to be always present and worsening during the time because of inflammation and impairment. In an October 2020 addendum opinion, the examiner explained that bone blastic areas are not a common condition, however, they are out of his usual medical activity and interest. However, the scientific article he cited makes it clear that "this benign lesion is probably congenital or developmental in origin and reflects failure of resorption during endochondral ossification." More simply stated, it is more likely to be congenital or started during early youth. Therefore, it is more likely than not that the condition had its onset before service but was diagnosed in service with no impact in service/Persian Gulf on its clinical course. Inasmuch as the C&P examinations show that the Veteran does not have a disability of a left hip disability, service connection must be denied. The examiners have indicated that he does not have a left hip disability. Moreover, the lack of a showing of current chronic disability of the left hip precludes the consideration of an undiagnosed or medically unexplained chronic multi-symptom illness because the findings here are completely normal rather than unexplained. In short, the Veteran is not shown to have a left hip disability, nor joint pain, and the requirements for service connection are therefore not met. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In so finding, the Board acknowledges that the Veteran is competent to report his observable symptomatology. However, he lacks the medical expertise to conclude that such symptoms are manifestations of a left hip disability, to include a chronic multi-symptom illness. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the claim of service connection for a left hip disability must be denied. Regarding the right hip, based on the findings contained in the service treatment records and the December 2019 C&P examination, the objective medical evidence reflects a congenital condition affecting the right hip that preexisted service. Thus, a right hip condition is congenital in origin. Congenital or developmental defects may not be service-connected because they are not diseases or injuries under the law. Thus, as a congenital deformity, direct service connection could not be awarded. See 38 C.F.R. § 4.9. VA regulations specifically prohibit service connection for a congenital defect, unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). As detailed, the December 2019 examiner diagnosed a congenital condition affecting the right hip and the medical evidence of record does not reflect that the Veteran suffered any residual chronic right hip disability due to a superimposed injury to the right hip during service. Moreover, to the extent that the congenital condition is a disease rather than a defect, there remains no showing of in-service aggravation. In the absence of proof of a current right hip disability, other than a congenital right hip condition, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A Veteran's belief that he is entitled to some sort of benefit simply because he had a disease or injury while on active service is mistaken, as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of a chronic right hip disability, the Board must conclude the Veteran does not currently suffer from such a disability. In view of the aforementioned, since the competent evidence shows no chronic right hip disability as a result of a superimposed disease or injury to a preexisting congenital defect as a result of service, and shows no aggravation of congenital disease in service there is no basis for granting service connection for a right hip disability in this case. There is no basis for reasonable doubt so as to resolve this matter in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Thus, the Veteran's claim of service connection for a right hip disability is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.§ 1155; 38 C.F.R.§ 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. With regard to the bilateral knee, cervical spine, and lumbar spine disability issues, evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202, 205-08 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the DCs predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Also, functional loss due to pain must be supported by pathology and shown through objective observation. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997) (citing 38 C.F.R. § 4.40); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011) (relying on DeLuca for proposition that an adequate joint examination report must comply with § 4.40 and include an "opinion on whether pain could significantly limit functional ability during flare-ups or when the [joint] is used repeatedly over a period of time"). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court of Appeals for Veterans Claims has held that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The spine has no opposite joint. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. 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 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. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board has reviewed all the evidence in the Virtual folders, which includes: the Veteran's contentions, treatment records, and C&P examination reports. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). It is noted that the Veteran has not raised any challenges with respect to any deficiencies in the examination reports. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). PTSD PTSD has been rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (PTSD), and is rated 50 percent disabling prior to August 5, 2015, and 70 percent disabling from August 5, 2015. Based on review of the medical evidence of record, the subjective complaints of the Veteran, and affording the Veteran reasonable doubt, the Board finds that the 70 percent disability rating is warranted from April 16, 2013, but a higher rating is not warranted for any period contemplated by this appeal. The Board first observes that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit (Federal Circuit) explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Indeed, "VA must engage in a holistic analysis" that assess the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Pursuant to 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, an evaluation of 50 percent is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech 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); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to symptoms such as the following: 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. 38 C.F.R. § 4.130. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.1994) (DSM-IV). VA implemented DSM-5, effective August 4, 2014, which no longer considers GAF scores. For claims certified prior to August 4, 2014, the scores assigned under the Global Assessment of Functioning (GAF) scale are an important consideration. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996). They reflect the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores between 61 and 70 reflect either some mild symptoms (e.g., depressed mood and mild insomnia); or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. By comparison, GAF scores between 51 and 60 reflect either moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks); or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers), and GAF scores between 41 and 50 reflect either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores between 31 and 40 reflect either some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). As the instant appeal was certified in May 2017, DSM-V applies, and consideration of GAF scores is not necessary. From April 16, 2013, corresponding to the date of his claim for compensation, the Board finds that a 70 percent disability rating is warranted. Indeed, while not all of the criteria for a 70 percent rating are met, the medical evidence of record reflects that the Veteran's PTSD is manifested by difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. The February 2013 C&P examination reflects that the Veteran was employed at that time but he reported anti-social behavior, isolating at work, and taking frequent breaks due to irritability and anxiety. He also had decreased concentration and difficulty following conversations, noting episodes of disassociation at work. While the examiner did not check the box for 'chronic sleep impairment,' the Veteran reported nightmares several times per month related to his combat experiences, being violent during his sleep, and difficulty falling asleep. He reported an emotional detachment towards others. He had a panic attack prior to the evaluation as it was crowded. He reported having panic attacks every day, often several times per day. The examiner indicated that his PTSD was manifested by anxiety, panic attacks more than once per week, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. An August 2015 Disability Benefits Questionnaire reflects objective findings of depressed mood, anxiety, mild memory loss, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a worklike setting. A December 2019 C&P examination reflects objective findings of anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. While some of the criteria for a 70 percent rating, to include difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships, the Board finds that a 100 percent rating is not warranted for any period contemplated by this appeal. Indeed, total social impairment with is not shown for any period contemplated by this appeal. The competent and probative evidence of record weighs against showing symptomatology, such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, nor memory loss for names of close relatives. The other medical evidence of record does not support a finding of total social impairment due to his PTSD. Based on the foregoing medical and lay evidence, to include the treatment records and examination reports, the Board finds that social and occupational impairment with deficiencies in most areas have been more nearly approximated over the course of the period on appeal but total social impairment is not shown. Cervical spine The Veteran's cervical spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242 (degenerative arthritis of the spine). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Effective February 7, 2021, the General Rating Formula for Diseases and Injuries of the Spine was revised as follows: 5242 Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010); 5243 Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses. Part 4 - Schedule for Rating Disabilities, § 4.71a Schedule of ratings musculoskeletal system, 85 Fed. Reg. 230, 76462 (November 30, 2020). Pursuant to Diagnostic Code 5003, arthritis, degenerative (hypertrophic or osteoarthritis), established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. 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 two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4,71a, Diagnostic Code 5003. Effective February 7, 2021, Diagnostic Code 5003 was revised as follows: Degenerative arthritis, other than post-traumatic: Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 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, with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent disability rating is warranted. With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent disability rating is warranted. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 CFR Part 4, Schedule for Rating Disability: Musculoskeletal System and Muscle Injuries; Correction, 85 Fed. Reg. 249, 85523 (December 29, 2020). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for his cervical spine disability. The Board acknowledges the Veteran's lay reports of symptoms, such as pain. However, even considering such lay reports of symptoms, the evidence of record does not reflect that such symptoms would result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees. The February 2013 examination report reflects normal flexion, without objective evidence of painful motion with no change on repetitive motion testing. The examination report and treatment records, however, reflect reports of neck pain. The December 2019 examination reported noted pain on range of motion testing that did not result in or cause functional loss. The Veteran reported pain and stiffness associated with his neck. Review of the entire evidence of record does not support a rating in excess of 10 percent. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. The evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. In consideration of the DeLuca factors, there have been objective findings of pain, but such does not cause functional loss, and there have been no objective findings of fatigue, weakness, and lack of endurance. The objective findings contained within the record, based on examination reports and treatment records, do not more nearly approximate the criteria for a higher rating even with consideration of pain. The 10 percent rating in effect compensates him for painful motion and any functional limitations but assigning the next higher rating for painful motion would not accurately assess the resulting functional loss, even when considering the pain. The 10 percent rating contemplates the Veteran's functional loss associated with his cervical spine. The Board finds that 38 C.F.R. §§ 4.40, 4.45 and 4.59 do not provide a basis for an increased rating for either period contemplated by this appeal. See DeLuca, 8 Vet. App. at 204 -07. In other words, the functional loss does not most nearly approximate the criteria for the next-higher respective 20 percent evaluation. With regard to consideration of flare-ups per Sharp v. Shulkin, 29 Vet. App. 26 (2017), the December 2019 examination report reflects that the Veteran denied flare-ups. The examiner found that pain, weakness, fatigue and incoordination would not limit functional ability of the cervical spine during flare-ups or repeated use over time, and there was no change in his reported flexion of the spine during repetitive motion testing. There is no basis for the assignment of a rating in excess of 10 percent in contemplation of symptomatology during flare-ups. Radiculopathy of the upper extremities is not shown, nor is bladder and bowel symptomatology shown. Thus, there is no basis for assignment of further ratings for neurological symptomatology. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Knees The Veteran's left knee and right knee disabilities are separately rated 10 percent disabling pursuant to 38 C.F.R. § 4.71A, Diagnostic Code 5260. The Board notes that the 10 percent ratings were assigned in contemplation of the Veteran's subjective complaints of pain, rather than objective findings of compensable limitation of flexion. See Petitti v. McDonald, 27 Vet. App. 415, 427 (2015) (holding that painful motion may be "objectively confirmed" by either a clinician, including a claimant's assertion of painful joints that is confirmed by a clinician's statement there is a history of "recurrent" joint pain or a layperson who witnessed the Veteran experience difficulty walking, standing, or sitting, or display a facial expression, such as wincing, indicative of pain) For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluation for cartilage, semilunar, dislocated knee with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent disability rating. 38 C.F.R. § 4.71, Diagnostic Code 5258. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5257 was revised, effective February 7, 2021. Part 4 - Schedule for Rating Disabilities, § 4.71a Schedule of ratings musculoskeletal system, 85 Fed. Reg. 230, 76463 (November 30, 2020). Effective February 7, 2021, Diagnostic Code 5257, concerning recurrent subluxation or instability, provides a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 30 percent award is also warranted for sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. A 20 percent rating applies where the evidence shows unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation A 10 percent rating is for application for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation Regarding patellar instability: A 30 percent rating applies for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker A 20 percent rating applies for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker A 10 percent rating applies for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98 (Aug. 1998). Moreover, the General Counsel also held more recently that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (Sept. 2004). With regard to the limitation of motion criteria, a disability rating in excess of 10 percent is not warranted for limitation of flexion or extension. The Board acknowledges the Veteran's lay reports of symptoms and recognizes his functional limitations. However, flexion limited to 30 degrees is not shown, and limitation of extension to any degree is not shown. A February 2013 C&P examination reflects flexion to 135 degrees with no objective evidence of painful motion with regard to both knees. The examiner commented that his range of motion was normal for his body habitus. There was no change on repetitive motion testing. There was no limitation of extension and no objective evidence of painful motion. The examiner indicated that there was no functional loss for either the right or left lower extremity. 04/03/2013 C&P Exam at 13. A December 2019 C&P examination reflects normal flexion with no change on repetitive motion testing. As the evidence does not demonstrate limitation of flexion to 30 degrees or less at any time during the pendency of this appeal nor limitation of extension, a higher evaluation based on limitation of flexion and extension under the above cited rating code is not warranted. Per a VA General Counsel opinion, separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). However, there is no evidence of limitation of extension; thus, separate ratings are not warranted for any period contemplated by this appeal. With regard to Diagnostic Code 5257, the evidence of record does not support a separate disability rating for recurrent subluxation or lateral instability, as such is not shown. The February 2013 and December 2019 examination reports reflect that joint stability testing was normal. Both the February 2013 and December 2019 examinations reflect there was no evidence or history of recurrent patellar subluxation or dislocation. As there are no objective findings of instability on examination and in the treatment records, there is no basis for assignment of a separate compensable rating under either the pre-amended or newly revised diagnostic criteria. A separate 20 percent rating is also not warranted pursuant to Diagnostic Code 5258 contemplating dislocated, semilunar cartilage, as locking and effusion were not shown on C&P examinations nor in treatment records. With regard to the other potentially applicable rating codes, Diagnostic Code 5256 provides a higher rating for ankylosis of the knee; however, ankylosis of the knee joint has not been shown. Diagnostic Code 5262, impairment of the tibia and fibula is inapplicable on the facts of this case. The Board must also consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 205-08 (1995). In finding that a higher evaluation is not warranted for any period, the Board has considered the Veteran's subjective complaints, as well as whether there is additional functional loss due to lack of endurance, weakness, fatigue, and pain per 38 C.F.R. §§ 4.40 and 4.45. DeLuca, 8 Vet. App. at 206-07. These factors have been taken into consideration in awarding the separate 10 percent ratings pursuant to Diagnostic Code 5260. The most recent December 2019 C&P examination reports reflect the Veteran's report of retropatellar pain syndrome affecting both knees and difficulty ascending stairs. The Board notes that pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss but does not itself constitute functional loss. Mitchell, 25 Vet. App. at 38. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; 38 C.F.R. § 4.40. The findings reflected in the C&P examination reports and treatment records do not support ratings in excess of the separate 10 percent ratings already in effect. In consideration of the DeLuca factors, while it is clear that the Veteran experiences pain and limitations due to his left knee and right knee disabilities, the disability ratings in effect take into consideration the Veteran's functional limitations associated with his left and right lower extremities. The Board finds that 38 C.F.R. § 4.40, 4.45 and 4.59 do not provide a basis for higher ratings. The Board has also considered whether additional ratings for neurological manifestations are warranted. However, because no such manifestations have been diagnosed, additional ratings for neurological manifestations are inapplicable in this case. 38 C.F.R. § 4.124a. Applying all of the appropriate diagnostic codes to the facts of this case, the objective assessment of the Veteran's present impairment of the left knee and right knee disabilities do not suggest that he has sufficient symptoms at any time during the pendency of this appeal, so as to warrant the assignment of evaluations in excess of the 10 percent ratings in effect. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Thoracic spine The Veteran's thoracic scoliosis is rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237 (lumbosacral strain). Intervertebral disc syndrome is to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and, a 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula For Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Effective February 7, 2021, the General Rating Formula for Diseases and Injuries of the Spine was revised as follows: 5242 Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010); 5243 Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses. Part 4 - Schedule for Rating Disabilities, § 4.71a Schedule of ratings musculoskeletal system, 85 Fed. Reg. 230, 76462 (November 30, 2020). The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's thoracic scoliosis. The Board acknowledges the Veteran's lay reports of symptoms associated with his thoracic spine. However, even considering the lay reports of symptoms and noted functional loss, the degree of additional limitation would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 60 degrees or less. The Veteran's forward flexion has been shown to be normal, to 90 degrees, on range of motion testing. On examination in December 2019, there was pain on examination, but it did not result in or cause functional loss. Furthermore, there is no evidence of any muscle spasm or guarding that resulted in abnormal spinal contour or gait. The Veteran denied flare-ups and pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. There was no guarding or muscle spasm of the spine. He experiences interference with sitting and standing. The objective findings combined with the subjective complaints of the Veteran do not support a 20 percent for his thoracic scoliosis, as even with consideration of his functional limitations forward flexion of 60 degrees or less is not shown, nor muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. In consideration of the DeLuca factors, there have been objective findings of pain, but such does not cause functional loss, and there have been no objective findings of fatigue, weakness, and lack of endurance. The objective findings contained within the record, based on examination reports and treatment records, do not more nearly approximate the criteria for a higher rating even with consideration of pain. The 10 percent rating in effect compensates him for painful motion and functional limitations with sitting and standing for long periods but assigning the next higher rating for painful motion would not accurately assess the resulting functional loss, even when considering the pain. The 10 percent rating contemplates the Veteran's functional loss associated with his thoracic spine. The Board finds that 38 C.F.R. §§ 4.40, 4.45 and 4.59 do not provide a basis for an increased rating for either period contemplated by this appeal. See DeLuca, 8 Vet. App. at 204 -07. In other words, the functional loss does not most nearly approximate the criteria for the next-higher respective 20 percent evaluation. Consideration has also been given to assigning a higher rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that he was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. With regard to consideration of flare-ups per Sharp v. Shulkin, 29 Vet. App. 26 (2017), the December 2019 examination report reflects that the Veteran denied flare-ups. The examiner found that pain, weakness, fatigue and incoordination would not limit functional ability of the thoracolumbar spine during flare-ups or repeated use over time, and there was no change in his reported flexion of the spine during repetitive motion testing. There is no basis for the assignment of a rating in excess of 10 percent in contemplation of symptomatology during flare-ups. Regarding neurological impairment, radiculopathy of the lower extremities associated with his thoracic scoliosis has not been found on objective examination or diagnosed. With regard to any bowel and bladder impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Thus, there is no basis for assignment of separate ratings for bowel or bladder impairment. Based on the foregoing, a rating in excess of 10 percent for thoracic scoliosis is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Separate noncompensable disability ratings have been assigned to sinusitis per 38 C.F.R. § 4.97, Diagnostic Code 6511, and allergic rhinitis per Diagnostic Code 6522. The sinusitis diagnostic criteria contemplates incapacitating episodes with antibiotic treatment, and symptoms such as headaches, pain, purulent discharge, and crusting. See 38 C.F.R. § 4.97, Diagnostic Code 6515. The allergic rhinitis diagnostic criteria contemplates a showing of polyps and obstruction of nasal passage. See 38 C.F.R. § 4.97, Diagnostic Code 6522. In December 2019, the Veteran underwent a C&P examination wherein the examiner did not complete the Part A Sinusitis section of the examination report and the examiner stated that there were no symptoms of sinusitis found during the examination. With regard to allergic rhinitis, the examiner checked the 'No' boxes for any obstruction of the nasal passage and nasal polyps. An October 2020 VA treatment record, however, reflects the Veteran's complaints of chronic sinusitis with nasal polyps with objective findings of septum deviated to the left posteriorly, inferior turbinates hypertrophied, with no findings of polyps. A November 2020 VA treatment record reflects a finding of nasal polyps. 01/20/2021 CAPRI at 35-39. In light of the incomplete C&P examination report and the findings contained in the treatment records, the Veteran should be afforded an examination to assess the severity of his sinusitis and allergic rhinitis. With regard to his asthma, the Veteran underwent a C&P examination in December 2019 wherein pulmonary function tests were not performed. The examiner noted that the Veteran denied PTFs and chest x-ray diagnostics. It is not clear if the Veteran declined testing or if he was denied further testing. A November 2020 VA treatment record reflects that the Veteran's moderate, persistent asthma symptoms were controlled with his current regimen and PFTs were pending for January. VA treatment records have been associated with the claims folder through January 7, 2021 which do not contain PFTs. Outstanding VA treatment records must be associated with the claims folder. If PFTs are not of record, the Veteran should be afforded a C&P examination in which such testing is conducted. The matters are REMANDED for the following actions: 1. Associate updated VA treatment records for the period from January 8, 2021, to include any outstanding PFT results. 2. The Veteran should be scheduled for an examination with a qualified clinician to determine the severity of his sinusitis. It is imperative that the claims file be made available to and reviewed by the examiner in connection with the examination. All indicated studies, including X-rays, should be performed. The examiner should indicate whether the Veteran's sinusitis is manifested by the presence of polyps; incapacitating episodes requiring prolonged antibiotic treatment (please state the length of the treatment); non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting (please state the amount of non-incapacitating episodes per year); chronic osteomyelitis following radical surgery, or whether the Veteran experiences near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and whether he experiences purulent discharge or crusting after repeated surgeries. 3. The Veteran should be scheduled for an examination with a qualified clinician to ascertain the current severity of his allergic rhinitis. The claims file should be made available to the examiner for review. The examiner should expressly report (1) whether there is greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side and (2) whether there is evidence of polyps. 4. IF AND ONLY IF the Veteran did not undergo PFT testing in January 2021 or thereafter, schedule the Veteran for an examination with a qualified clinician with appropriate expertise to determine the current extent of his asthma. The virtual folder should be made available to and be reviewed by the examiner to become familiar with the Veteran's pertinent medical history. Any medically indicated tests should be accomplished and reported. All indicated tests and studies should be performed. The examiner should report FEV-1 percent predicted; and FEV-1/FVC percent. If any of the above cannot be measured, the examiner may provide an estimate of the value that would likely be obtained if the test were provided. The examiner should comment on whether the Veteran requires at least monthly visits to a physician for required care of exacerbations; whether he has had intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids; whether he has had more than one attack per week with episodes of respiratory failure; or whether he requires daily use of systemic high dose corticosteroids or immuno-suppressive medication. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.W. Kreindler, 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.