Citation Nr: 21029913 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-00 001A DATE: May 17, 2021 ORDER Entitlement to service connection for a right ear disability, to include cerumen impaction, is denied. Entitlement to service connection for a left ear disability, to include cerumen impaction, is denied. Entitlement to service connection for flu residuals is denied. Entitlement to an initial rating higher than 20 percent for right (major) shoulder sprain residuals is denied. Entitlement to an initial rating higher than 10 percent for lumbar spine strain residuals is denied. Entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome is denied. Entitlement to an initial rating higher than 10 percent for left ankle sprain residuals is denied. Entitlement to an initial rating higher than 0 percent for bilateral Eustachian tube dysfunction is denied. Entitlement to an initial rating higher than 0 percent for allergic rhinitis is denied. FINDINGS OF FACT 1. The Veteran's right ear cerumen impaction has not resulted in an impairment of earning capacity, and the preponderance of the evidence is against finding that the Veteran has a right ear hearing loss disability as defined by VA regulations. 2. The Veteran's left ear cerumen impaction has not resulted in an impairment of earning capacity, and the preponderance of the evidence is against finding that the Veteran has a left ear hearing loss disability as defined by VA regulations. 3. The Veteran's claimed flu residuals have not resulted in an impairment of earning capacity, and the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a disability manifested by flu residuals. 4. Throughout the period of appeal, a right shoulder disability was manifested by no more than limitation of motion to approximately 170 degrees with pain and tenderness. 5. Throughout the period of appeal, a lumbar spine disability was manifested by no more than limitation of motion of thoracolumbar spine flexion to approximately 90 degrees with pain; no ankylosis or incapacitating episodes requiring bed rest prescribed by a physician were shown. 6. Throughout the period of appeal, a right knee disability has been manifested by flexion limited to 90 degrees and extension, overall, to 0 degrees; it has not been manifested by flexion limited to 30 degrees or less, extension limited to 10 degrees or less, ankylosis, objective evidence of recurrent subluxation or lateral instability, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum.. 7. Throughout the period of appeal, left ankle sprain residuals have been manifested by no more than moderate limitation of motion with no evidence of joint ankylosis or any other residual disability. 8. Throughout the period of appeal, bilateral Eustachian tube dysfunction was manifest by intermittent episodes of pressure and popping, with no evidence of suppuration or aural polyps; and no evidence of otitis externa with swelling, dry and scaly or serous discharge, or itching requiring frequent or prolonged treatment, or a compensable degree of hearing impairment. 9. Throughout the period of appeal, allergic rhinitis was not manifest by polyps or greater than 50 percent obstruction of a nasal passage.. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right ear disability, to include cerumen impaction, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.385. 2. The criteria for entitlement to service connection for a left ear disability, to include cerumen impaction, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.385. 3. The criteria for entitlement to service connection for flu residuals have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. The criteria for entitlement to an initial rating higher than 20 percent for right (major) shoulder sprain residuals have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5201. 5. The criteria for entitlement to an initial rating higher than 10 percent for lumbar spine strain residuals have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5237-5243. 6. The criteria for entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263. 7. The criteria for entitlement to an initial rating higher than 10 percent for left ankle sprain residuals have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 8. The criteria for entitlement to an initial rating higher than 0 percent for bilateral Eustachian tube dysfunction have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.85, 4.87, Diagnostic Codes 6100, 6200, 6201, 6210. 9. The criteria for entitlement to an initial rating higher than 0 percent for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.97, Diagnostic Code 6522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1998 to November 2009. The Veteran appeared at a July 2018 hearing before the undersigned Veterans Law Judge. The hearing transcript is of record. In April 2019, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for further development. As part of the remand, the Board requested the issuance of a statement of the case which addressed the issues of entitlement to an initial rating higher than 10 percent for left knee degenerative arthritis and entitlement to an initial rating higher than 0 percent for headaches. The Veteran was to be notified of his appeal rights and that he must submit a timely substantive appeal to receive appellate review of those claims. In November 2019, the AOJ issued statement of the case which addressed the issues of entitlement to an initial rating higher than 10 percent for left knee degenerative arthritis and entitlement to an initial rating higher than 0 percent for headaches. The Veteran has not submitted a timely substantive appeal regarding those issues. Therefore, the issues of entitlement to an initial rating higher than 10 percent for left knee degenerative arthritis and entitlement to an initial rating higher than 0 percent for headaches are not before the Board. During the course of the appeal, a December 2020 rating decision established service connection for left rib strain, representing a full grant of that benefit sought. Therefore, that issue is no longer before the Board. A December 2020 rating decision granted a higher 20 percent rating for a right shoulder disability. However, as a higher rating is available for a right shoulder disability, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). In July 2019, the AOJ sent the Veteran a letter asking him to complete an enclosed VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs, so that VA could obtain the treatment records from the Veteran's private providers, including Kaiser Permanente. No response from the Veteran to the July 2019 letter is of record. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the AOJ, the Board finds that there has been substantial compliance with the remand requests. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection In general, service connection may be established for disability due to disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303 (d). To establish a service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability may be service-connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or that was chronic as defined by regulation with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303 (a),(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a right ear disability, to include cerumen impaction 2. Entitlement to service connection for a left ear disability, to include cerumen impaction A March 2005 service medical record shows that the Veteran had cerumen impaction of both ears. At a December 2009 VA examination, the Veteran stated that cerumen impaction caused muffled hearing. The examiner recorded the Veteran's report that he did not experience any overall functional impairment from the condition. The examiner found that there was no ear disease or active infection in either ear. There was no effusion in either ear. There was no disturbance of balance on either side. There was no staggering gait. Auricle examination was normal. There was complete cerumen impaction of both ears which the examiner removed. Pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 10 15 LEFT 5 15 05 15 15 Speech discrimination scores were 100 percent for the right ear and 100 percent for the left ear. The examiner opined that there was no hearing loss present. At a July 2018 Board hearing, the Veteran stated that he had stuffy ears. He stated that the stuffy ears affected his hearing. An October 2018 VA examination shows pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 20 25 LEFT 15 15 10 25 20 Speech discrimination scores were 98 percent for the right ear and 96 percent for the left ear. The examiner opined that the Veteran had normal hearing. In a September 2019 addendum, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran had right and left ear disabilities caused by service or aggravated by service-connected disability as there was no current or recent objective evidence of Eustachian tube or other dysfunction involving either ear. After review of all the lay and medical evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran currently has a disability manifested by cerumen impaction for VA compensation purposes. The Veteran states that he has experienced cerumen impaction. However, the evidence does not show any currently diagnosed disability or medical findings of disability that would constitute a disability for which service connection could be established. While the record shows evidence of cerumen impaction, the record does not show any diagnosed disability underlying the ear wax. In the September 2019 VA examination addendum, the VA examiner stated that there was no objective evidence of dysfunction involving either ear. The Board has considered that pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, while the Veteran presently experiences ear pressure and popping, he has not claimed that such pain has reached the level of a functional impairment of earning capacity, nor has any medical professional found a functional impairment of either ear due to pain. Additionally, the available treatment records do not indicate that the Veteran's ear pressure and popping has reached the level of a functional impairment of earning capacity. Concerning the Veteran's assertion that his cerumen impaction has decreased hearing acuity, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is between 0 and 20 decibels and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). The Board notes that none of the pure tone thresholds as recorded by any audiologist of record meet the numerical standards enumerated by 38 C.F.R. § 3.385. Therefore, the Veteran does not have a hearing loss disability of either ear for VA benefits purposes. Without a diagnosis of a current hearing loss disability that meets the standards of 38 C.F.R. § 3.385, service connection cannot be established for a hearing loss disability of either ear. The Veteran is competent to report difficulty hearing. However, he is not competent to state that his pure tone thresholds or speech recognition scores arise to levels sufficient to constitute a disability for VA purposes. Accordingly, the Board has placed greater probative value on the contemporaneous objective medical evidence that does not support a finding of a hearing loss disability of either ear for VA purposes. Under applicable regulations, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may not be established for symptoms unaccompanied by a diagnosed disability. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). In the absence of a diagnosis of a current disability, or any abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, no valid claim for service connection for a right or left ear disability exists. As the preponderance of the evidence is against the claim for service connection for right and left ear disabilities, to include cerumen impaction, the claims must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for flu residuals On an October 2009 Report of Medical Assessment, the Veteran reported that he was treated for flu-like symptoms in 2009. At a November 2009 VA examination, the Veteran reported that he had been previously diagnosed with the flu. After performing an examination, the examiner stated that the Veteran had no current symptoms, no more treatment, and no functional impairment. At a July 2018 Board hearing, the Veteran stated that he had not necessarily noticed any permanent residuals or chronic disability that resulted from the flu he experienced in 2009. He stated that it was more difficult for him to fight colds away. On VA examination in September 2019, the examiner found no evidence of a flu residual. Considering the claim for service connection for flu residuals, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to any injury, event, or disease in service. The Board concludes that the Veteran does not have a current diagnosis of a disability manifested by flu residuals and has not had one at any time during the pendency of the claim or contemporary to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board has considered that pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, the Veteran has not claimed that he experiences pain as a flu residual that has reached the level of a functional impairment of earning capacity, nor has any medical professional found a functional impairment of a flu residual due to pain. Additionally, the available treatment records do not indicate that the Veteran has flu residuals While the Veteran may believe that he has a current diagnosis of flu residuals, the Board notes that the Veteran has sought consistent medical treatment from both VA and private facilities. However, despite that consistent treatment, the treatment records do not contain a diagnosis of a disability manifested by flu residuals at any time during the pendency of the claim or contemporary to the filing of the claim. The Board gives more probative weight to the competent medical evidence, as the medical records were created by objective professionals who have the education, training, and expertise to be able to determine diagnoses. Absent competent and credible evidence of diagnoses of a disability manifested by flu residuals, the Board concludes that the claim of entitlement to service connection for flu residuals must be denied because the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45. The intent of the 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. 4. Entitlement to an initial rating higher than 20 percent for right (major) shoulder sprain residuals With regard to the right shoulder disability, the Veteran has not been shown to have ankylosis of the scapulohumeral articulation. Nor is there objective evidence of impairment of the humerus, such as loss of the head of the humerus (flail shoulder), nonunion of the shoulder (flail joint), fibrous union of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, or malunion of the humerus. Accordingly, the Board finds that the criteria pertaining to rating those disabilities are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. Normal forward flexion of the shoulder is from 0 to 180 degrees, normal abduction is from 0 to 180 degrees, and normal internal and external rotation is from 0 to 90 degrees. Forward flexion and abduction to 90 degrees amounts to shoulder level. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5201 provides criteria for rating limitation of motion of the arm. The criteria in Diagnostic Code 5201 provide different ratings for the minor arm and the major arm. The Veteran has indicated in service medical records and at VA examinations that he is right-handed. Therefore, with respect to the right shoulder, the Board will apply the ratings and criteria for the major arm under the relevant Diagnostic Codes. Under Diagnostic Code 5201, a 20 percent rating is warranted where there is limitation of motion of the major arm at shoulder level (flexion and/or abduction limited to 90 degrees). A 30 percent rating is warranted where there is limitation of motion of the major arm to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). A 40 percent rating is warranted where motion of the major arm is limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. On VA examination in November 2009, the Veteran reported experiencing weakness, stiffness, giving way, lack of endurance, fatigability, and pain. The Veteran reported experiencing flare-ups twice a month. The Veteran rated his flare-up pain as a 5 on a 1 (low) to 10 (high) scale. The Veteran treated the pain with Motrin. The examiner found that the right shoulder showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. There was no ankylosis. The examiner measured right shoulder flexion to 180 degrees. Abduction was to 180 degrees. External rotation was to 90 degrees. Internal rotation was to 90 degrees. Ranges of motion for the left shoulder were noted the same as the right shoulder. At a July 2018 Board hearing, the Veteran stated that he experienced flare-ups and stiffness. He had difficulty sleeping on his side. During the course of the week, the Veteran stated that he experienced pain he rated as an 8 on a 1 (low) to 10 (high) pain scale. He treated the pain with Tylenol and Ibuprofen. He also used ice packs. At a September 2019 VA examination, the examiner diagnosed right acromioclavicular joint osteoarthritis. The Veteran reported experiencing pain, stiffness, and popping. He treated the pain with Motrin. The Veteran was right-handed. No flare-ups were reported. The examiner observed flexion of the right shoulder to 170 degrees. Abduction was to 170 degrees. External rotation was to 90 degrees. Internal rotation was to 70 degrees. Pain was noted on internal rotation. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. There was no additional functional loss or range of motion after repetitive use testing. Ranges of motion of the left shoulder were noted to be normal. Muscle strength testing showed normal strength for both shoulders. There was no muscle atrophy. There was no ankylosis. No clavicle, scapula, acromioclavicular joint, or sternoclavicular joint conditions were suspected. No pain with non-weight bearing, passive range of motion testing, or weight bearing was noted on examination. After review of all of the evidence of record, the Board finds that a rating higher than 20 percent is not warranted at any time during the period of appeal. Throughout the period of appeal, the evidence shows shoulder motion limited at most to 170 degrees of flexion or adduction, with painful motion. However, the evidence does not show that pain or any other limiting factors limited motion to midway between the side and shoulder level, or 45 degrees, which would be required to assign a higher rating. That does not end the inquiry, as the Board must consider functional loss and the impact of pain upon the disability. In this case, the medical evidence shows that the Veteran has consistently complained of pain in shoulder motion. 38 C.F.R. §§ 4.40, 4.45. However, the effect of right shoulder pain is included in the currently assigned 20 percent rating. The limitation of motion and functional loss documented in the medical records as resulting from pain, including flare-ups, is already contemplated in the disability rating now currently assigned. Moreover, although the Veteran had pain on repetitive motion, that pain did not result in limitation of motion to the level that any separate or higher rating would be warranted. There is otherwise no evidence of additional significant impairment of motor skills, muscle function, or strength attributable to the right shoulder disability beyond what is already being compensated. Consequently, the Board finds that a higher rating based on limitation of motion is not warranted for the right shoulder. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 20 percent for a right shoulder disability and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to an initial rating higher than 10 percent for lumbar spine strain residuals Disabilities of the spine are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome is rated under the General Formula for Rating 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 rating when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, 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, a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the 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 an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is assigned 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. 38 C.F.R. § 4.71a. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). Diagnostic Code 5243 provides that intervertebral disc syndrome is to be rated either 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 rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). At a November 2009 VA examination, the Veteran reported experiencing stiffness, fatigue, decreased motion, and numbness. The Veteran did not experience spasms and paresthesia. The Veteran did not experience any bladder or bowel problems. The low back pain occurred constantly. The Veteran reported that the back condition had not resulted in any incapacitation over the prior 12 months. The examiner found no evidence of radiating pain on movement. Muscle spasm was absent. No tenderness was noted. There was no guarding of movement. Objective examination did not reveal any weakness. There was no atrophy. There was no ankylosis of the thoracolumbar spine. The examiner measured flexion of the thoracolumbar spine to 90 degrees. Extension was to 30 degrees. Right and left lateral flexion were each to 30 degrees. Right and left rotation were each to 30 degrees. There were no changes in any of the ranges of motion on repetitive use testing. There was symmetry of spinal motion with normal curves of the spine. Neurological examination revealed no sensory deficits of S1 or from L1-L5. There was no lumbosacral motor weakness. Reflexes were normal. There were no signs of intervertebral disc syndrome. At a July 2018 Board hearing, the Veteran stated that he experienced pain and numbness. He stated that pain in the lower back caused him to limit activities. On a 1 (low) to 10 (high) pain scale, the Veteran rated the pain as a 15. He used a back brace. At a September 2019 VA examination, the examiner diagnosed lumbosacral strain. The Veteran reported experiencing pain and stiffness. There were no reported flare-ups. The examiner specified that all range of motion findings were normal. Forward flexion of the thoracolumbar spine was to 90 degrees. Extension was to 30 degrees. Right and left lateral flexion were each to 30 degrees. Right and left lateral rotation were each to 30 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. There was no additional loss of function or range of motion after repetitive use testing. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing yielded normal results. There was no muscle atrophy. Sensory examination was normal for both lower extremities. Straight leg raising test was normal for both lower extremities. The examiner specified that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine. The examiner stated that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. The Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of height. The examiner stated that there was no objective evidence of a back condition on examination. There were only subjective complaints of pain. No pain with non-weight bearing, passive range of motion testing, or weight bearing was noted on examination. The VA examiner stated that after examination of the Veteran, listening to his complete history and current subjective complaints, combined with a review of the available records, the examiner had no basis to offer additional loss of function or motion findings when it came to repetitive use or during flare-ups. On review of all the evidence of record, both lay and medical, the Board finds that the Veteran's back disability has not more nearly approximated the criteria for a rating higher than 10 percent at any time throughout the period of appeal. No ankylosis, either favorable or unfavorable, has been shown. Moreover, at no time has the evidence found forward flexion of the lumbar spine limited to 60 degrees or less. The VA examinations showed forward flexion, at worst, limited to 90 degrees with pain after repetitive motion. Therefore, the Board finds that flexion was not limited to 60 degrees of less. As reviewed above, the combined range of motion of the thoracolumbar spine has been greater than 120 degrees throughout the period of appeal. The other treatment records show continuing complaints of pain and flare-ups. However, the treatment records do not show functional impairment that more nearly approximates the range of motion criteria to support a higher rating under the General Rating Formula, even considering the Veteran's subjective complaints. Similarly, the evidence does not show muscle spasm or guarding severe enough to result in an abnormal gait, and the Veteran's spinal contour was noted to be normal. The Board has also considered the Veteran's reported impairment of function and has considered additional limitations of motion due to pain, incoordination, fatigability, excess motion, weakened motion, or on flare up. Even considering additional limitation of motion or function of the spine due to pain or other symptoms such as weakness, fatigability, pain, or incoordination the evidence still does not show that the back disability more nearly approximates the criteria for a higher rating. On repetitive use testing, range of motion of the spine did not show flexion of the thoracolumbar spine limited to 60 degrees or less, and while the Veteran experienced pain during flare-ups, overall he remained able to function. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The factors that may additionally limit motion and function were considered and assessed by the examination reports. The VA examiners noted less movement than normal, pain on movement, and interference with sitting, standing, and weight-bearing. The Veteran described flare-ups were manifested by increased pain but continued ability to function. The Board finds that pain and reduced range of motion is fully contemplated in the current 10 percent rating assigned. The evidence does not show that any additional factors approximate thoracolumbar flexion to 60 degrees or less. The Board has also considered whether a higher rating could be assigned under the IVDS formula based on incapacitating episodes. Notably, the VA examiners specified that the Veteran does not have IVDS. However, although the Veteran rests following flare-ups, the evidence shows that throughout the entire period of appeal, the Veteran was never prescribed bed rest by a physician as due to IVDS. Therefore, he has not been shown to have incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician of a total duration of at least two weeks. Finally, although the Veteran has stated that he experiences numbness, a neurological examination has found no sensory deficits. There are no neurological disabilities which have been attributed to the Veteran's lumbar spine disability by a medical professional. The Board finds that the reports of the November 2009 and September 2019 VA examiners outweigh the Veteran's reports concerning any possible neurological problems related to the service-connected lumbar spine disability, as the VA examiners have the training and expertise to identify and diagnose neurological abnormalities. The competent evidence does not show any other objective neurologic abnormalities associated with the low back disability so as to warrant any higher or separate rating. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 10 percent for a lumbar spine disability and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to an initial rating higher than 10 percent for right knee patellofemoral syndrome Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, limitation of flexion of the knee is rated 10 percent for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee is rated 10 percent for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004);VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). At a November 2009 VA examination, the Veteran reported experiencing weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, and pain. The Veteran reported experiencing flare-ups that he rated as a 9 on a 1 (low) to 10 (high) pain scale. He treated flare-ups with Motrin and rest. The examiner noted that the right knee showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. There was no ankylosis. Right knee flexion was to 120 degrees with pain at 90 degrees. Right knee extension was to 0 degrees. Left knee flexion was also to 120 degrees with pain at 90 degrees. Left knee extension was to 0 degrees. There was no change in the range of motion findings on repetitive use. The examiner stated that the right knee stability tests were within normal limits. The right knee showed no signs of subluxation. At an August 2017 VA examination, no flare-ups were reported. The examiner indicated that the Veteran did not report having any functional loss or functional impairment of the right knee joint. The examiner measured forward flexion of the right knee to 110 degrees. Extension was 0 to 110 degrees. Pain was noted on examination but did not result in or cause functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no additional functional loss or range of motion after repetitive use testing. Flexion of the left knee was to 90 degrees. Extension of the left knee was to 0 degrees. Muscle strength testing of the right knee was normal. There was no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation or lateral instability. Joint stability testing was performed, and there was no joint instability. The Veteran regularly used a brace. At a July 2018 Board hearing, the Veteran reported that he experienced weakness, stiffness, and swelling. Sometimes the knee locked. At a September 2019 VA examination, the examiner diagnosed right knee osteoarthritis. The Veteran reported experiencing pain and stiffness. He treated the knee with Motrin and a brace. No flare-ups were reported. The examiner measured right knee flexion to 140 degrees. Extension was to 0 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. There was no additional functional loss or range of motion after three repetitions. Muscle strength testing yielded normal results. There was no muscle atrophy. No ankylosis was present. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed, and there was no instability. The examiner found that the Veteran did not have recurrent patellar dislocation or a meniscus condition. No pain with nonweight bearing, passive range of motion testing, or weight bearing was noted on examination. In a May 2020 addendum, the VA examiner stated that after examination of the Veteran, listening to his complete history and current subjective complaints, combined with a review of the available records, the examiner had no basis to offer additional loss of function or motion findings when it came to repetitive use or during flare-ups. The Board finds that the preponderance of the evidence is against the assignment of any higher or separate disability rating under Diagnostic Code 5260 for limitation of flexion of the right knee at any time during the course of the appeal. Concerning the right knee, the evidence shows that flexion of the knee was limited, at worst, to 90 degrees, with consideration of pain. The flexion measurements are consistent with no more than a 0 percent rating under Diagnostic Code 5260. The Board also finds that the weight of the evidence is against assigning a higher rating throughout the period of appeal under Diagnostic Code 5261 for limitation of extension for right knee. The evidence shows that extension of the right knee was to 0 degrees throughout the period of appeal. Considering the record as a whole, the extension measurements are consistent with no more than a 0 percent rating under Diagnostic Code 5261. The Veteran has repeatedly reported that he experiences pain. He has reported pain to each medical examiner, and he has additionally discussed his pain in repeated submissions to the AOJ. Because of the Veteran's painful limitation of knee motion, and other symptoms, the presently assigned disability rating of 10 percent based on painful motion for the right knee is warranted. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40, 4.45, 4.59. However, the Board finds that the preponderance of the evidence is against the assignment of any higher or additional separate rating for limitation of motion of the right knee. The rating assigned has considered additional functional loss due to pain and other factors. Turning to instability, the Board concludes that a separate compensable rating is not warranted at any time throughout the period of appeal for the right knee. Significantly, all of the VA examiners and treatment providers indicate that the Veteran's knees were stable on objective observation. To whatever extent the Veteran may assert that the right knee is unstable, the Board finds that the objective medical evidence outweighs the subjective complaints, as the medical evidence was created by trained health care providers objectively performing professional duties following objective testing, which determined there was not objective evidence of recurrent lateral instability or subluxation. The Board finds that those objective medical findings are more persuasive because of the training and experience of the medical professionals. In light of those medical records, the Board finds that a separate disability rating is not warranted at any time during the period of appeal for instability of the right knee. In addition, subluxation of the right knee is not shown. None of the treatment records, to include X-ray and MRI findings, show dislocated or removed semilunar cartilage of either knee. Thus, Diagnostic Codes 5258 and 5259 cannot serve as a basis for an increased or separate rating for the right knee. Finally, in considering the applicability of other diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable, as the medical evidence does not show that the Veteran has any of those conditions. The Board notes that the Veteran's functional loss was considered as the medical evidence shows that the Veteran has consistently complained of pain. 38 C.F.R. §§ 4.40, 4.45. However, the limitation of motion and functional loss documented in the medical records as resulting from pain, including flare-ups, is contemplated in the disability rating now currently assigned. Moreover, although the Veteran had pain on repetitive motion, that pain did not result in limitation of flexion or extension to the level that any separate or higher rating would be warranted. There is otherwise no evidence of additional significant impairment of motor skills, muscle function, or strength attributable to the Veteran's knee disability, beyond what is already being compensated. Consequently, the Board finds that a higher rating based on functional loss is not warranted for the right knee. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher or separate rating for the right knee disability and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Entitlement to an initial rating higher than 10 percent for left ankle sprain residuals For the foot, a 90 degree angle to the ankle as the neutral or starting position, a normal or full range of ankle motion is defined as from 0 degrees to 20 degrees of dorsiflexion and from 0 degrees to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5271 provides that limitation of motion of an ankle warrants a 10 percent rating when moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) and 20 percent when marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). 38 C.F.R. § 4.71a. The terms moderate, moderately severe, and marked, as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that Board decisions are equitable and just. 38 C.F.R. § 4.6. At a November 2009 VA examination, the Veteran reported experiencing weakness, swelling, tenderness, and pain. The Veteran experienced flare-ups of pain that he rated as a 7 on a 1 (low) to 10 (high) pain scale. He treated the flare-ups with rest and Motrin. He used braces when doing physical training. The examiner noted that the left ankle showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. There was no ankylosis. Left and right ankle dorsiflexion was to 20 degrees. Plantar flexion was to 45 degrees. There was no change in range of motion on repetitive use testing. At a July 2018 Board hearing, the Veteran reported experiencing instability and weakness of his left ankle. He occasionally used an ankle brace. At a September 2019 VA examination, the examiner diagnosed left ankle arthritis. The Veteran reported experiencing pain and stiffness. The Veteran treated the ankle with Motrin. The Veteran stated that mobility was impaired during flare-ups. The examiner measured left ankle dorsiflexion to 20 degrees. Plantar flexion was to 45 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive use testing. Muscle strength testing yielded normal results. There was no muscle atrophy or ankylosis. Anterior Drawer Testing and Talar Tilt Testing showed that there was no left ankle laxity compared with the opposite side. No pain with nonweight bearing, passive range of motion testing, or weight bearing was noted on examination. In a May 2020 addendum, the VA examiner stated that after examination of the Veteran, listening to his complete history and current subjective complaints, combined with a review of the available records, the examiner had no basis to offer additional loss of function or motion findings when it came to repetitive use or during flare-ups. Collectively, the evidence of record shows that throughout the entire period of appeal the Veteran's left ankle sprain residuals were manifested by a normal range of motion, as described as such by the VA examiners of record. While the Veteran has asserted that the fracture residuals include severe pain, the objective examination findings did not show that the level of severity caused by the pain resulted in limitation of motion that would warrant any higher rating. The objective evidence demonstrates a normal range of motion. The Board finds that level of motion does not constitute marked limitation of ankle motion, as required for a higher 20 percent rating under the appropriate Diagnostic Code, or ankylosis as required for any higher rating. Even considering the objective evidence of swelling, tenderness, and painful motion in the right ankle, and functional loss due to increased pain and weakness during flare-ups associated with prolonged walking and standing, the current 10 percent rating accounts sufficiently for that symptomology. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The pain on motion has been considered in assigning the current 10 percent rating. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a higher rating higher than 10 percent and the claim must be denied. 38 C.F.R. § 4.71a, Diagnostic Code 5271. 8. Entitlement to an initial rating higher than 0 percent for bilateral Eustachian tube dysfunction Throughout the rating period on appeal, the Veteran's service-connected chronic bilateral Eustachian tube dysfunction has been rated by analogy under the criteria of 38 C.F.R. § 4.87, Diagnostic Code 6201 for rating chronic nonsuppurative otitis media. Chronic nonsuppurative otitis media with effusion (serous otitis media), is rated based on hearing impairment. 38 C.F.R. § 4.87, Diagnostic Code 6201. At a December 2009 VA examination, the Veteran stated that cerumen impaction caused muffled hearing. The examiner recorded the Veteran's report that he did not experience any overall functional impairment from the condition. The examiner observed that there was no ear disease or active infection in either ear. There was no effusion in either ear. There was no disturbance of balance on either side. There was no staggering gait. Auricle examination was normal. There was complete cerumen impaction of both ears which the examiner removed. Pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 15 10 10 15 13 LEFT 15 5 15 15 13 Speech discrimination scores were 100 percent for the right ear and 100 percent for the left ear. The examiner remarked that there was no hearing loss present. At a December 2009 VA examination, the examiner stated that the Veteran experienced subjective pressure sensation and popping in the ears. Objectively, the examiner observed retraction of both tympanic membranes. At a July 2018 Board hearing, the Veteran stated that when he was travelling by plane, he could feel pressure in the ears. At higher altitudes, the ears popped. At an October 2018 VA examination, pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 15 15 20 25 19 LEFT 15 10 25 20 18 Speech discrimination scores were 98 percent for the right ear and 96 percent for the left ear. The examiner indicated that the Veteran had normal hearing. At a September 2019 VA examination, the examiner noted that the Veteran had been diagnosed with Eustachian tube dysfunction in the past. The examiner noted that audiometry and tympanometry in October 2018 showed normal hearing and middle ear pressure. The Veteran did not take medication for the condition. The examiner found no signs or symptoms attributable to Eustachian tube dysfunction. Physical examination showed normal external ears, ear canals, and tympanic membranes. The examiner found no current or recent objective evidence of Eustachian tube or other dysfunction involving either ear. In a September 2019 addendum, the VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran had right and left ear disabilities caused by service or aggravated by service-connected disability as there was no current or recent objective evidence of Eustachian tube or other dysfunction involving either ear. On review of the evidence of record, the Board finds that a rating higher than 0 percent for bilateral Eustachian tube dysfunction is not warranted. A higher 10 percent rating is not warranted under Diagnostic Code 6200 (chronic suppurative otitis media) because there is no clinical or lay evidence of suppuration throughout the rating period on appeal. There is no evidence of treatment for Eustachian tube dysfunction during the rating period. A 10 percent rating is potentially available under Diagnostic Code 6210 (chronic otitis externa) but there is no indication that the Veteran has experienced swelling, dry and scaly or serous discharge, and itching requiring frequent or prolonged treatment during the period under review. Considering the disability under Diagnostic Code 6201 (chronic nonsuppurative otitis media with effusion), based on hearing impairment, the criteria for a compensable rating are not met. The puretone thresholds for bilateral hearing are noncompensable under Diagnostic Code 6100. 38 C.F.R. § 4.85. The severity of a hearing loss disability is determined by applying the criteria set forth at 38 C.F.R. § 4.85. Under those criteria, ratings for bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85. To evaluate an individual's level of disability, Table VI is used to assign a Roman numeral designation for hearing impairment based on a combination of the percent of speech discrimination and the puretone threshold average. 38 C.F.R. § 4.85(b). Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment for each ear. 38 C.F.R. § 4.85(e). The findings on the Veteran's audiometric study in December 2009 correlate to a designation of level I hearing in the right ear and level I hearing in the left ear, using Table VI. Table VII of § 4.85 provides for a 0 percent (noncompensable) evaluation under Diagnostic Code 6100 when those levels of hearing are demonstrated. The findings on the Veteran's audiometric study in October 2018 correlate to a designation of level I hearing in the right ear and level I hearing in the left ear, using Table VI. Table VII of § 4.85 provides for a 0 percent (noncompensable) evaluation under Diagnostic Code 6100 when those levels of hearing are demonstrated. Thus a higher rating is not warranted under Diagnostic Codes 6201 and 6100. There are no other applicable rating criteria for consideration. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher rating for a bilateral Eustachian tube dysfunction, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to an initial rating higher than 0 percent for allergic rhinitis The Veteran's allergic rhinitis has been rated under Diagnostic Code 6522. Under Diagnostic Code 6522, a 10 percent rating is assigned for allergic rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A 30 percent disability rating is assigned for rhinitis with polyps. A March 2011 private treatment record contains the Veteran's report of runny nose, nasal congestion, itchy eyes and throat, watery eyes, and a mild cough. The assessment was allergic rhinitis. A February 2013 private treatment record shows that the Veteran had sinus pressure with a cough and a runny nose. The diagnosis was rhinitis. A prescription for Flonase was given. At a March 2013 VA examination, the examiner diagnosed allergic rhinitis. The examiner specified that the Veteran did not have any findings, signs, or symptoms attributable to sinusitis. The examiner noted that there was not complete obstruction on either side due to rhinitis. The Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. At a May 2017 VA examination, the examiner diagnosed allergic rhinitis. The Veteran took Flonase and Claritin. The examiner noted that there was not complete obstruction on either side due to rhinitis. The Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. At a July 2018 Board hearing, the Veteran the Veteran reported feeling nasal congestion. He also had facial pain around the eyes, nose, and temple. He sneezed and had a runny nose. He experienced postnasal drip. At a September 2019 VA examination, the examiner diagnosed allergic rhinitis. The Veteran reported experiencing nasal congestion, paranasal headaches, periorbital pain, postnasal drainage, and cough. The Veteran had been treated with Flonase, antihistamines, and cough suppressants about four times a month. The examiner noted that there was not complete obstruction on either side due to rhinitis. The Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was no permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The examiner specified that the Veteran's disability did not impact the ability to work. The Board finds that a rating higher than 0 percent is not warranted at any time during the period of appeal. The record does not show greater than 50 percent obstruction of a nasal passage or nasal polyps at any time. While the Veteran has testified that he experiences congestion and difficulty breathing, the measurement of more than 50 percent obstruction of a nasal passage is not an observation easily made by a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer). The Veteran has not shown he has the requisite medical training to make such a determination, and no medical evidence of record shows that the Veteran has polyps or greater than 50 percent obstruction of the nasal passage on either side or complete obstruction on either side. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for increased rating. Assignment of staged ratings has been considered and is not warranted. Therefore, the claim for increased rating is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Layton, 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.