Citation Nr: 21030271 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-37 736 DATE: May 18, 2021 ORDER Entitlement to an initial compensable disability evaluation for herpes simplex virus 1 (HSV1) is denied. Entitlement to an increased disability evaluation for mid-back spasms and muscular strain, initially rated as 10 percent disabling, prior to September 14, 2019, is denied. Entitlement to an increased disability evaluation for mid-back spasms and muscular strain, rated as 40 percent disabling for the rating period since September 4, 2019, is denied. Entitlement to an increased disability evaluation for right hand carpal tunnel syndrome, initially rated as 10 percent disabling, is denied. Entitlement to an increased disability evaluation for left knee iliotibial band friction syndrome and degenerative joint disease, initially rated as 10 percent disabling, is denied. Entitlement to an increased disability evaluation for right knee iliotibial band friction syndrome and degenerative joint disease, initially rated as 10 percent disabling, is denied. Entitlement to an initial compensable disability evaluation for left hip tendinopathy, limitation of extension, is denied. Entitlement to an initial compensable disability evaluation for right hip tendinopathy, limitation of extension, is denied. Entitlement to an increased disability evaluation for left hip abductor tendinopathy, initially rated as 10 percent disabling, is denied. Entitlement to an increased disability evaluation for right hip abductor tendinopathy, initially rated as 10 percent disabling, is denied. FINDINGS OF FACT 1. The Veteran's HSV1 affects less than 5 percent of the entire body; there is no intermittent use of systematic therapy or immunosuppressive drugs required. 2. For the initial rating period (prior to September 14, 2019), the Veteran's mid-back spasms and muscular strain is manifested by pain, with a history of muscle spasm with no impact on gait or spinal contour. Forward flexion is to 90 degrees, and combined range of motion of the thoracolumbar spine is to 185 degrees with no ankylosis and no functional loss beyond pain. 3. For the rating period since September 14, 2019, the Veteran's service-connected mid-back spasms and muscular strain is manifested by pain and forward flexion of the thoracolumbar spine to 30 degrees, without ankylosis. 4. Right hand carpal tunnel syndrome is manifested by mild incomplete paralysis of the major median nerve. 5. The Veteran's left knee iliotibial band friction syndrome and degenerative joint disease is manifested by limitation of flexion; remaining functional flexion was better than 45 degrees and extension was full; there was no indication of locking, tibia or fibula impairment, genu recurvatum, instability or ankylosis, or additional functional loss warranting greater compensation. 6. The Veteran's right knee iliotibial band friction syndrome and degenerative joint disease is manifested by limitation of flexion; remaining functional flexion was better than 45 degrees and extension was full; there was no indication of locking, tibia or fibula impairment, genu recurvatum, instability or ankylosis, or additional functional loss warranting greater compensation. 7. The Veteran's left hip tendinopathy, limitation of extension, is manifested by pain on motion with extension greater than 5 degrees, flexion greater than 45 degrees, and no additional functional loss. 8. The Veteran's right hip tendinopathy, limitation of extension, is manifested by pain on motion with extension greater than 5 degrees, flexion greater than 45 degrees, and no additional functional loss. 9. The Veteran's left hip abductor tendinopathy is manifested by painful motion without limitation of abduction, adduction, rotation, flail joint impairment, ankylosis or functional loss beyond pain. 10. The Veteran's right hip abductor tendinopathy is manifested by painful motion without limitation of abduction, adduction, rotation, flail joint impairment, ankylosis or functional loss beyond pain. CONCLUSIONS OF LAW 1. The criteria for a compensable disability evaluation for HSV1 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Codes 7899-7806 (2020). 2. The criteria for an initial disability evaluation in excess of 10 percent for mid-back spasms and muscular strain, for the rating period prior to September 14, 2019, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 3. The criteria for a disability evaluation in excess of 40 percent for mid-back spasms and muscular strain for the rating period since September 14, 2019 have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 4. The criteria for a disability rating in excess of 10 percent for right hand carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2020). 5. The criteria for a disability rating in excess of 10 percent for left knee iliotibial band friction syndrome and degenerative joint disease have not been met. 38 U.S.C. § §§ 1155, 5103A, 5107(b); 38 C.F.R. § § 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2020). 6. The criteria for a disability rating in excess of 10 percent for right knee iliotibial band friction syndrome and degenerative joint disease have not been met. 38 U.S.C. § §§ 1155, 5103A, 5107(b); 38 C.F.R. § § 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2020). 7. The criteria for an initial compensable disability rating for left hip tendinopathy, limitation of extension, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251 (2020). 8. The criteria for an initial compensable disability rating for right hip tendinopathy, limitation of extension, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251 (2020). 9. The criteria for a disability evaluation in excess of 10 percent for left hip abductor tendinopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253 (2020). 10. The criteria for a disability evaluation in excess of 10 percent for right hip abductor tendinopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Marine Corps from October 2008 to October 2013. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2013 and March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. During the pendency of the appeal, in an August 2020 rating decision, the Veteran was awarded an increased, 40 percent disability evaluation for his mid-back spasms and muscular strain, effective September 14, 2019. As the Veteran has not been granted the maximum benefits allowed, the claims of entitlement to increased disability ratings for his left his mid-back spasms and muscular strain remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In November 2018, the Board remanded the case to the Agency of Original Jurisdiction (AOJ). A supplemental statement of the case was most recently issued in September 2020. The case has since been returned to the Board for appellate review. The Board finds that there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board acknowledges that additional VA treatment records were associated with the Veteran's electronic claims file following the issuance of the most recent supplemental statement of the case. However, remand for review by the AOJ in the first instance is not required. To the extent that the VA treatment records are relevant to the issues on appeal, the VA treatment records are duplicative of those considered in the September 2020 supplemental statement of the case; the remaining VA treatment records pertain to claims not currently before the Board. See 38 C.F.R. §§ 19.37(a), 20.1305(c) (2020). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2020). The VCAA requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. § § 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). Notably, during the appeal period, changes were made to 38 C.F.R. § 4.71a, Diagnostic Codes 5003. 5242, 5243, and 5257. Effective February 7, 2021, VA amended its regulations governing the schedule of rating musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 1. Entitlement to an initial compensable disability evaluation for HSV1. The Veteran's HSV1 is currently evaluated as noncompensable pursuant to 38 C.F.R. § 4.118, Diagnostic Codes 7899 7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. Unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." 38 C.F.R. § 4.27 (2020). The Veteran's claim was received on September16, 2013. The Board notes that regulations pertaining to skin disabilities were recently amended and new criteria for rating skin disabilities became effective on August 13, 2018. Id. When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3- 2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The recently revised skin regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, August 13, 2018. Hence, for the period beginning August 13, 2018, the version more favorable to the veteran will apply. Under the regulations in effect prior to August 13, 2018, Diagnostic Code 7806 provides a noncompensable disability evaluation for dermatitis or eczema of less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and no more than topical therapy required during the past 12-month period. A 10 percent disability evaluation is assigned for dermatitis or eczema of at least 5 percent of the entire body, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed affected areas, or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the prior 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806. For the next higher 30 percent disability evaluation, there must be dermatitis or eczema over 20 to 40 percent of the body or 20 to 40 percent of the exposed areas affected, or systemic therapy, such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the prior 12-month period. For the next higher 60 percent disability evaluation, there must be dermatitis or eczema over more than 40 percent of the entire body, or more than 40 percent of the exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs for the past 12-month period. Id. Under the revised regulations, Diagnostic Code 7806 directs that the disability be rated under the General Rating Formula for the Skin. The General Rating Formula for the Skin under the new regulations is as follows: a maximum 60 percent rating requires at least one of the following: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. A 30 percent rating requires at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) systemic therapy such as those listed under the 60 percent criteria required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 10 percent rating requires at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) intermittent systemic therapy such as those listed under the 60 percent criteria required for a total duration of less than 6 weeks over the past 12-month period. Id. A noncompensable (0 percent) rating is assigned where there is no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. Id. The Federal Circuit addressed the meaning of "systemic" and "topical" for rating skin disabilities under the regulatory criteria prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). For these purposes, systemic therapy means treatment pertaining to or affecting the body as a whole, whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Id. at 1355. The Federal Circuit acknowledged that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the facts of each case. Id. at 1356. Under the revised VA regulations, it is explicitly stated that for the purposes of the skin disability ratings, "systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin." 38 C.F.R. § 4.118(a). Following a review of the evidence, the Board finds that the Veteran's HSV1 more nearly approximates the criteria for the currently assigned noncompensable disability evaluation under both the old and new versions of Diagnostic Code 7806 for the entire rating period on appeal. The evidence shows that the Veteran does not have HSV1 over at least 5 percent of his entire body. Indeed, the medical evidence, including the October 2013 and September 2019 VA examination reports, indicates that the Veteran has herpes simplex virus 1 over less than 5 percent of his entire body. The Board acknowledges that the Veteran reports that he was treated with acyclovir, an oral medication, for less than 6 weeks, within one year prior to his September 2019 VA examination. However, a September 2020 VA treatment record reflects that the Veteran's skin is free of lesions. Moreover, there is no evidence that the Veteran treats his herpes simplex virus 1 with a systemic therapy as required for the regulation. A higher rating is not warranted as he does not have at least 5 percent of his entire body affected, and the Veteran does not require intermittent systemic therapy of corticosteroids or other immunosuppressive drugs to treat his HSV1. To the extent that the Veteran previously treated his HSV1 with acyclovir, the Board notes that the Veteran's use of the antiviral drug does not constitute a systemic (oral) corticosteroid or immunosuppressive as required for a higher rating. Therefore, the Board finds that the preponderance of the evidence is against the assignment of a compensable disability rating for HSV1 for the entire appeal period. 2. Entitlement to an increased disability evaluation for mid-back spasms and muscular strain, initially rated as 10 percent disabling. 3. Entitlement to an increased disability evaluation for mid-back spasms and muscular strain, rated as 40 percent disabling for the rating period since September 4, 2019. The Veteran is currently assigned an initial 10 percent disability rating for the rating period prior to September 14, 2019 and a 40 percent disability rating thereafter for his service-connected mid-back spasms and muscular strain pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5237. See 38 C.F.R. § 4.20. Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome (IVDS) is rated under the General Rating Formula for Rating Diseases and Injuries of the Spine or the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as 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. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Board notes that effective February 7, 2021, the spine regulations were amended to state that Diagnostic Code 5243 governing intervertebral disc syndrome should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Board notes that this change does not impact the evaluation in this case as the Veteran does not have any evidence of intervertebral disc syndrome or incapacitating episodes that would warrant a compensable rating under Diagnostic Code 5243. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, 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 combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as 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 (zero degrees) always represents favorable ankylosis. Note 6 provides that 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. According to the general rating formula, a 10 percent evaluation is to be assigned 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 evaluation is to be 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. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is to be assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235 for vertebral fracture or dislocation; 5236 for sacroiliac injury and weakness; 5237 for lumbosacral strain; Diagnostic Code 5238 for spinal stenosis; Diagnostic Code 5239 for spondylolisthesis or segmental instability; Diagnostic Code 5240 for ankylosing spondylitis; Diagnostic Code 5241 for spinal fusion; Diagnostic Code 5242 for degenerative arthritis of the spine; and Diagnostic Code 5243 for intervertebral disc syndrome. The Veteran contends that he is entitled to a higher rating and that his symptoms have been consistent throughout the appeal period from September 16, 2013. a. Initial Rating Period Prior to September 14, 2019 After a review of all the evidence, the Board finds that the Veteran's disability picture does not warrant a disability evaluation in excess of the currently assigned 10 percent disability rating for the rating period prior to September 14, 2019. At the October 2013 VA examination, the Veteran had forward flexion to 90 degrees, extension to 20 degrees, right lateral flexion to 20 degrees and left lateral flexion to 15 degrees, and lateral rotation to 20 degrees bilaterally. Examination reports and treatment records indicate that the Veteran experienced decreased or abnormal range of motion, pain, and muscle spasm without abnormal gait and spinal contour. The VA examination report and treatment records indicate that there was pain on motion, without incoordination or atrophy, or additional loss of range of motion upon repetitive use testing; strength and reflex testing was normal. Thus, applying the facts to the criteria set forth above, the Veteran is entitled to a 10 percent evaluation for his service-connected mid-back spasms and muscular strain for the entire rating period on appeal under the General Rating Formula for Diseases and Injuries of the Spine. VA treatment records dated throughout the rating period on appeal reflect that the Veteran was treated for back pain; however, no range of motion measurements were provided. The Board finds that the weight of the evidence demonstrates that the Veteran's mid-back spasms and muscular strain most closely approximates the criteria for the currently assigned 10 percent disability rating for the rating period prior to September 14, 2019, as the Veteran's service-connected mid-back spasms and muscular strain is productive of forward flexion of greater than 60 degrees and he has a combined range of motion of the thoracolumbar spine of 185 degrees. Further, the Board notes that the evidence does not show that the Veteran's spasms were severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The lay evidence has been considered; however, that evidence does not establish that he is functionally limited to 60 degrees or less flexion or that his spasms are sufficiently severe to meet the criteria for a 20 percent rating. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion and impairment, as well as estimated limitation of motion during a flare-up; the projected limitation of motion was based on the Veteran's report of symptomatology and reports of functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current 10 percent disability rating. As noted earlier, the Veteran does not have intervertebral disc syndrome. Nevertheless, the Board finds that the Veteran's mid-back spasms and muscular strain has not been productive of incapacitating episodes for the rating period on appeal. The evidence does not demonstrate that the Veteran experiences incapacitating episodes requiring bed rest; the Veteran's treatment records do not confirm that his treating physicians noted any incapacitating episodes or prescribed bed rest, and the Veteran's VA examination reports reflect that the Veteran has not experienced any incapacitating episodes requiring bed rest. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, VA examination reports, as well as VA treatment records reflect that the Veteran did not have any neurological deficits of the right and left lower extremities during the rating period prior to September 14, 2019. As such, Note (1) of the General Rating Formula is not for consideration here. In light of the foregoing, the Board finds that a disability rating in excess of 10 percent for the service-connected mid-back spasms and muscular strain is not warranted for the rating period prior to September 14, 2019. b. Rating Period Since September 14, 2019 After a review of all the evidence, the Board finds that the Veteran's disability picture does not warrant a disability evaluation in excess of the currently assigned 40 percent disability rating for the rating period since September 14, 2019. In this regard, the Board notes that the September 2019 VA examination report reflects that the Veteran had flexion to 30 degrees, extension to 5 degrees, lateral flexion to 20 degrees on the right and 10 degrees on the left, and lateral rotation to 30 degrees bilaterally; he had pain on motion and at rest. The VA examiner noted that there was pain on motion that caused functional loss and tenderness to palpation; however, repetitive use testing did not reflect additional loss of range of motion. The VA examiner noted that pain could significantly limit functional ability with repeated use over a period of time or during flare-ups; the VA examiner noted that the findings on examination are medically consistent with the Veteran's statements describing functional loss during a flare-ups, but that no estimates as to additional loss of range of motion could be provided, as the Veteran was not giving a full effort upon examination. There was no guarding or muscle spasm, and that, upon testing, muscle strength was full; there was no muscle atrophy or ankylosis. In accordance with the above, the Veteran is entitled to a 40 percent disability evaluation, but no higher, for his service-connected mid-back spasms and muscular strain for the rating period since September 14, 2019. The Board finds that the criteria for a disability rating of 50 percent have not been met or more nearly approximated. As noted, the evidence does not demonstrate the presence of ankylosis. The Board has considered the lay evidence of pain. However, that evidence does not establish that there is ankylosis as required for a higher rating. As previously noted, throughout the rating period since September 14, 2019, the Veteran had flexion to no worse than 30 degrees on repetitive use testing. Likewise, at the September 2019 VA examination, the Veteran did not have pain on nonweight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran does not require the use of assistive devices for locomotion. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion, and there is no evidence that his pain is the equivalent of ankylosis. See Mitchell, supra. The Veteran is at the maximum evaluation for limited motion. The provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis, as is the case here. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). As previously discussed, the medical evidence reflects that the Veteran does not have intervertebral disc syndrome. Regardless his mid-back spasms and muscular strain has not been productive of incapacitating episodes at any time during the rating period on appeal. The Veteran has not reported, and the evidence does not demonstrate, that the Veteran experienced incapacitating episodes requiring bed rest; the Veteran's VA examination reports and treatment records do not demonstrate that his treating physicians noted any incapacitating episodes or prescribed bed rest. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Veteran's September 2019 VA examination and VA treatment records reflect that the Veteran did not experience any lower extremity neurological deficits. The Veteran's September 2019 VA examination report indicates that sensory examination was normal and that there was no evidence of any signs or symptoms of radiculopathy. The Board acknowledges that a September 2020 VA treatment note reflects a diagnosis of sciatica. However, this diagnosis does not appear to be based on any evidence of neurological defects in the right lower extremity; the relevant treatment record reflects that the Veteran complained of right buttock and leg pain and the Board observes that the Veteran's September 2019 hip and thigh VA examination report reflects that the Veteran's right and left hip tendinopathy is productive of gluteal pain. As such, separate ratings for neurological deficits are not for consideration here. Therefore, the Board finds that the evidence does not support a disability evaluation in excess of 40 percent for the Veteran's service-connected mid-back spasms and muscular strain for the rating period since September 14, 2019. 4. Entitlement to an increased disability evaluation for right hand carpal tunnel syndrome, initially rated as 10 percent disabling. The Veteran was assigned a 10 percent disability rating for his right hand carpal tunnel syndrome in accordance with the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8515. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology, are closely analogous). Under Diagnostic Code 8515, for the major wrist, a 10 percent evaluation is assigned for mild incomplete paralysis; a 30 percent rating requires moderate incomplete paralysis; and a 50 percent rating requires severe incomplete paralysis. A 70 percent disability rating requires complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran contends that a higher disability rating is warranted for his right hand carpal tunnel syndrome. The Veteran is right-hand dominant. This was confirmed in the October 2013 and September 2019 VA examination reports. After a review of the evidence, the Board finds that for the entire rating period on appeal the Veteran's service-connected right hand carpal tunnel syndrome more nearly approximates the criteria for the currently assigned 10 percent disability rating for the rating period on appeal. The Veteran's right hand carpal tunnel syndrome has been characterized by no more than mild incomplete paralysis of the median nerve. According to the September 2019 VA examination report, the Veteran reported experiencing mild intermittent pain, numbness, and paresthesias/dysesthesias of the right upper extremity. Upon examination, muscle strength was normal, and deep tendon reflexes were 2+ bilaterally; sensory examination of the upper extremities was also normal, although there was decreased sensation to light touch in the hands and fingers. There was decreased sensation to vibration, but nerve testing was normal. At the October 2013 VA examination, the Veteran was asymptomatic except for complaints of mild numbness of the right hand. The Board acknowledges that the Veteran complained of symptoms at both VA examinations, but points out that he had full fist closure without pain and objective manifestations did not show that the Veteran has moderate or severe incomplete paralysis of the median nerve. In conclusion, the evidence of record reveals manifestations consistent with a 10 percent disability rating per upper extremity, but no higher, for right hand carpal tunnel syndrome for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an increased disability evaluation for left knee iliotibial band friction syndrome and degenerative joint disease, initially rated as 10 percent disabling. 6. Entitlement to an increased disability evaluation for right knee iliotibial band friction syndrome and degenerative joint disease, initially rated as 10 percent disabling. The Veteran is currently assigned a 10 percent rating, per knee, for his service-connected left and right knee iliotibial band friction syndrome and degenerative joint disease pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003 5260. See 38 C.F.R. § 4.20. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. The Board notes that the amended Diagnostic Code 5003, effective February 7, 2021, is substantively unchanged. To this point, the Board notes that Diagnostic Code 5003 was revised to reflect that this Diagnostic Code only applies to degenerative arthritis. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Diagnostic Code 5003 provides that degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, the Veteran has not reported experiencing any incapacitating exacerbations with regard to his left and right knees. The appropriate diagnostic codes for the knee joint are Diagnostic Codes 5260 and 5261, applicable to limitation of flexion and extension of the leg, respectively. Under Diagnostic Code 5260, limitation of flexion of a leg warrants a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating is warranted if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of a leg is noncompensable when extension is limited to 5 degrees, warrants a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). In VAOGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA's General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. The Board observes that there is no evidence of left or right knee instability; the October 2013 and September 2019 VA examination reports reflect that stability testing was negative and the Veteran has not reported giving way. Thus, the Board will not consider Diagnostic Code 5257 as it is not applicable. 38 C.F.R. § 4.71a, Diagnostic Code 5257. See also Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257) (revised regulation for Diagnostic Code 5257). The Board finds that the weight of the evidence demonstrates that the symptoms of the Veteran's service-connected left and right knee iliotibial band friction syndrome and degenerative joint disease most closely approximate the diagnostic criteria for the currently assigned 10 percent rating per knee. With regard to limitation of motion, the Veteran has not demonstrated that his left and/or right knees have compensable limitation of flexion or extension. The Board observes that the Veteran, at his VA examinations, had flexion of the right and left knee to no worse than 100 degrees, with full extension. Nevertheless, the Veteran reported that he experienced pain on motion based on repeated use over time. Likewise, he had tenderness to palpation of the interior patella of the knees. A higher, 20 percent rating would require flexion of 30 degrees and/or extension of 15 degrees. In the absence of this level of limited motion, a higher rating based on limitation of motion is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Further, there is no evidence of ankylosis, dislocation of the semilunar cartilage, or locking of the left and/or right knees, tibia or fibula impairment, or genu recurvatum, at any time during the rating period on appeal. Thus, higher ratings for the left and/or right knees based on Diagnostic Codes 5256, 5258, 5259, 5262, and 5262 are not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5262. See also Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5262) (revised regulations for Diagnostic Code 5262). Finally, with regard to functional loss, the Veteran's current evaluation contemplates pathology productive of painful motion. The evaluation is consistent with the functional equivalent of limitation of flexion to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees (Diagnostic Code 5260) or extension to 15 degrees (Diagnostic Code 5261). The Board accepts the lay evidence that the Veteran experiences pain. Similarly, the Board accepts the evidence that he has limitation of flexion and pain upon extension. However, the limitation of motion due to pain is contemplated in the current evaluation that recognizes his painful motion. Although the Veteran has pain, such pain does not functionally limit flexion to less than 45 degrees or functionally limit extension; the September 2019 VA examiner found that a flare-up would not change the Veteran's range of motion, as the Veteran reported experiencing mildly increased pain for hours during a flare-up. There is no indication that he has additional functional impairment, above and beyond the 10 percent level for his service-connected left and right knee iliotibial band friction syndrome and degenerative joint disease which would support a higher rating for either knee. The Board acknowledges that the VA examination reports reflect complaints of pain; however, there was no objective evidence of deformity or reduced muscle strength. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. Here, neither the medical nor lay evidence suggests that his limitation of motion approximated 30 degrees of flexion or 15 degrees extension for the right and/or left knees. Moreover, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss warranting the assignment of any higher evaluation for the right and/or left knees during the entire appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). Therefore, the Board finds that the evidence does not support a disability evaluation in excess of 10 percent, per knee, for the Veteran's service-connected left and right knee iliotibial band friction syndrome and degenerative joint disease for the entire rating period on appeal. 7. Entitlement to an initial compensable disability evaluation for left hip tendinopathy, limitation of extension. 8. Entitlement to an initial compensable disability evaluation for right hip tendinopathy, limitation of extension. The Veteran's left and right hip tendinopathy, limitation of extension, is rated as noncompensable pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5251. Diagnostic Code 5251 assigns a 10 percent disability evaluation where there is limitation of extension of the thigh to 5 degrees; no higher evaluation is provided for under this Code. See 38 C.F.R. § 4.71a, Diagnostic Code 5251. Normal range of motion for the hips consists of flexion to 125 degrees, extension to 0 degrees, and abduction to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Board finds that the weight of the evidence demonstrates that the symptoms of the Veteran's service-connected left and right hip tendinopathy, limitation of extension, most closely approximates the criteria for the currently assigned noncompensable disability rating. The Veteran does not experience extension limited to 5 degrees. The evidence of record reflects that the Veteran experiences pain on flexion and extension of the left and right hips. However, there is no evidence of limitation of extension to 5 degrees or less. The February 2014 VA examination reflects that the Veteran had extension greater than 5 degrees and the September 2019 VA examination reflects that the Veteran had extension to 30 degrees. Both VA examination reports indicated that the Veteran experienced pain on motion, without decreased range of motion upon repetitive use, and no other evidence or record demonstrates compensable loss of motion in extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5251. Thus, higher, compensable disability ratings for left and right hip tendinopathy, limitation of extension, under Diagnostic Code 5251 is not available. Additionally, the Veteran does not have compensable limitation of flexion or pain on motion productive of any limitation of flexion. As such, a separate compensable disability evaluation for limitation of flexion under Diagnostic Code 5252 is unavailable. Further, although there is evidence of tenderness, there is no evidence of ankylosis. Thus, a higher rating for the left hip based on Diagnostic Code 5250 is not warranted. Nor is there evidence of a flail joint impairment, thus a higher rating under Diagnostic Code 5254 is not appropriate. With regard to functional loss, the Board notes that the Veteran is already being compensated for painful hip joint motion in his evaluations for his left and right hip abductor tendinopathy. To award him additional compensation for painful, noncompensable limitation of motion of flexion and extension would constitute prohibited pyramiding by compensating the same hip joint symptom, pain, in different planes. 38 C.F.R. § 4.14. Absent actual compensable limitation of motion in these planes, the Board finds that separately compensating painful motion alone in multiple planes is prohibited. In concluding the Veteran is not entitled to higher ratings for his limitation of extension of the left and right hips, the Board has also considered whether he has additional functional loss, beyond that objectively shown due to pain, because of weakness, premature or excess fatigability, incoordination, etc. See DeLuca, supra. The Board acknowledges that the Veteran reports functional loss due to pain on motion and tenderness to palpation of the hip. Nonetheless, there is no indication in the record that his functional ability is decreased. Moreover, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss warranting the assignment of any higher evaluation for the left and/or right hip during the appeal period. See Correia, supra. Therefore, additional compensation for functional loss is not warranted. As a result, compensable evaluations for left and right tendinopathy, limitation of extension, are not warranted. 9. Entitlement to an increased disability evaluation for left hip abductor tendinopathy, initially rated as 10 percent disabling. 10. Entitlement to an increased disability evaluation for right hip abductor tendinopathy, initially rated as 10 percent disabling. The Veteran's left and right hip abductor tendinopathy is currently evaluated as 10 percent disabling, per hip abductor, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5252. However, as Diagnostic Code 5253 is applicable to limitation of abduction, use of an alternative diagnostic code is not appropriate. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). As such, the Board is amending the Diagnostic Code assigned for the Veteran's left and right hip abductor tendinopathy to reflect that Diagnostic Code 5253 more accurately evaluates the Veteran's disability. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); see also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Under Diagnostic Code 5253, a 20 percent rating is warranted for abduction limited beyond 10 degrees; a 10 percent is warranted for adduction where the claimant cannot cross his or her legs; and a 10 percent rating is warranted for rotation limited where the ability to toe out is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The Board finds that the weight of the evidence demonstrates that the symptoms of the Veteran's service-connected left and right hip abductor tendinopathy most closely approximates the criteria for the currently assigned 10 percent disability rating, per hip, for the entire rating period on appeal under Diagnostic Code 5253. With regard to limitation of motion, the Veteran has not objectively demonstrated that his left and/or right hip abductor tendinopathy is productive of limitation of abduction beyond 10 degrees; to the contrary, the Veteran does not have compensable limitation of motion of either hip abductor. To this point, the Board observes that the February 2014 VA examination report reflects that the Veteran had range of motion of the abductors greater than 10 degrees bilaterally; the September 2019 VA examination report reflects that the Veteran had abduction to 45 degrees bilaterally. Further, both the February 2014 and September 2019 examinations indicated that the Veteran could cross both legs and that rotation was not limited to toeing out only to 15 degrees in either leg. Thus, he does not meet the criteria for a compensable rating under these two joint motions either. Nevertheless, as noted earlier, the Veteran has demonstrated pain on motion of the hips, without additional functional loss, and tenderness to palpation. The Board also observes that repetitive use testing did not demonstrate additional limitation of motion. Therefore, the currently assigned 10 percent disability rating, per hip, for service-connected impairment of the left and right abductor tendinopathy is sufficient to compensate him for the extent of his painful motion during the entire rating period. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (Painful motion is an important factor of disability, and 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.). As noted earlier, there is no evidence of ankylosis or flail joint impairment of either hip. Thus, higher ratings based on Diagnostic Code 5250 and Diagnostic Code 5254 are not appropriate. Finally, with regard to functional loss, the Veteran's current evaluation contemplates pathology productive of painful motion. The Board accepts the lay evidence that the Veteran experiences pain, and the Veteran's report of limitation of function due to pain. However, such evidence does not establish that the Veteran is so functionally limited as to equivalent to ankylosis. As indicated earlier, limitation due to pain is contemplated in the current evaluation that recognizes his painful motion. See Burton, supra. In this regard, the Board acknowledges that the VA examination reports reflect complaints of pain and pain on motion; however, there was no objective evidence of deformity, reduced muscle strength, or functional loss warranting the assignment of a higher disability evaluation for either hip during the rating period on appeal. See DeLuca, citing 38 C.F.R. § § 4.40, 4.45, and 4.59. The Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current ratings are based on the objectively demonstrated pain on motion. See Correia, supra. Therefore, the Board finds that the evidence does not support a disability evaluation in excess of 10 percent, per hip, for the Veteran's service-connected left and right hip abductor tendinopathy for the entire rating period on appeal. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hallie E. Brokowsky, 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.