Citation Nr: 21032022 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-61 731 DATE: May 25, 2021 ORDER Entitlement to a disability evaluation greater than 50 percent, prior to December 3, 2020, and 70 percent, thereafter, for service-connected posttraumatic stress disorder (PTSD) with traumatic brain injury is denied. Entitlement to a compensable initial rating for traumatic brain injury (TBI) residuals is denied. REMANDED Service connection for a right ankle disorder is remanded. Service connection for right foot numbness and tingling (right foot disability) is remanded. Service connection for right foot numbness and tingling (left foot disability) is remanded. Service connection for gastrointestinal disorder is remanded. Entitlement to a disability evaluation greater than 10 percent prior to December 3, 2020, and 20 percent thereafter, for service-connected L1-2disc protrusion without any impingement (low back disability) is remanded. FINDINGS OF FACT 1. Prior to December 3, 2020, the Veteran's psychiatric disorder was occupational and social impairment with reduced reliability and productivity, but the severity, frequency, and duration of his symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 2. From December 3, 2020, the Veteran's PTSD with TBI has not been manifested by total social and occupational impairment. 2. For the initial rating period, prior to December 3, 2020, on appeal, the Veteran's TBI did not manifest any residuals or cognitive, emotional/behavioral, or physical impairment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent, prior to December 3, 2020, for a psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130 Diagnostic Code 9411. 2. The criteria for a disability rating in excess of 70 percent, from December 3, 2020, for a psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130 Diagnostic Code 9411. 3. The criteria for entitlement to a compensable rating for a traumatic brain injury (TBI), prior to December 3, 2020, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 8045. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from September 2006 to August 2013. For his meritorious service, the Veteran was awarded (among other decorations) the Purple Heart, and the Army Commendation Medal. This matter is before the Board of Veterans' Appeal (Board) on appeal from a November 2015 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). The Board previously remanded the appeal in December 2018 and August 2020, and the matter has been returned for appellate consideration. Of note, the December 2018 Board decision and remand denied reopening a claim for service connection for a right ankle disability, and denied an increased rating for the Veteran's service-connected back disability. Those denials were vacated in a December 2019 Joint Motion for Remand. In August 2020, the Board reopened and remanded the Veteran's claim for service connection for a right ankle disability, so that issue may be considered on a de novo basis here. A January 2021 rating decision increased the disability rating for PTSD with TBI from 50 percent to 70 percent, effective December 3, 2020. However, as this grant does not represent a total grant of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The development ordered specific to the issues decided herein has been completed (namely, obtaining additional records and a new VA examination). Accordingly, the Board finds substantial compliance with those remand instructions. Increased Rating Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran's symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disability evaluations are determined by assessing the extent to which a Veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If there is a question as to which evaluation should be applied to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran's disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the Board will analyze the evidence of record to determine the Veteran's current levels of disability. In doing so, the Board first notes that it has reviewed all the evidence in the Veteran's claims file, placing an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. 1. Entitlement to a disability evaluation greater than 50 percent, prior to December 3, 2020, and 70 percent thereafter. The Veteran seeks higher ratings for his service-connected psychiatric disorder. The disability is currently rated at 50 percent prior to December 3, 2020, at 70 percent, thereafter. The Veteran's service-connected psychiatric disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, and the General Rating Formula for Mental Disorders. Relevant to the issue on appeal, under the General Rating Formula for Mental Disorders, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130 A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty understanding complex commands, impairment of short and long term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the United States Court of Appeals for Veterans Claims held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. A. Prior to December 3, 2020. Turning to the relevant evidence of record for this period, the evidence does not indicate that the Veteran's psychiatric disorder and its resulting symptoms caused occupational and social impairment with deficiencies in most areas. The Veteran was afforded an August 2015 VA examination to determine the severity of the Veteran's service-connected psychiatric disorder. The VA examiner assigned a level of occupational and social impairment associated with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). The Veteran reported living alone in a farmhouse. He stated that he maintains no friendships, and no participation in activities. The Veteran endorsed enjoying outdoor maintenance projects. The Veteran stated that he worries about his finances, health, and future. After discharge, the Veteran reported working as a contractor overseas for 1.5 years. He endorsed good job performance with no interpersonal issues but reported issues with memory and concentration. The Veteran, however, reported being unemployed since April 2015. The VA examined noted that the Veteran endorsed the symptoms of depressed mood, anxiety, panic attack that occur weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, difficulty in understanding complex commands, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Upon examination, the Veteran was alert and cooperative with adequate grooming/hygiene. His mood was fair, and affect was blunted. He presented with linear, coherent and goal directed thought flow without psychosis, suicidality or homicidal intent. The Veteran also endorsed mood swings and suspiciousness. VA treatment records from this period show a similar level of symptoms as those described by the August 2015 examination. October 2018, 2019, and 2020 primary care notes reflect that the Veteran felt that his PTSD was "under control." He noted that he is a "loner" who primarily stays by himself, but he denied any suicidal ideation. After considering all the evidence, the Board finds that, throughout the relevant rating period prior to December 3, 2020, the Veteran's service-connected psychiatric disability does not meet the criteria for a 70 percent or higher rating. As above, the Veteran's service-connected psychiatric disorder manifested in depressed mood, anxiety, panic attack that occur weekly or less often, chronic sleep impairment, mild memory loss, mood swings, suspiciousness, flattened affect, difficulty in understanding complex commands, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. At no time during the relevant rating period from did the Veteran's service-connected psychiatric disability more closely approximate the criteria for a 70 percent rating in terms of severity, frequency, and duration. Specifically, prior to December 3, 2020, the Veteran exhibited occupational and social impairment with reduced reliability and productivity due to his service-connected psychiatric disability. Furthermore, he did not demonstrate symptoms consistent with many of those specifically listed under the 70 percent ratings in terms of severity, frequency, and duration such that the criteria for a 70 percent rating was more closely approximated. He did not exhibit suicidal ideation; obsessional rituals which interfered with routine activities; speech that was intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; and neglect of personal appearance. The symptoms described above also do not approximate these symptoms, and instead more closely approximate those described by the 50 percent rating currently assigned. In summary, the Board finds that, for the Veteran's service-connected psychiatric disorder, a rating in excess of 50 percent is not warranted during the period from prior to December 3, 2020. B. From December 3, 2020. As noted above, the RO increased the Veteran's rating for his psychiatric disorder to 70 percent effective December 3, 2020. At that time, the RO decided to consider the Veteran's service-connected PTSD and TBI under a single evaluation because the December 2020 VA examination found that the Veteran's TBI and PTSD symptoms can no longer be differentiated. In order to warrant an increased, 100 percent rating, the evidence would have to show that the Veteran's psychiatric symptoms have resulted in total occupational and social impairment. The December 2020 VA examination assigned a level of occupational and social impairment with reduced reliability and productivity due to his service-connected psychiatric disability. The VA acknowledged that the Veteran had been diagnosed with TBI and that his TBI and PTSD symptoms could not be differentiated. The Veteran reported that he continued to live alone on his farm. The Veteran denied history of psychiatric hospitalizations, psychiatric treatments, or suicide attempts. The VA examiner assigned the symptoms of depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, flattened attack, impaired impulse control, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and difficulty in establishing and maintaining effective work and social relationships to the Veteran's psychiatric disability. Upon examination, the Veteran was observed to be casually dressed with good hygiene, fair eye contact, and cooperative disposition. His affect was constricted, flattened, low intensity, stable, congruent with mood and less with content. The Veteran's thought process was linear, and goal directed. Thought content was without suicidal or homicidal ideations. Insight was fair and judgment was fair to good. The VA examiner found the Veteran to be oriented in three spheres. The Veteran's December 2020 VA TBI examination found the Veteran's reported symptomology results in mild interference with work, instrumental activities of daily living, work, family or other close relationships. The VA examiner found that the PTSD and TBI symptoms were impossible to distinguish due to the overlap of symptoms. After considering all the evidence, the Board finds that, throughout the relevant rating period, the Veteran's service-connected psychiatric symptoms with TBI do not meet or approximate the criteria for a 100 percent rating. During that period the Veteran's service-connected psychiatric disability manifested in symptoms such as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, flattened attack, impaired impulse control, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and difficulty in establishing and maintaining effective work and social relationships. That said, the Veteran did not exhibit obsessive or ritualistic behavior that interfere with routine activities, gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, and own occupation or own name as described by the 100 percent rating. The frequency, severity, and duration of the Veteran's symptoms as described do not approximate those described by this rating, either, but instead are commensurate with the 70 percent rating currently assigned for this period. Further, the Veteran's psychiatric symptoms did not result in total occupational and social impairment. Under these circumstances, the Board cannot find that the Veteran's psychiatric disorder has resulted in total social impairment as required for a 100 percent rating. 2. Entitlement to a compensable initial rating for traumatic brain injury (TBI) residuals, prior to December 3, 2020. The Veteran is in receipt of a noncompensable disability rating for TBI residuals under Diagnostic Code 8405, prior to December 3, 2020. From December 3, 2020, the Veteran's PTSD and TBI are evaluated as single evaluation because the December 2020 VA examination found that the Veteran's PTSD and TBI symptoms were impossible to distinguish due to the overlap of symptoms. As such, the Board will only need to discuss the eligibility to a compensable rating for TBI, prior to December 3, 2020. Diagnostic Code 8045 provides for the evaluation of TBI. 38 C.F.R. § 4.124a. Under Diagnostic Code 8045, there are three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all these brain functions may be affected in everyone with cognitive impairment, and some functions may be affected more severely than others. In everyone, symptoms may fluctuate in severity from day to day. Adjudicators are to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Adjudicators are to evaluate subjective symptoms that are residuals of TBI, whether they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, they are to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Adjudicators are to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, they are to evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Adjudicators are to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate Diagnostic Code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, adjudicators are to evaluate under the most appropriate Diagnostic Code. Adjudicators are to evaluate each condition separately, if the same signs and symptoms are not used to support more than one evaluation and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. After review of the evidence, the Board finds that the Veteran has no residuals of a TBI that are subject to evaluation under 38 C.F.R. § 4.124a, Diagnostic Code 8045. This diagnostic code provides for three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive, emotional/behavioral, and physical. 38 C.F.R. § 4.124a, Diagnostic Code 8045. On VA TBI examination in December 2013, the VA examiner noted that the TBI did not manifest as any residual symptoms, aside from mild bilateral tinnitus for 7-8 hours after exposure to blast that resulted in his TBI. The VA examiner did not find complaints of impairment of memory, attention, concentration, or executive functions. The Veteran had subjective symptoms that did not interfere with work; instrumental activities of daily living; or work, family or other close relationships. The Veteran was able to communicate by spoken and written language and to comprehend spoken and written language. Consciousness was normal. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. The September 2015 VA TBI examination report found no evidence of a TBI. The VA examiner did not find complaints of impairment of memory, attention, concentration, or executive functions. The Veteran had subjective symptoms that did not interfere with work; instrumental activities of daily living; or work, family or other close relationships. The Veteran was able to communicate by spoken and written language and to comprehend spoken and written language. Consciousness was normal. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. As such, the preponderance of the evidence is against a higher (compensable) initial rating for TBI residuals and the appeal must be denied. REASONS FOR REMAND Service connection for a right ankle disorder is remanded. Service connection for right foot numbness and tingling (right foot disability) is remanded. Service connection for right foot numbness and tingling (left foot disability) is remanded. The Veteran is seeking service connection for a bilateral foot numbness and tingling and a right ankle disorder. The August 2020 Board decision remanded the claims for clarification of whether the Veteran had diagnoses related to his feet and right ankle. Specifically, the RO was asked to obtain medical opinions as to the nature of the Veteran's claimed bilateral foot and right ankle disabilities. The Board asked for the medical opinion to whether the numbness and tingling of the feet, and right ankle pain resulted in functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). In Saunders v. Wilkie, the Court held that where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis. To that end, the February 2021 VA addendum opinions were obtained. The Board finds the medical opinions to be inadequate. The VA examiner failed to provide an opinion considering the ruling in Saunders v. Wilkie. The VA examiner found that the Veteran's feet and right ankle were normal, but justified the finding with the fact that the Veteran is able to run a goat farm as support for finding the Veteran had normal functioning in both his feet and right ankle. The Board finds the VA examiner's justification to be inadequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, upon remand, the Veteran shall be provided new VA examinations to determine the nature and etiology of his claimed right ankle and bilateral foot disabilities. Service connection for a gastrointestinal disorder is remanded. The Veteran is seeking service connection for a gastrointestinal disorder. The Veteran contends that his claimed gastrointestinal disorder is proximately due to, caused by, or aggravated by his service-connected PTSD. The September 2015 VA examiner found that the Veteran did not have a diagnosis of a gastrointestinal disorder. However, the VA examiner advised the Veteran to seek medical care for evaluation and diagnosis of his reported symptomology. As such the September 2015 VA examination's findings are inconclusive as to whether the Veteran has diagnosis of a gastrointestinal disorder. Upon remand, the Board will afford the Veteran another VA examination to address the nature and etiology of his claimed gastrointestinal disorder. Entitlement to a disability evaluation greater than 10 percent prior to December 3, 2020, and 20 percent thereafter, for service-connected L1-2 disc protrusion without any impingement (low back disability) is remanded. As noted above, this claim was remanded by the Court in December 2019 for action consistent with the terms of the parties' Joint Motion. The Joint Motion found the September 2015 VA examination to be inadequate due to non-compliance with Sharp v. Shulkin. 29 Vet. App. 26, 33 (2017). To that end, the Board remanded the claim in August 2020 for action consistent with the December 2019 Joint Motion. The Veteran was afforded the February 2021 VA examination. However, review of the February VA examination report revealed that the examination does not comply with the findings in Sharp. In Sharp, the Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of veterans. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner. The February 2019 VA examination of the low back disability have noted the Veteran's report of flare-ups, however the detailed findings contemplated by the Sharp case have not been included. A Remand for a new VA examination to address the Sharp standards is required. 38 C.F.R. § 4.2. The matters are REMANDED for the following actions: 1. Schedule the Veteran for VA examinations to assess the nature and etiology of the claimed right ankle and bilateral foot numbness and tingling. The claims file and a copy of this remand must be made available for review, and the examination report must reflect that review of the claims file occurred. In particular, the examiner must address the following: (a) Provide diagnoses for all current right ankle and bilateral foot disabilities, to include those noted during the appeal period. If it is found that the Veteran does not have any disability of the right ankle, right foot, and/or, left foot, the examiner must opine whether the Veteran's right ankle, right foot, and/or, left foot reach the level of a functional impairment of earning capacity. (b) Is it at least likely as not that any right ankle disability or evidence of functional impairment is related to his active duty service? (c) Is it at least likely as not that any bilateral foot disabilities are related to his active duty service? Is any identified bilateral foot disability proximately due to, the result of, or aggravated by the Veteran's service-connected back disability? 2. Schedule the Veteran for an appropriate VA examination to determine the nature of his claimed gastrointestinal disorder. After reviewing the record and examining the Veteran, the examiner is to answer the following questions: (a) Provide diagnoses for all current gastrointestinal disorders, to include any noted during the appeal period. (b) Is it at least likely as not (a fifty percent probability or greater) that a claimed gastrointestinal disorder is related to his active duty service? (c) State whether it is at least as likely as not that any gastrointestinal disability is proximately due to, the result of, or aggravated by the Veteran's service-connected PTSD. 3. Schedule a VA examination to ascertain the current severity of the Veteran's service-connected low back disability. All indicated testing should be accomplished and all symptomatology associated with each knee disability should be identified. The examiner is to state whether there is any evidence of objective neurological impairment related to the Veteran's back disability, to include bowel or bladder impairment and radiculopathy or similar symptoms of the Veteran's bilateral lower extremities. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced range of motion during flares or repetitive use. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. R. Higgins, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.