Citation Nr: 21041271 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 05-12 201 DATE: July 8, 2021 ORDER Entitlement to service connection for hearing loss is denied. Entitlement to an effective date prior to July 14, 2004 for the award of service connection for depressive disorder is denied. Entitlement to an initial rating in excess of 50 percent for depressive disorder is denied. Entitlement to an effective date of April 4, 2003 for a10 percent rating for sacroiliitis of the right hip is granted. Entitlement to an evaluation in excess of 10 percent for sacroiliitis of the right hip is denied. REMANDED What is the proper rating assigned for a low back disability from February 23, 2007 is remanded? The issue of entitlement to a rating in excess of 10 percent prior to January 25, 2015 and in excess of 20 percent thereafter for residuals of right elbow fracture is remanded. The issue of entitlement to a compensable rating prior to January 25, 2016 and in excess of 10 percent thereafter for residuals of left fifth metacarpal fracture (left wrist disability) is remanded. The issue of entitlement to a compensable rating for nasal pterygium of the left eye and nasal pinguecula of the right eye is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had hearing loss disability for VA purpose at any time during or approximate to the pendency of the claim. 2. The Veteran did not file a claim that can be reasonably construed as a claim for service connection for depression prior to July 14, 2004. 3. For the entire appeal period from July 14, 2004 to the present, the Veteran's depressive disorder was manifested by psychiatric symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 4. For the entire appeal period from April 4, 2003 to the present, the Veteran's right hip disability has had painful motion and has gradually worsened over the years as evidenced by the flexion that decreased from over 100 degrees to 40 degrees, at worst. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an effective date earlier than July 14, 2004, for the award of service connection for depression have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.155, 3.400. 3. The criteria for an initial rating in excess of 50 percent rating for depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 4. The criteria for a 10 percent rating, but no higher, for right hip sacroiliitis have been met from April 4, 2003. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1975 to August 1978. The Board previously remanded various claims for further development in January 2007, September 2008, May 2015, and August 2018. In January 2007, the Board denied service connection for depression; the denial was vacated and remanded by a March 2008 the United States Court of Appeals for Veterans Claims (hereafter "the Court") order. Subsequently, the Board granted service connection for depression in a May 2015 decision, which was implemented in an October 2016 rating decision. The Veteran perfected his appeal for the issues of entitlement to an increased rating and an earlier effective date for the award of service connection for depression. In August 2018, the Board remanded these issues for further development. The issues of entitlement to service connection for hearing loss and entitlement to a compensable rating for bilateral eye disabilities were denied in a February 2015 rating decision, and the denial was continued in an April 2017 statement of the case. The Veteran perfected the appeal. In August 2018, the Board remanded the issue for further development. The case has now been returned to the Board for appellate review. Subsequent to the August 2018 remand, the Agency of Original Jurisdiction (AOJ) granted the Veteran's claim for service connection for radiculopathy of bilateral lower extremities in a September 2020 rating decision. As this grant represents a full grant of the benefits sought, these issues are no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). 1. Hearing loss With respect to claims for service connection for hearing loss, the Court has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further opined that 38 C.F.R. § 3.385 then operated to establish when a hearing loss could be service connected as disability. Hensley, 5 Vet. App. at 159. For the purposes of applying the laws administered by the VA, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 or greater; or when word recognition scores using the Maryland CNC test are less than 94 percent. 38 C.F.R. § 3.385. Here, the evidence of record does not show that the Veteran has hearing impairment for the VA purpose as prescribed in 38 C.F.R. § 3.385. Indeed, the most recent February 2015 VA examination found that the Veteran had puretone thresholds of 15 decibels (dB) at 500 Hertz (Hz), 15 dB at 1000 dB, 5 dB at 2000 Hz, 15 dB at 3000 Hz, and 25 dB at 4000 Hz in the right ear and 15 dB, 15 dB, 10 dB, 15 dB, 15 dB, and 35 dB at the respective frequency in Hz in the left ear. Speech discrimination was noted to be 100 percent in both ears. Moreover, the evidence of record for the entire appeal period does not indicate that the Veteran suffers from hearing impairment. As such, the weight of the evidence is against finding that the Veteran has a current diagnosis of hearing loss or hearing impairment. Absent a showing of a left ear hearing loss disability for VA purposes related to active service, entitlement to service connection for left ear hearing loss must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for bilateral hearing loss, and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. Effective Date Generally, the effective date of an award of a claim is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Unless otherwise provided, the effective date of compensation will be fixed in accordance with the facts found, but will not be earlier than the date of the claimant's application. 38 U.S.C. § 5110 (a). If a claim for disability compensation for direct service connection is received within one year after separation from service, the effective date awarded is the day following separation from active service or the date entitlement arose. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b)(2). A claim is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p); 3.155. The Board recognizes that this regulation was amended; however, the version above is applicable to this appeal. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). Any communication or action from a claimant indicating an intent to apply for one or more benefits under the laws administered by VA and which identified the benefit sought, may be considered an informal claim. 38 C.F.R. § 3.155 (a). Thus, the essential elements for any claim, whether formal or informal are "(1) an intent to apply for benefits, (2) an indication of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). 2. Effective date prior to July 14, 2004 for the award of service connection for depression Entitlement to an effective date prior to July 14, 2004 for the award of service connection for depression is denied. The Veteran's claim for service connection for depression was received on July 14, 2004. Prior to the claim submission, private medical treatment records, to include records from a psychiatric institute, were associated with the claims file on June 19, 2003. However, the Veteran's intent to apply for benefits is not communicated in the submitted evidence. As such, it does not meet requirement of a claim, informal or formal. Therefore, an effective date prior to July 14, 2004 for the award of service connection for depression is not warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignment of disability ratings following awards of service connection for depression. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran is also requesting higher ratings for the already established service-connected disabilities of right hip, spine, right elbow, and left wrist. As such, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. , quoting 38 C.F.R. § 4.40. Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 38 C.F.R. § 4.59 provides, "The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. Here, the Veteran's claim for increased rating for the disability of right hip, lumbar spine, left wrist, and right elbow was received on April 4, 2003. Moreover, his claim for service connection for depression was received on July 14, 2004. Therefore, the Board looks to the evidence of record since April 2002 for the disability of right hip and lumbar spine and the evidence of record since July 2004 for depression. Moreover, the Board notes that as explained in the August 2018 remand, the Veteran's right hip and lumbar spine disability must be evaluated separately. As such, the appeal period for the hip disability is from April 4, 2003 to the present. 3. Initial rating in excess of 50 percent for depression The Veteran is in receipt of 50 percent rating for depressive disorder under Diagnostic Code 6434 for the entire appeal period from July 14, 2004. Diagnostic Code 6434 provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. He contends that such disability is more severe than as reflected by the currently assigned rating, and as such, a higher initial rating is warranted. Under the General Rating Formula, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is 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; memory loss for names of close relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, 713 F.3d at 117-118 ; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran's claim was certified to the Board in April 2005 and, as such, the DSM-IV applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. However, as the DSM-IV governs the Veteran's claim, such scores are relevant to the evaluation of his psychiatric disorder. A GAF score is another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994)). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 61 to 70 reflect mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). Lower numbers on the GAF scale reflect more severe symptoms; higher number reflects less severe symptoms. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126 (a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id. ; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). The Board finds that an initial evaluation in excess of 50 percent for the Veteran's depressive disorder is not warranted for the entire appeal period for the following reasons. An August 2004 VA examination reflects a diagnosis of depressive disorder, not otherwise specified (NOS). The Veteran reported feeling of sadness with irritability, loss of energy, insomnia, anxiety, and tension. The GAF score was 60. A May 2007 private psychiatric evaluation reflects a diagnosis of severe recurrent major depression under DSM-IV. The examiner noted that the Veteran had severe anxiety and depressive symptoms such as low self-esteem, feelings of disability, poor impulse control, frequent crying, isolation, restlessness, tension, irritability, distress, nervousness, and suspiciousness. He denied suicidal or homicidal ideas. He reported having nightmares and trouble with sleeping. He also reported frustration secondary to his disabilities. The Veteran reported a marked limitation in his ability to work. The examiner determined that the Veteran's depression had caused severe dysfunction at the level of all facets of daily life. A December 2010 private psychiatric evaluation reflects a diagnosis of recurrent, severe major depressive disorder. The examiner reviewed the August 2004 VA examination and the May 2007 private evaluations and concluded that the Veteran's depression was aggravated by his lower back pain. A November 2011 VA examination reflects a diagnosis of depressive disorder, NOS under DSM-IV. The GAF score was 65 to 67. The examiner determined that psychiatric symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. Symptoms noted were anxiety, impaired judgment, difficulty in adapting to stressful circumstances, including work or worklike setting. A January 2018 VA treatment record indicates that the Veteran had symptoms of depression, anxiety, irritability, poor concentration, restlessness, and nervousness. Prescription for clonazepam and zolpidem was continued. A February 2020 VA examination reflects a diagnosis of moderate major depressive disorder under DSM-5. The examiner determined that the Veteran's psychiatric disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Symptoms noted were depressed mood, anxiety, chronic sleep impairment, flattened affect, and disturbance of motivation and mood. He did not indicate suicidal or homicidal ideation. Judgment and insight were good. There was no indication of a perceptual or though disorder. Based on a review of the records, the Board finds that the weight of the evidence is against finding that the Veteran's depression was productive of symptoms, in severity, duration, and frequency, that resulted in occupational and social impairment with deficiencies in most areas. For the entire appeal period, the Veteran's psychiatric symptomatology has been productive of depressive feeling, anxiety, irritability, poor impulse control, sleep impairment, disturbance of motivation and mood. At no time during the appeal period, the Veteran had psychiatric symptoms sever enough to cause deficiencies in most areas of his life such as suicidal ideation, obsessional rituals, speech irregularities, debilitating panic attacks, spatial disorientation, neglect of personal appearance and hygiene. . The GAF score when DSM-IV applied was never below 60. Moreover, he has never had 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name, indicative of total occupational and social impairment. Therefore, an initial evaluation in excess of 50 percent for depressive disorder is not warranted. 4. Increased rating, to include an earlier effective date for 10 percent rating, for sacroiliitis of the right hip As noted above, the appeal period for the issue of right hip is from April 4, 2003, and as decided in the August 2018 Board decision, the Veteran is in receipt of 10 percent rating for sacroiliitis of the right hip with the RO assigned effective date of February 23, 2007. Based on the evidence of record, the Board finds that a rating of 10 percent, but no higher, is warranted from April 4, 2003 to the present for the Veteran's right hip sacroiliitis under Diagnostic Code 5252. Diagnostic Code 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. 38 C.F.R. § 4.71a. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. A May 2003 VA examination documents the Veteran's complaint of anterior hip pain occasionally with sensation of locking or clunking of the right hip as well as numbness in the right thigh and calf. Treatment consisted of orphenadrine citrate and hot pack. An episode of flareup was precipitated by ambulation and weightbearing. He reported that he was unable to do household chores such as yard work. Use of assistive device was not noted. At the examination, the right hip had flexion to 130 degrees with pain started at 126 degrees. Pain was observed in the right hip with external rotation with repetitive range of motion. The x ray of the right hip did not show bone abnormalities. A February 2007 VA examination reflects the Veteran's complaint of pain and stiffness. Treatment consisted of Ultracet and acetaminophen. Periods of flareup were reported at least once a week with a duration of 3-4 hours in the morning. Rain would precipitate the flareups. No functional impairment during flareups was reported. Tenderness in the right hip was observed. The Veteran reported that antalgia affected him sporadically, though the gait observed was not antalgic. The range of motion test found flexion to 125 degrees with pain at 95 degrees. He was unable to squat due to pain. A January 2016 VA examination reflects a diagnosis of sacroiliitis of the right hip. He reported having flareups daily, which would last for hours, and loss of standing and ambulation tolerance during a flareup. The range of motion test found flexion to 100 degrees. No estimate for loss of range of motion during a flareup was provided. No estimate for impact on range of motion for weight-bearing and passive motion was noted. A November 2018 VA examination reflects a diagnosis of sacroiliitis of the right hip. The Veteran reported that he still had intermittent pain in the right hip, which was productive of a stabbing sensation. It was precipitated after sitting for long periods of time. The pain was alleviated by tramadol. He did not report flareups of the right hip. The range of motion test found flexion to 40 degrees. Pain was noted, but did not result in functional loss. Regular use of cane was noted. The examiner reported that the Veteran was unable to sit or stand for long periods of time and he had difficulty climbing stairs. A February 2020 VA examination reflects a diagnosis of sacroiliitis of the right hip. The Veteran reported that his hip condition was worse with persisting pain than at the last examination. The Veteran reported having flareups, which would last all day long. However, flareups and repetitive use over time did not affect the range of motion at the right hip. He reported inability to sit, stand, or walk for prolonged periods of time during flareups. The range of motion test found flexion to 40 degrees. The examiner found that the Veteran's right hip disability prevented him from doing activities that required walking on irregular surface, climbing stairs or ladders and that he was limited to sedentary or semi-sedentary type of activities. Considering the evidence of record in its entirety, the Board finds that the Veteran's right hip disability had painful motion for the entire appeal period and gradually worsened over the years as evidenced by the flexion that decreased from over 100 degrees to 40 degrees, at worst. In particular, the weight of the evidence is against finding that the Veteran's right hip flexion was 30 degrees or less or abduction was lost beyond 10 degrees at any time during the appeal period. Moreover, the evidence does not show ankylosis of the right hip joint, flail hip joint, impairment of femur, or malunion of femur at any time during the appeal period. Therefore, a10 percent rating, but no higher, from April 4, 2003 is warranted for sacroiliitis of the right hip. REASONS FOR REMAND 1. What is the proper rating assigned for the low back disability from February 2, 2007? Review of the record reveals some confusion as to the ratings assigned to the low back disorder. In an August 2018 decision, the Board granted a 40 percent rating for a low back disorder that had been rated 20 percent disabling from February 2, 2007. By rating action of November 2018, a 40 percent rating was assigned, said to be effective January 25, 2016, the date of a VA examination. The effective date of the 40 percent was appealed. The January 2021 Supplemental Statement of the Case lists the issue as entitlement to an effective date earlier than February 23, 2007, for the grant of the 40 percent rating. The Board is unable to find a rating assigning that date. Before the Board can decide the appropriate effective date of the 40 percent rating, these matters must be reconciled. 2. Increased rating for right elbow disability 3. Increased rating for left wrist disability During the most recent February 2020 VA examination, the Veteran reported having loss of hand grip strength in the left hand and limited range of motion in the right elbow during flareups. However, no estimate of loss in range of motion was reported for either disability. The Veteran must be afforded a new VA examination that reflects such an estimate. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 4. Increased rating for nasal pterygium in the left eye and nasal pinguecula in the right eye The Veteran had the last eye examination in February 2015. Moreover, the most recent VA treatment record documents dry eye in the problem list. Therefore, upon remand, the Veteran must be afforded a new VA examination to ascertain the current severity of his service-connected bilateral eye disability, to include possibly additional disability. Green v. Derwinski, 1 Vet. App. 121, 124 (1991); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Review the record and clarify the ratings for the low back disorder from February 23, 2007, to include setting the effective date for the increased rating to 40 percent. 2. Schedule the Veteran an examination by an appropriate clinician to determine the current severity of his service-connected right elbow disability and left wrist disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Moreover, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Schedule the Veteran an examination by an appropriate clinician to determine the current severity of his service-connected eye disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. If additional diagnosis is found, the examiner must provide an opinion on whether the additional disability is related to service or proximately due to/aggravated beyond its natural progression by a service-connected disability. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor 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.