Citation Nr: 22044979 Decision Date: 08/09/22 Archive Date: 08/09/22 DOCKET NO. 19-23 904 DATE: August 9, 2022 ORDER Entitlement to service connection for left shoulder rotator cuff tear and labral tear is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial 10 percent disability rating for nevus and photophobia of the left eye is granted. Entitlement to an initial disability rating in excess of 10 percent for the lumbar spine is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for a neck disability is remanded. FINDINGS OF FACT 1. The evidence persuasively favors a finding that the Veteran's left shoulder rotator cuff tear and labral tear is related to a left shoulder injury that occurred during a qualifying period of active service. 2. The Veteran does not have a current hearing loss disability for VA purposes. 3. For the entire period on appeal, the Veteran has experienced photophobia with intermittent dull ache and occasional sharp pain. 4. During the period on appeal, the Veteran's lumbar spine did not manifest with forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 contour such as scoliosis. CONCLUSIONS OF LAW 1. The criteria for service connection for left shoulder rotator cuff tear and labral tear are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for entitlement to a separate 10 percent rating, but not higher, for nevus and photophobia of the left eye have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.75, 4.76(a), 4.77, 4.79, 4.118, Diagnostic Code 6036. 4. The criteria for a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Air Force from September 1981 to July 1997; from February 1999 to April 2000; and from October 2001 to March 2004, with additional service in the Air Force Reserve. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in December 2015. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for a left shoulder disability The Veteran seeks service connection for a left shoulder disability, which he attributes to an injury sustained while playing softball for his Air Force Reserve unit. Alternatively, the Veteran's attorney has contended that the Veteran's current left shoulder disability is etiologically related to shoulder surgery he underwent during a period of active service. Under 38 U.S.C. § 101 (24), "active military, naval, or air service" includes active duty; any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in the line of duty; and any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred in or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. For the purposes of determining service connection based on Reserve service, ACDUTRA means full-time training duty, where the service member is available for duty around-the-clock performed by the Reserve components. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). Annual two-week training is an example of ACDUTRA. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA. 38 U.S.C. §§ 101 (24), 106, 1131. When a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA or INACDUTRA for service connection to be granted. 38 U.S.C. §§ 101 (2), (22), (24); 38 C.F.R. § 3.6 (a); Donnellan v. Shinseki, 24 Vet. App. 167 (2010); Acciola v. Peake, 22 Vet. App. 320, 324 (2008). In the absence of such evidence, the period of ACDUTRA or INACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "Veteran" for that period of ACDUTRA or INACDUTRA service alone. 38 U.S.C. § 101 (2), (24); Acciola, 22 Vet. App. at 324. Turning to the evidence, the Board observes that the Veteran has been diagnosed with left shoulder rotator cuff tear and labral tear during the period on appeal. See May 2015 VA examination. Therefore, the first element of direct service connection is met. Reserve personnel records show the Veteran was in a paid inactive duty status from July 14, 2001 to July 15, 2001. Of record is a July 2001 Physical Profile Serial Report from the 610th Security Forces Squadron, a U.S. Air Force Reserve unit, showing the Veteran was put on limited duty related to his left shoulder. Private medical treatment records show the Veteran underwent surgery to his left shoulder in November 2001, during a period of active service, for an injury he reported occurred while playing softball on July 17, 2001. In an April 2019 letter, the Veteran's physician wrote that the Veteran had left shoulder pain that stemmed directly from an injury sustained while playing softball for his unit, which consisted of a rotator cuff tear, dislocation, and fracture. He underwent initial surgery and physical therapy but had suffered continuous pain since, with increased pain and limitation in mobility in recent years. The record includes lay statements from service members who served with the Veteran in the 610th Security Forces Squadron. In a May 2019 statement, R.M. wrote that he witnessed the Veteran playing intramural softball supporting his unit, the 610th Security Forces Squadron, when he dislocated his shoulder while sliding into a base. R.M. wrote that the Veteran was placed on light duty until he underwent surgery, then later returned to duty status and deployed in support of Operation Enduring Freedom. In a June 2019 statement, T.F., a retired Command Master Sergeant, wrote that he and the Veteran had served together in the 610th Security Forces Squadron. He wrote that both were on the unit's intramural softball team, and he recalled the Veteran injuring his shoulder during a July 2001 game. He wrote that he knew the Veteran was on either an annual tour or a unit training assembly order and representing the 610th Security Forces Squadron at the time of his injury, as it was the unit's policy to be on orders to be able to represent the unit during physical activities. T.F. further wrote that the Veteran had to undergo shoulder surgery and several months of physical therapy to regain mobility in his arm and return to full mobility ready status. T.F. added that he now conducts federal background investigations for national security clearances, and that he stood by his statement. In a November 2020 brief, the Veteran's attorney contended that service connection was warranted based on the fact that the Veteran underwent surgery on his left shoulder in November 2001, during a period of active service. In this regard, he submitted a letter from Dr. S.B., who opined that the Veteran's current left shoulder disability was at least as likely as not secondary to the shoulder surgery he underwent during a period of active service. Dr. S.B. wrote that chronic postoperative pain was a potential outcome from an otherwise successful surgical procedure, and he emphasized the fact that the Veteran, during his May 2015 VA examination, reported experiencing a residual symptom of stiffness resulting from his 2001 shoulder surgery. He further wrote that posttraumatic arthritis (PTA) was the most plausible explanation for the Veteran's left shoulder pain, and suggested that his shoulder pain was aggravated due to high impact activities he engaged in while in the military. Dr. S.B. concluded by writing that the Veteran still complained of left shoulder pain and suffering after a surgical procedure to his left shoulder, and the fact that the Veteran had surgery did not mean his symptoms had resolved. Overall, based on the foregoing, the Board finds that the evidence persuasively favors a finding that the Veteran's current left shoulder rotator cuff tear and labral tear had its onset during a qualifying period of active service. Reserve personnel records show the Veteran was in an INACDUTRA status on July 14 and July 15, 2001. Two servicemembers who served with the Veteran at 610th Security Forces Squadron provided competent and credible statements attesting to the fact that they witnessed the Veteran injure his shoulder during a unit softball game in July 2001. T.F., retired Chief Master Sergeant, confirmed that the Veteran would have been in a duty status based on the command's policy for representing the unit in physical activities. There is also a Physical Profile from the command indicating the Veteran was put on limited duty in July 2001 due to his left shoulder. Finally, the Board finds Dr. S.B.'s conclusion that the Veteran's current left shoulder pain could be attributable to his in-service left shoulder surgery to be persuasive, especially given the Veteran's current report of experiencing residual left shoulder stiffness due to his November 2001 shoulder surgery. In reaching this conclusion, the Board acknowledges the May 2015 VA examiner's negative nexus opinion concerning the relationship between the Veteran's left shoulder disability and service. The examiner concluded that the Veteran's left shoulder injury occurred while the Veteran was on inactive duty in July 2001 and was therefore less likely than not related to service. However, as previously discussed, service connection may be warranted for disability resulting from injury incurred during a period of INACDUTRA. Further, the examiner did not address the Veteran's report of experiencing residual stiffness as a result of his left shoulder surgery, which occurred in November 2001, during a period of active service. As is true with any piece of evidence, the credibility and weight to be attached to medical opinions and observations are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Ultimately, the Board finds that the evidence establishes that the Veteran's current left shoulder disability had its onset during a qualifying period of active service. Under such circumstances and granting the Veteran the benefit of the doubt in this matter, the Board concludes that service connection for left shoulder rotator cuff tear and labral tear is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for hearing loss For VA compensation purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of hearing loss and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran underwent a VA audiological examination in connection with his claim in May 2015. The examiner found that the Veteran had sensorineural hearing loss in the frequency range of 6000 Hz or higher in both ears and determined that it was at least as likely as not caused by or a result of hazardous noise exposure in service. However, physical examination did not reveal hearing loss to the extent necessary to establish a current bilateral hearing loss disability for purposes of VA compensation. That is, the examination did not show that the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz was 40 decibels or greater in either ear; that the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz were 26 decibels or greater in either ear; or that speech recognition scores using the Maryland CNC Speech Recognition Test were less than 94 percent. The Board finds the May 2015 VA audiological examination to be of great probative value and dispositive of the current disability question presented in this case. The Veteran's bilateral hearing loss does not meet the threshold established by 38 C.F.R. § 3.385. Since there is no evidence the Veteran currently has hearing loss that meets the definition of a disability for VA purposes, service connection for bilateral hearing loss must be denied. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. A Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 3. Entitlement to an initial compensable rating for nevus and photophobia of the left eye The Veteran seeks an increased rating for his service-connected nevus and photophobia of the left eye, currently assigned a noncompensable (0 percent) rating under 38 C.F.R. § 4.79, Diagnostic Code 6009, for an unhealed eye injury. The General Rating Formula for Diagnostic Codes 6000 through 6009 instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. The Board notes that the rating criteria for evaluating diseases of the eye were amended during the pendency of this appeal. See 89 Fed. Reg. 15316 (Apr. 10, 2018). Where there is a change in the rating criteria during the period on appeal, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Effective May 13, 2018, the General Rating Formula provides a 10 percent disability rating for documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months. A 20 percent rating is warranted for documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months. A 40 percent rating is warranted for documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months. A 60 percent rating is warranted for documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months. For VA purposes, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. 38 C.F.R. § 4.79, Diagnostic Codes 6000 through 6009. Additionally, Diagnostic Code 6036, which was unaffected by the May 2018 rating criteria changes, provides for a minimum 10 percent rating for pain, photophobia, and glare sensitivity. Under this code, the disability is to be rated on the basis of visual impairment, with a minimum rating of 10 percent if there is pain; however, it does not instruct that an additional rating for pain be combined with a compensable rating for visual impairment. Under Diagnostic Code 6066, which was also not affected by the May 2018 rating criteria changes, a non-compensable rating is assigned for impairment of central visual acuity when vision in both eyes is correctable to 20/40. A 10 percent rating is assigned for impairment of central visual acuity in the following situations: (1) when the corrected visual acuity is 20/50 in one eye and 20/40 in the other eye; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.79, Diagnostic Code 6066. Turning to the evidence, the Board observes that the Veteran underwent a VA examination in connection with his claim in May 2015. He reported that he had suffered an orbital fracture during service, and while it had since resolved, he continued to experience residual photophobia with intermittent dull ache near the brow and occasional sharp pain and lid droop. Corrected distance vision was 20/40 bilaterally. There was no visual field defect. Slit lamp and external eye examination revealed lid drooping and numbness in the left eye; however, the examiner did not indicate that the Veteran had ptosis and found that there was no scarring or disfigurement attributable to any eye condition. There was a 2 disc diameter (DD) nevus on the left eye. The examiner indicated that the Veteran had not had any incapacitating episodes attributable to any eye conditions over the past 12 months. The examiner determined that the Veteran's eye conditions did not impact his ability to work. Assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Codes by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, after careful review of the evidence, the Board finds that an increased 10 percent disability rating is warranted under Diagnostic Code 6036. While the Veteran's eye disability has previously been evaluated under Diagnostic Code 6009, the Board finds that Diagnostic Code 6036 better contemplates his symptoms of photophobia and pain. As previously discussed, it provides a minimum 10 percent rating for symptoms such as photophobia and pain, which the Veteran has reported during the period on appeal. To this extent, the Veteran's claim for an increased rating for his photophobia and nevus of the left eye is granted. However, an even higher rating would require incapacitating episodes or more severe visual impairment than that demonstrated during the period on appeal. The evidence does not show that the Veteran has decreased visual acuity or a visual field defect attributable to his disability, with best corrected distance visual acuity no worse than 20/40 in the left eye. Further, the record does not indicate the Veteran has experienced incapacitating episodes under either the pre-May 2018 or current criteria. The Board has considered the applicability of Diagnostic Code 6019, for ptosis, given the examiner's finding of left eyelid drooping and numbness, but, as previously noted, the examiner indicated that there was no scarring or disfigurement attributable to any eye condition, and a higher rating is not warranted based on visual impairment. Finally, the Board has also considered the Veteran's attorney's argument, in a brief submitted in November 2020, that the Veteran be afforded a VA examination to evaluate the severity of his headaches. In this regard, the Board has considered whether a claim of entitlement to service connection for headaches was part of the Veteran's claim for an increased rating for his eye disability pursuant to Bailey v. Wilkie, 33 Vet. App. 188 (2021). Under Bailey, VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for an increased rating for the primary service-connected disability. However, in this case, a claim of entitlement to service connection for headaches was part of the Veteran's initial claim, submitted in June 2014. The December 2015 rating decision on appeal denied the claim, and the Veteran included the issue on his subsequent notice of disagreement (NOD). A June 2019 Statement of the Case (SOC) continued to deny the claim. However, the Veteran specifically omitted the issue of service connection for headaches from his August 2019 VA Form 9 and therefore did not perfect a substantive appeal for that issue. Unlike in Bailey, where the RO did not develop secondary service connection claims, in this case, the RO developed and adjudicated a claim for service connection for headaches. The Veteran chose not to perfect a substantive appeal for that issue. Therefore, the Board will not raise a claim of entitlement to service connection for headaches in connection with the claim for an increased rating for the Veteran's eye disability. Therefore, based on the foregoing, a disability rating in excess of 10 percent is not warranted for photophobia and nevus of the left eye at any point during the period on appeal. 4. Entitlement to a disability rating in excess of 10 percent for the lumbar spine The Veteran seeks a higher rating for his lumbar spine disability, currently rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board notes that, effective February 7, 2021, the applicable rating criteria for certain musculoskeletal disorders were revised. 85 Fed. Reg. 76453 (Nov. 30, 2020). Generally, a change in rating criteria during the pendency of the claim applies prospectively, if more favorable. Here, the changes to the rating criteria evaluating disorders of the spine have no impact on the Veteran's rating. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is zero to 30 degrees; left and right lateral flexion are zero to 30 degrees; and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The combined normal range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note (2). Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Turning to the evidence, the Board notes that the Veteran underwent a VA back conditions examination in connection with his claim in May 2015. He reported pain that would come and go and that he had been awakened by pain spasms. He also reported that he consistently suffered from slight soreness, and that he treated his pain with muscle relaxers, meloxicam, and oral pain medications. He reported flare-ups that impacted the function of the thoracolumbar spine. He described the flare-ups as consisting of symptoms of pain and stiffness, occurring four times per year lasting approximately two to three days at a time, with productivity loss of 50 percent compared to when he did not have a flare-up. Range of motion testing showed forward flexion to 90 degrees or greater, with objective evidence of painful motion beginning at 90 degrees or greater; extension to 20 degrees, with objective evidence of painful motion beginning at 15 degrees; left lateral flexion to 30 degrees or greater, with no objective evidence of painful motion; right lateral flexion to 30 degrees, with no objective evidence of painful motion; left lateral rotation to 30 degrees, with no objective evidence of painful motion; and right lateral rotation to 30 degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. Contributing factors to functional loss were less movement than normal and pain on movement. The examiner noted that the Veteran was not examined immediately after repetitive use over time or during a flare-up but determined that the examination was medically consistent with the Veteran's statement describing functional loss with repetitive use over time. Muscle strength, reflex, and sensory tests were all normal. There was no ankylosis of the spine, no intervertebral disc syndrome, no radiculopathy, and no other neurologic abnormalities. There was no guarding or muscle spasm of the thoracolumbar spine. The Veteran reported occasional use of a brace. The examiner found that the Veteran's lumbar spine disability did not impact his ability to work. In an April 2019 letter, the Veteran's private physician wrote that the Veteran's low back pain was long-term and episodic, at times severe, and required injection therapy, medication use, and physical therapy. He wrote that flare-ups significantly restricted his mobility. The Veteran underwent another VA back conditions examination in May 2019. He reported frequent flare-ups and daily discomfort. Treatment included diclofenac gel 1% as needed, physical therapy in the past, and pain/steroid injections in the past. He described the flare-ups as lasting for about one week to a month. His description of functional loss was that bending would make his back tighten. Range of motion testing showed forward flexion to 70 degrees, extension to 20 degrees, left lateral flexion to 20 degrees, right lateral flexion to 20 degrees, left lateral rotation to 20 degrees, and right lateral rotation to 20 degrees. The combined range of motion of the thoracolumbar spine equaled 170 degrees. Range of motion did not contribute to functional loss. Pain was noted on examination of each range of motion but did not result in or cause functional loss. There was objective evidence of localized tenderness or pain of moderate severity on palpation of the lower back. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. The examiner noted that the Veteran was not examined immediately after repetitive use over time or during a flare-up but determined that the examination was medically consistent with the Veteran's statement describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time or during a flare-up. The examiner described no additional range of motion during flare-ups and after repeated use over time. Muscle strength, reflex, and sensory tests were all normal. There was no ankylosis of the spine, no intervertebral disc syndrome, no radiculopathy, and no other neurologic abnormalities. There was no guarding or muscle spasm of the thoracolumbar spine. The Veteran reported occasional use of a brace. The examiner found that the Veteran's lumbar spine disability impacted his ability to work in that he was limited in bending, stooping, pushing, pulling, carrying, and lifting moderate objects. The Board finds that the evidence of record persuasively weighs against awarding a disability rating in excess of 10 percent for the lumbar spine at any point during the period on appeal. As previously discussed, a higher 20 percent rating would require forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 contour such as scoliosis. Here, the evidence shows that forward flexion of the Veteran's lumbar spine was greater than 60 degrees and the combined range of motion of the thoracolumbar spine was greater than 120 degrees throughout the period on appeal. Muscle strength, reflex, and sensory tests were all normal. There was no ankylosis of the spine, no intervertebral disc syndrome, and no other neurologic abnormalities. There was no guarding or muscle spasm severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Therefore, based on the foregoing, the Board finds that the claim for a rating in excess of 10 percent for the lumbar spine must be denied. REASONS FOR REMAND Regrettably, for the reasons discussed below, the remaining claims on appeal must be remanded for additional development. 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for hemorrhoids is remanded. 4. Entitlement to service connection for a neck disability is remanded. The Board notes that the Veteran's Reserve service treatment records (STRs) appear to be incomplete. For instance, there do not appear to be any records from his deployment in support of Operation Enduring Freedom. The Board notes that the RO has made attempts to obtain records directly from the Veteran's previous Reserve unit, as well as records for periods of active service through Defense Personnel Records Information Retrieval System (DPRIS). However, it is not clear that the RO requested complete STRs, to include periods of ACDUTRA, INACDUTRA, and active duty service. The RO should attempt to obtain these records on remand. Additionally, the Board notes that the evidence, including an April 2019 letter from the Veteran's physician, indicates the Veteran has current right and left knee disabilities, a neck disability, and hemorrhoids. The Veteran attributes these disabilities to military service. However, he has not yet been afforded a VA examination to determine the nature and etiology of these disabilities. Therefore, remand is warranted to schedule the Veteran for VA examinations concerning these disabilities. The matters are REMANDED for the following actions: 1. Arrange for further development to obtain from any appropriate official source, complete service treatment records from the Veteran's Air Force Reserve service, to include periods of ACDUTRA, INACDUTRA, or active duty service. All attempts to obtain these records must be documented and associated with the claims file. 2. Then, schedule the Veteran for VA examinations to determine the nature and etiology of his claimed right and left knee, neck, and hemorrhoid disabilities. The entire claims file must be provided to the examiner for review, and the examination report should reflect that such a review was accomplished. Any clinically indicated testing and/or consultations must be performed. Elicit a complete history from the Veteran. Following a review of the claims file and examination of the Veteran, the examiner is to address the following questions FOR EACH DISABILITY: (a.) Does the Veteran have a currently diagnosed disability? The Board notes that pain alone that causes functional impairment can be a disability, even if there is no identified diagnosis. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability was incurred during active service? A complete rationale for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 3. Then, readjudicate the claims on appeal. If the benefits sought remain denied, issue a supplemental statement of the case to the Veteran and his representative and return the case to the Board. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. T. Raftery, 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.