A 10 percent rating for recurrent lateral instability due to left knee patellofemoral syndrome is granted.
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Citation Nr: 18159158 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-48 153 DATE: December 18, 2018 ORDER Service connection for bilateral knee arthritis, to include as secondary to bilateral patellofemoral syndrome, is denied. A rating in excess of 10 percent for pain and limitation of motion due to left knee patellofemoral syndrome is denied. A 10 percent rating for recurrent lateral instability due to left knee patellofemoral syndrome is granted. A rating in excess of 10 percent from June 17, 2010 through January 27, 2016, and a compensable rating from January 28, 2016, for recurrent lateral instability due to right knee patellofemoral syndrome is denied. A 10 percent rating for pain and limitation of motion due to right knee patellofemoral syndrome, is granted. A rating in excess of 10 percent for a right shoulder strain is denied. A rating in excess of 10 percent for a left elbow strain is denied. A rating in excess of 10 percent from June 17, 2010 to January 27, 2016, and a compensable rating from January 28, 2016, for a left wrist strain is denied. A rating in excess of 10 percent from June 17, 2010 to January 27, 2016, and a compensable rating from January 28, 2016, for a right wrist strain is denied. A rating in excess of 20 percent for a lumbar spine strain with intervertebral disc syndrome is denied. A rating in excess of 10 percent for gastroesophageal reflux disease is denied. REMANDED The issue of a compensable evaluation for left ear hearing loss is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of bilateral knee arthritis. 2. The Veteran’s left knee patellofemoral syndrome manifested as pain and noncompensable limitation of motion. 3. Since June 17, 2010, the Veteran’s left knee patellofemoral syndrome manifested as slight recurrent lateral instability. 4. From June 17, 2010 through January 27, 2016, the Veteran’s right knee patellofemoral syndrome manifested as slight recurrent lateral instability. Since January 28, 2016, the Veteran’s right knee patellofemoral syndrome did not manifest as recurrent lateral instability. 5. Since June 17, 2010, the Veteran’s right knee patellofemoral syndrome manifested as pain and noncompensable limitation of motion. 6. The Veteran’s right shoulder strain manifested as pain and noncompensable limitation of motion. 7. The Veteran’s left elbow strain manifested as pain. 8. From June 17, 2010 through January 27, 2016, the Veteran’s bilateral wrist strains manifested as pain. Since January 28, 2016, the Veteran’s bilateral wrist strains had resolved. 9. The Veteran’s lumbar spine strain with intervertebral disc syndrome (IVDS) manifested as pain, and, at worst, forward flexion to 60 degrees. 10. The Veteran’s gastroesophageal reflux disease (GERD) manifested as symptoms including pyrosis and regurgitation. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral knee arthritis, to include as secondary to bilateral patellofemoral syndrome, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for a rating in excess of 10 percent for pain and limitation of motion due to left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5019 (2017). 3. The criteria for a 10 percent rating for recurrent lateral instability due to left knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257-5019 (2017). 4. The criteria for a rating in excess of 10 percent from June 17, 2010 through January 27, 2016, and a compensable rating from January 28, 2016, for recurrent lateral instability due to right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257-5019 (2017). 5. The criteria for a rating of 10 percent for pain and limitation of motion due to right knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5019 (2017). 6. The criteria for a rating in excess of 10 percent for a right shoulder strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.69, 4.71, 4.71a, Diagnostic Code 5201-5019. 7. The criteria for a rating in excess of 10 percent for a left elbow strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206 (2017). 8. The criteria for a rating in excess of 10 percent from June 17, 2010 to January 27, 2016, and a compensable rating from January 28, 2016, for a left wrist strain have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 5215 (2017). 9. The criteria for a rating in excess of 10 percent from June 17, 2010 to January 27, 2016, and a compensable rating from January 28, 2016 for a right wrist strain have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 5215 (2017). 10. The criteria for a rating in excess of 20 percent for a lumbar strain with IVDS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5237-5243. 11. The criteria for a rating in excess of 10 percent for GERD are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.27, 4.114, Diagnostic Code 7399-7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2003 to October 2007. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2011, September 2012, and September 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 1. Entitlement to service connection for bilateral knee arthritis, to include as secondary to bilateral patellofemoral syndrome The Veteran contends that he is entitled to service connection for bilateral knee arthritis, to include as secondary to bilateral patellofemoral syndrome. A lay statement in August 2010 indicates the witness was aware of the Veteran’s pain associated with arthritis of the joints. In a December 2016 brief, the Veteran’s representative stated that evidence shows the Veteran was diagnosed with knee arthritis during service. The questions before the Board are 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, or, in the alternative, whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by a service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of arthritis of the knees, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Service treatment records show the Veteran’s health was normal at his service entrance physical examination in February 2003. A March 2007 post deployment health assessment indicates the Veteran reported having stiff and painful joints. During a physical examination in June 2007, the Veteran stated that his joints hurt and he has limited use of his knees. In-service medical records fail to show the Veteran was diagnosed with arthritis. In August 2007, X-rays of the Veteran’s knees showed no evidence of fracture, or significant bone joint or soft tissue abnormality. At an August 2010 VA examination, X-rays of the Veteran’s knees showed bilateral trace joint effusion and mild anterior soft tissue swelling. The Veteran was not diagnosed with arthritis of the knees. VA medical records from December 2011 include knee X-rays that showed no significant degenerative changes. The Veteran was afforded another VA examination in April 2012. Images of the knees showed no degenerative or traumatic arthritis. At his most recent VA examination in February 2016, the examiner did not list arthritis as a diagnosis associated with the Veteran’s knees. While the Veteran believes he has a current diagnosis of bilateral knee arthritis, they are not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Several images of the Veteran’s knees taken between 2007 and 2016 show the Veteran does not have arthritis of the knees, nor does the record contain a diagnosis of knee arthritis from any physician. Accordingly, the Board finds that the preponderance of the evidence weighs against finding in favor of service connection for bilateral knee arthritis, including as secondary to bilateral patellofemoral syndrome. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Disability evaluations are determined by applying the criteria set forth in the Schedule for Rating Disabilities to the Veteran’s current symptomatology. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2017). It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all of these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Id. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. Additionally, the Court has held that when evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be “‘portray[ed]’ (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” Id. at 206. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). 2. Entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome; Entitlement to a rating in excess of 10 percent from June 17, 2010 through January 27, 2016, and a compensable rating from January 28, 2016, for right knee patellofemoral syndrome Knees Rating Criteria The Veteran is seeking an evaluation in excess of 10 percent for left knee patellofemoral syndrome, and an evaluation in excess of 10 percent from June 17, 2010 through January 27, 2016 and a compensable rating from January 28, 2016, for right knee patellofemoral syndrome. His service-connected left knee disorder is evaluated under Diagnostic Code 5099-5019, and the right knee disorder is evaluated under Diagnostic Code 5257-5019. 38 C.F.R. § 4.71a, Diagnostic Codes 5099-5019, 5257-5019 (2017). These hyphenated diagnostic codes contemplate an unlisted condition analogous to bursitis. 38 C.F.R. §§ 4.20, 4.27 (2017). Diagnostic Code 5019 subscribes to the criteria underlying other musculoskeletal codes, specifically Diagnostic Code 5003 for arthritis and Diagnostic Codes 5260 and 5261 for limitation of flexion and extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261 (2017). Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II (2017). Under Diagnostic Code 5019, bursitis is to be rated on limitation of motion of the affected parts, as degenerative arthritis. Degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints involved. When the limitation of motion is noncompensable under the appropriate diagnostic codes, a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5257 provides ratings for recurrent subluxation or lateral instability. Slight disability warrants a 10 percent rating and a moderate disability warrants a 20 percent rating. Severe disability warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5260 pertains to limitation of flexion of the knee and provides that flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 pertains to limitation of extension and provides that extension limited to 5 degrees warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. At an August 2010 VA examination, the Veteran reported having pain, instability, weakness, stiffness, swelling, locking and fatigability of both knees. He also reported having flare-ups caused by physical activity. During flare-ups, the Veteran experienced knee pain and locking, three to seven times per week lasting two to five hours. The examiner noted the Veteran was diagnosed with bilateral knee patellofemoral syndrome. Upon examination, the Veteran had normal range of motion of both knees. Bilateral knee X-rays showed trace joint effusion and mild anterior soft tissue swelling. VA medical records from December 2011 indicate the Veteran reported having right knee pain for several years, worsening in the last few months. He wore a knee brace for partial relief, and stated that severe, twisting motions cause his right knee to pop out. In April 2012, the Veteran was afforded another VA examination. He reported having flare-ups and worsening symptoms of both knees, including pain and tenderness. He stated that prolonged sitting, standing, walking and stair climbing caused stiffness and instability. During initial and repetitive use range of motion testing, the Veteran demonstrated left knee flexion to 120 degrees, and right knee flexion to 90 degrees without pain or hyperextension. The examiner noted the Veteran had normal knee strength and no instability. Images of the knees showed no degenerative or traumatic arthritis. The Veteran submitted an independent medical opinion from Dr. C. Bash in April 2013. In his report, Dr. Bash stated that he did not physically examine the Veteran, but instead reviewed imaging studies, and conducted an extensive history and clinical telephone interview. Dr. Bash stated that the Veteran described his right knee as giving way on uneven surfaces. The Veteran reported that his left knee was better than the right, but symptoms for both knees included grinding, popping, and weakness with limited range of motion. According to Dr. Bash, the Veteran’s description is consistent with a 20 percent rating for instability for each knee. At the Veteran’s most recent VA examination in January 2016, he reported having left anterior cruciate ligament (ACL) reconstruction in 2014 after falling from a cliff. Regarding his left knee, the Veteran reported that since the fall he has experienced locking, giving out, grinding, and moderate swelling up to three times per week causes by certain movements. He also stated he cannot perform a squat due to the left knee, has constant pain rated at a 10 out of 10, and believes movement helps his condition. The Veteran reported having pain in the right knee with occasional locking and grinding. Initial and repetitive use test results were normal, and the Veteran did not exhibit ankylosis, subluxation or instability. The examiner stated that because the examination was not conducted after repeated use over time or during a flare-up, the examination was neither medically consistent or inconsistent with the Veteran’s statements regarding functional loss. However, the examiner noted that the Veteran reported having flare-ups with increased activity, causing functional loss or impairment when standing, sitting or driving for longer than 30 minutes, primarily due to the left knee. The examiner stated that in addition to the diagnosis of patellofemoral syndrome, the Veteran also has a diagnosis of left knee ACL avulsion that is separate and unrelated to his service-connected left patellofemoral syndrome. Left Knee The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee patellofemoral syndrome rated under Diagnostic Code 5099-5019. As noted above, the Veteran is currently in receipt of a 10 percent rating due to pain and noncompensable limitation of motion. To receive a higher rating for limitation of motion, the Veteran’s left knee would have to demonstrate flexion limited to 30 degrees or less, or extension limited to 15 degrees or more. The Veteran has reported flare-ups caused by prolonged sitting, standing and walking that result in in symptoms including pain, instability, and locking. However, at worst, he has had left knee flexion to 120 degrees throughout the period on appeal. The Veteran was consistently noted to have normal range of motion, normal strength and no ankylosis upon examination. Further, images of the left knee failed to show a worsening of patellofemoral syndrome that would support the Veteran’s claim for an increased rating. Accordingly, an increased rating for pain and limitation of motion under Diagnostic Code 5099-5019 is denied. After reviewing other potentially relevant Diagnostic Codes regarding the Veteran’s left knee, the Board finds that the Veteran is entitled to 10 percent rating for recurrent lateral instability under Diagnostic Code 5257. Since the August 2010 VA examination, the Veteran has consistently reported instability of the left knee. Dr. Bash opined in April 2013 that the Veteran’s description of his knees is consistent with a 20 percent instability rating. The Board notes that Dr. Bash did not physically examine the Veteran. At each VA examination, the Veteran was found not to have instability of the left knee. However, the Veteran is competent to report having knee instability. See Jandreau, 492 F.3d at 1377. As the evidence demonstrates the Veteran experiences at least slight recurrent lateral instability, a 10 percent rating under Diagnostic Code 5257 is warranted. The Board has considered the remaining Diagnostic Codes for knees. 38 C.F.R. § 4.71a, DC 5256, 525 -5259, 5262-5263. However, there is no evidence of any ankylosis, episodes of locking and joint effusion, malunion/nonunion of the tibia and fibular, or genu recurvatum to warrant separate ratings for the left knee due to patellofemoral syndrome. Right Knee June 17, 2010 – January 27, 2016 The Board finds that based on a preponderance of the evidence, the Veteran is not entitled to a rating in excess of 10 percent for recurrent lateral instability due to right knee patellofemoral syndrome rated under Diagnostic Code 5257-5019 from June 17, 2010 through January 27, 2016. To receive a higher rating, the Veteran would have to demonstrate having moderate or severe lateral instability. Prior to January 28, 2016, the Veteran reported flare-ups caused by prolonged sitting, standing and walking that result in in symptoms including pain, instability, and locking. In December 2011, the Veteran experience right knee instability and that he wore a brace for pain relief. He reported to Dr. Bash in April 2013 that his right knee instability when on uneven surfaces. The Veteran was consistently noted to have normal strength, and no ankylosis upon examination of the right knee. Further, images of the right knee failed to show a worsening of patellofemoral syndrome that would support the Veteran’s claim for an increased rating. The Veteran has not been found to have moderate or severe instability of the right knee. Accordingly, an increased rating for recurrent lateral instability due to right knee patellofemoral syndrome rated under Diagnostic Code 5257-5019 from June 17, 2010 through January 27, 2016 is denied. January 28, 2016 - Present The Board finds that based on a preponderance of the evidence, the Veteran is not entitled to a compensable rating for lateral instability due to right knee patellofemoral syndrome rated under Diagnostic Code 5257-5019 since January 28, 2016. At the January 2016 VA examination, the Veteran reported having right knee pain with occasional locking and grinding, as well as flare-ups caused by increased activity. He did not report having any right knee instability. Accordingly, a compensable rating for recurrent lateral instability due to right knee patellofemoral syndrome rated under Diagnostic Code 5257-5019 from January 28, 2016 is denied. After reviewing other potentially relevant Diagnostic Codes regarding the Veteran’s right knee, the Board finds that the Veteran is entitled to a 10 percent rating for pain and noncompensable limitation of motion under Diagnostic Code 5099-5019. Since the August 2010 VA examination, the Veteran has consistently reported having pain and stiffness of the right knee. Additionally, at the April 2012 VA examination, the Veteran had right knee flexion only to 90 degrees. Based on the evidence, the Veteran is entitled to a 10 percent rating for pain and noncompensable limitation of motion due to right knee patellofemoral syndrome. The Board has considered the remaining Diagnostic Codes for knees. 38 C.F.R. § 4.71a, DC 5256, 525 -5259, 5262-5263. However, there is no evidence of any ankylosis, episodes of locking and joint effusion, malunion/nonunion of the tibia and fibular, or genu recurvatum to warrant separate ratings for the right knee due to patellofemoral syndrome. 3. Entitlement to a rating in excess of 10 percent for a right shoulder strain The Veteran contends he is entitled to a rating in excess of 10 percent for a right shoulder strain. In a September 2011 statement, the Veteran reported having pain, locking, limited movement, and popping of the right shoulder that interferes with his daily activities. His shoulder disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201-5019. The Veteran is right-handed and, therefore, his right shoulder is to be addressed as the major arm. Diagnostic Code 5019 compensates for bursitis, which is rated on limitation of motion for the affected extremity. See 38 C.F.R. § 4.71a, DC 5019. Diagnostic Code 5201 evaluates the right shoulder and arm based on limitation of motion. To warrant a rating in excess of 10 percent for a disability based on limitation of motion to the dominant shoulder, the evidence must show arm limitation of motion at shoulder level for a 20 percent rating, midway between side and shoulder level for a 30 percent rating, and to 25 degrees from side for a 40 percent rating. Standard range of motion of the shoulder is forward elevation (flexion) to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. The Veteran’s right shoulder was not found to be compensable under Diagnostic Code 5201, but a 10 percent rating was assigned for painful motion. See 38 C.F.R. § 4.59. At the August 2010 VA examination, the Veteran reported symptoms of pain and stiffness. The examiner stated the Veteran had normal range of motion, his shoulder condition had resolved, and that an X-ray of the right shoulder was unremarkable. The Veteran was afforded another VA examination in September 2011. He was diagnosed with a shoulder strain with subluxation. Symptoms included fatigue, pain, locking, popping, grinding, and repeated subluxations. The Veteran also reported having flare-ups. Range of motion testing revealed flexion and abduction to 170 degrees, with pain at 120 degrees. He exhibited additional range of motion limitation following repetitive use testing, and was noted to have functional impairment that would cause difficulty with repetitive reaching and motion of the right shoulder. Though there was localized pain on palpation of the right shoulder, there was no guarding or ankylosis. An X-ray of the right shoulder was unremarkable. VA medical records from December 2011 show the Veteran reported having occasional shoulder pain, but that he felt better due to working out regularly. At an April 2012 VA examination, the Veteran was diagnosed with a right shoulder strain. The Veteran reported having flare-ups and pain when lifting his arm above shoulder level. Upon examination, the Veteran had localized pain to palpation. Initial and repetitive range of motion testing showed flexion and abduction to 170 degrees without pain. The examiner noted that the Veteran had a history of infrequent episodes of recurrent dislocation, but he did not have any functional loss or impairment. The Veteran had normal muscle strength and no ankylosis. Imaging studies were negative for arthritis. The examiner concluded that the Veteran’s strain injury may improve with rest and physical therapy, and it may become aggravated with activity and overuse. In April 2013, Dr. Bash concluded that based on the Veteran’s reports, his shoulder elevation is 45 degrees from his side, he has decreased external and internal rotation, and he is unable to reach up, reach over his shoulder, or reach behind his back. At the Veteran’s most recent VA examination in January 2016, he exhibited normal range of motion during initial and repetitive use testing. The examiner stated the Veteran was not examined after repetitive use over time or during a flare-up, and therefore the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss. He noted, however, that the Veteran reported having flare-ups that limited his overhead reaching, and that he had a history of mechanical symptoms and infrequent episodes of instability. The Veteran’s muscle strength was normal, and there was no ankylosis. The Board finds that the preponderance of the evidence is against finding that a rating in excess of 10 percent is warranted for the Veteran’s right shoulder strain. At worst, the Veteran demonstrated flexion and abduction to 170 degrees at the September 2011 and April 2012 VA examination, with pain observed at 120 degrees at the September 2011 examination. Otherwise, his right shoulder had normal range of motion at all other VA examinations. Though Dr. Bash indicated the Veteran had decreased range of motion, this determination was based solely on reports from the Veteran rather than clinical findings from an examination. Based on the evidence of record, the right shoulder has never manifested limitation of motion to at least the shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board has considered the Veteran’s complaints of pain and reduced range of motion. The Veteran is competent to report pain and decreased mobility. See Jandreau, 492 F.3d at 1376. Specifically, the Veteran has stated that his right shoulder pain makes it difficult to reach above his head. However, these statements are consistent with the 10 percent rating assigned for the duration of the appellate period. The occurrence of shoulder pain while performing such activities is not an additional symptom, but rather the practical impact of the symptoms of pain and limited range of motion which have been clinically observed and measured at the Veteran’s VA examinations. To the extent that the Veteran contends his symptomatology is more severe than shown on evaluation, his statements must be weighed against the other evidence of record. The Board finds that the specific VA examination findings of trained health care professionals are of greater probative weight than the Veteran’s lay assertions. Additionally, the Board considered other potentially applicable diagnostic codes for rating the Veteran’s service-connected right shoulder strain. There is no indication that the Veteran had ankylosis of the scapulohumeral articulation, or loss of head of the humerus, nonunion, fibrous union, recurrent dislocation or malunion of the humerus for the right shoulder. Though the Veteran was noted to have a history of infrequent episodes of dislocation, it was not listed as a current condition at any of his VA examinations, and each of his crank apprehension and relocation tests were negative. Therefore, the provisions of Diagnostic Codes 5200 and 5202 are inapplicable. In sum, the Board finds that the preponderance of the evidence is against finding that a rating higher than 10 percent for a right shoulder strain is warranted, and the claim is denied. 4. Entitlement to a rating in excess of 10 percent for left elbow strain The Veteran contends he is entitled to a rating in excess of 10 percent for a left elbow strain for pain associated with noncompensable limitation of flexion, rated under Diagnostic Code 5206. As the Veteran is right-handed, his left elbow strain will be addressed as a minor arm. Under the rating schedule, normal forearm (elbow) extension and flexion is from 0 to 145 degrees. Normal forearm pronation and supination is from 0 to 80 degrees and from 0 to 85 degrees, respectively. 38 C.F.R. § 4.71, Plate I. Limitation of flexion of the forearm is evaluated pursuant to Diagnostic Code 5206 and provides a rating of zero percent for flexion limited to 110 degrees in the minor forearm; 10 percent for flexion limited to 100 degrees in the minor forearm; 20 percent for flexion limited to 90 degrees in the minor forearm; 20 percent for flexion limited to 70 degrees in the minor forearm; 30 percent for flexion limited to 55 degrees in the minor forearm; and 40 percent for flexion limited to 45 degrees in the minor forearm. 38 C.F.R. § 4.124a, Diagnostic Code 5206. Limitation of extension of the forearm is evaluated pursuant to Diagnostic Code 5207 and provides a rating of 10 percent for extension limited to 45 degrees; 10 percent for extension limited to 60 degrees; 20 percent for extension limited to 75 degrees; 20 percent for extension limited to 90 degrees; 30 percent for extension limited to 100 degrees; and 40 percent for extension limited to 110 degrees. 38 C.F.R. § 4.124a, Diagnostic Code 5207. At the August 2010 VA examination, the Veteran demonstrated left elbow flexion to 145 degrees, but was noted to have tenderness and pain on motion. He did not have ankylosis, flare-ups, or instability. An X-ray of the left elbow did not show acute osseous abnormality. The Veteran reported having left elbow flare-ups at the April 2012 VA examination. He stated flare-ups caused increased pain with repetitive motion. Upon examination, he demonstrated left elbow flexion to 145 degrees without pain. At the January 2016 VA examination, the Veteran demonstrated normal range of motion during initial and repetitive use testing. He exhibited no pain with weight-bearing, and had no functional loss following repetitive use testing. The Veteran was observed to have normal muscle strength, but localized tenderness was present. He also reported having flare-ups that cause throbbing pain and limit his lifting. The examiner stated that the Veteran was not examined during a flare-up or following repetitive use over time, and, therefore, the examination was neither medically consistent or inconsistent with the Veteran’s reports of functional loss. However, the examiner stated the functional impact of the left elbow strain may cause limited lifting. The Veteran did not have flail joint, joint fracture, or impairment of supination or pronation. The preponderance of the evidence is against a finding that a rating in excess of 10 percent is warranted for the Veteran’s left elbow strain. Throughout the appeal period, he has demonstrated full and normal range of motion of the left elbow. Thus, an increased rating under Diagnostic Codes 5206 or 5207 is not applicable. The Board has considered the Veteran’s complaints of pain and limited motion, and find he is competent to report pain and decreased mobility. See Jandreau, 492 F.3d at 1376. Specifically, the Veteran has stated that his left elbow strain causes pain when lifting. These statements are consistent with the 10 percent rating assigned for the duration of the appellate period. Finally, Diagnostic Codes 5209 through 5213 address upper extremity disabilities such as flail joints, nonunion, or malunion of the radius and ulna. These diagnostic codes are not applicable, as there is no evidence of record of these disabilities. The claim for a rating in excess of 10 percent for a left elbow strain is denied. 5. Entitlement to ratings in excess of 10 percent from June 17, 2010 to January 27, 2016, and compensable ratings from January 28, 2016, for left and right wrist strains The Veteran contends he is entitled to higher disability evaluations for wrist strains, rated under Diagnostic Code 5215. Disability ratings for the wrists are assigned pursuant to Diagnostic Codes 5214, ankylosis of the wrist, and 5215, limitation of motion of the wrist. 38 C.F.R. § 4.71a. The schedular rating criteria provide different disability ratings for wrist disorders depending on whether the wrist disorder impacts the dominant or nondominant wrist. Id. A normal range of motion in the wrist is dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. A limitation of motion of the wrist, whether the major or minor extremity, is rated 10 percent disabling when palmar flexion is limited to a position in line with the forearm, or when dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Favorable ankylosis in 20 degrees to 30 degrees dorsiflexion warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5214. Ankylosis of the wrist in any other position, except favorable, warrants a 30 percent rating for the minor extremity and a 40 percent rating for the major extremity. Unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation warrants a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. Extremely unfavorable ankylosis is rated on the basis of a loss of use of the hands. Id. The Veteran’s right wrist is dominant (major) and his left wrist is nondominant (minor). June 17, 2010 – January 27, 2016 The Veteran contends he is entitled to ratings in excess of 10 percent from June 17, 2010 through January 27, 2016 for right and left wrist strains. The Veteran was in receipt of the 10 percent ratings due to functional loss caused by painful motion pursuant to 38 C.F.R. §4.59. At the August 2010 VA examination, the Veteran reported having painful motion of both wrists. However, he demonstrated normal range of motion of both wrists, did not have ankylosis, and an X-ray showed no acute osseous abnormality. The examiner stated the Veteran’s wrist strains were resolved. The Veteran was diagnosed with bilateral wrist strains at the April 2012 VA examination. He reported having flare-ups of the wrists due to overuse, lifting, and writing. Initial and repetitive range of motion testing results were as follows: right wrist – palmar flexion to 35 degrees without pain; dorsiflexion to 55 degrees without pain; left wrist – palmar flexion to 40 degrees without pain; dorsiflexion to 35 degrees. The Veteran did not have any additional limitation following repetitive range of motion. He was noted to have localized tenderness of each wrist. Images did not show degenerative or traumatic arthritis. The Board finds the preponderance of the evidence is against finding that the Veteran is entitled to a rating in excess of 10 percent for bilateral wrist strains. Under Diagnostic Code 5215, 10 percent is the maximum rating available on the basis of limitation of motion. To warrant a higher rating for either wrist disability would require a finding that the Veteran’s wrists were ankylosed or immobile. No physician has found the Veteran’s wrists to be ankylosed at any time, nor has the Veteran sought clinical treatment for immobility of the wrists. Thus, a higher rating under Diagnostic Code 5214 is not applicable. The Board has considered the Veteran’s complaints of pain associated with his wrist strains. However, the 10 percent ratings the Veteran was awarded prior to January 28, 2016 accounted for the symptoms associated with his wrist strains and a higher rating cannot be granted. Thus, entitlement to ratings in excess of 10 percent for right and left wrist strains is denied. January 28, 2016 – Present The Veteran contends he is entitled to compensable ratings for right and left wrist strains from January 28, 2016. At the January 2016 VA examination, the Veteran denied having any wrist pain. He reported having flare-ups caused by use and that limit his lifting. Upon examination, the Veteran exhibited normal range of motion. As the Veteran demonstrated normal range of motion of both wrists, and did not report having any pain during his VA examination, the Board finds the Veteran is not entitled to compensable ratings for right and left wrist strains since January 28, 2016. The Veteran reported having wrist flare-ups at the January 2016 examination. However, the claims file does not contain any VA or private treatment notes since January 2016 documenting any complaints or treatment of the Veteran’s wrists. The Veteran has not demonstrated having either pain or limitation of motion to warrant a compensable rating for bilateral wrist strains since January 28, 2016. Accordingly, the claim for an increased evaluation is denied. 6. Entitlement to a rating in excess of 20 percent for a lumbar spine strain with intervertebral disc syndrome The Veteran contends he is entitled to a rating in excess of 20 percent for a lumbar spine strain with IVDS, rated under Diagnostic Code 5237-5243 Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, DC 5242. 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 normal combined range of motion of the thoracolumbar spine is 240 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. 38 C.F.R. 4.71a, Diagnostic Code 5242, Note (2). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent rating 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 assigned where forward flexion of the thoracolumbar spine is to 30 degrees or less, or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, while a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Additionally, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under the appropriate diagnostic codes. Id. at Note (1). At the August 2010 VA examination, the Veteran reported having constant moderate low back pain, mild daily stiffness, but no flare-ups. He was noted to have tenderness to palpation, but otherwise had normal range of motion, gait, and posture. He did not have ankylosis. The examiner concluded that the Veteran’s lumbar spine and IVDS conditions had resolved. In April 2012, the Veteran attended another VA examination, where he reported having back pain that causes flare-ups and occasionally requires the use of a brace. He stated that remaining in any position for more than 20 minutes caused increased pain and stiffness, and lifting more than 20 pounds was painful. A review of imaging studies showed no evidence of arthritis or a fracture. The examiner diagnosed a lumbar strain and IVDS. Upon examination, the Veteran had the following initial range of motion test results for the lumbar spine: flexion to 60 degrees; extension to 25 degrees; right lateral flexion to 30 degrees; left lateral flexion to 25 degrees; and right and left lateral rotation to 30 degrees. The same measurements were reported following repetitive range of motion testing, and the Veteran was not observed to have any objective evidence of painful motion. The Veteran reported having pain that radiates down to his buttocks and knees, but the examiner stated there was no evidence of radicular pain. He was not observed to have any guarding, and his muscle strength was normal. The examiner noted that the Veteran did not have any incapacitating episodes in the last 12 months due to IVDS. VA medical records from December 2011 show the Veteran reported having occasional back pain, but that he felt better due to working out regularly. At the Veteran’s January 2016 VA examination, the Veteran reported having constant low back pain. He stated he sees a chiropractor on a biweekly basis, and performs back strengthening exercises several days per week. Initial range of motion test results were as follows: flexion to 85 degrees; extension to 25 degrees; right and left lateral flexion to 25 degrees; right and left lateral rotation to 25 degrees. No pain was noted during the examination, and the Veteran did not have any additional functional loss following repetitive use range of motion testing. It was determined the Veteran had guarding or muscle spasm of the lumbar spine, but it did not result in an abnormal gait or spinal contour. The Veteran did not report having any radiating pain, nor was it noted during the examination. He did not have ankylosis of the spine, IVDS, or any other neurologic abnormalities. The January 2016 VA examiner stated that the examination did not occur during a flare-up or following repetitive use over time, and therefore the examination was neither consistent or inconsistent with the Veteran’s statements regarding functional loss. He went on to state that he could not say without mere speculation as to whether pain, weakness, fatigability, or incoordination significantly limit functional ability during flare-ups and following repetitive use due to lack of objective evidence. However, the examiner also stated that the Veteran’s lumbar strain may require periodic position changes, which is aligned with the Veteran’ report that flare-ups limit the duration of certain activities and movements. The Board finds that for the duration of the period on appeal, the Veteran was not entitled to a rating in excess of 20 percent for a lumbar strain with IVDS. To warrant a 40 percent rating, the Veteran would need to demonstrate either forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. At worst, the Veteran had forward flexion to 60 degrees at the April 2012 VA examination. Forward flexion improved to 85 degrees at the January 2016 VA examination. He was not found to have ankylosis of the spine. The Board has considered the Veteran’s reports of flare-ups, and has considered any additional functional limitation or pain due to flare-ups in accordance with 38 C.F.R. §§ 4.10, 4.40, 4.45, and Deluca. The Board finds additional symptomatology and impairment caused by flare-ups is contemplated by the 20 percent evaluation the Veteran currently receives. As noted above, the Veteran has actually experienced an improvement in his lumbar spine disability, consistent with the 10 percent rating under Diagnostic Code 5237. However, a 20 percent rating, but no higher, is appropriate for the Veteran’s lumbar strain disability based on his reports of painful motion and reduced range of motion during flare-ups. Though the Veteran was diagnosed with IVDS, the preponderance of the evidence is against a finding that would warrant a higher rating under Diagnostic Code 5243, as the Veteran has not had any incapacitating episodes. The Board has also considered whether the Veteran is entitled to additional ratings based on his reports of radiating pain. He is not currently service-connected for lower extremity radiculopathy. After a review of the record, the Board finds the Veteran is not entitled to additional ratings associated with lower extremity radiculopathy. The Veteran did not report having, nor did examiners find, radiculopathy of the lower extremities at the August 2010 or January 2016 VA examinations. At the April 2012 VA examination, the Veteran reported having lower back pain that radiated down his legs only due to prolonged sitting and standing. Following a physical examination, the examiner stated there was no radicular pain present. In April 2013, Dr. Bash stated that the Veteran has lower extremity numbness and tingling, and he has right foot drop. Dr. Bash concluded that these symptoms support a 20 percent rating for each lower extremity, as they are secondary to the Veteran’s service-connected lumbar spine disability. In the December 2016 brief, the Veteran’s representative contends that Dr. Bash determined the Veteran’s back disability altered his gait and caused foot drop. However, the Board notes again that Dr. Bash never physically examined the Veteran. There are no other treatment records in the file that indicate the Veteran complained of or was treated for lower extremity radiculopathy, an altered gait, or foot drop. Lastly, there has been no finding of any other related neurological conditions, such as associated bladder or bowel dysfunction. The claim for a rating in excess of 20 percent for a lumbar strain must be denied. 7. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) The Veteran contends he is entitled to an increased rating for GERD, currently evaluated at 10 percent under Diagnostic Code 7399-7346. Diagnostic Code 7399 refers to disabilities of the digestive system, while Diagnostic Code 7346 refers to hiatal hernia. GERD is not listed in the rating schedule. The use of the hyphenated Diagnostic Code 7399-7346 is appropriate as the Veteran’s GERD symptoms are more closely captured by those listed under 7346. Pursuant to Diagnostic Code 7346, a 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A rating of 10 percent is assigned when two or more of the symptoms for the 30 percent evaluation are present with less severity. VA treatment notes show the Veteran had a gastroenterology consultation in March 2011. He was diagnosed with pyrosis and regurgitation. The physician noted that the Veteran had a good response to Omeprazole as treatment for pyrosis and nocturnal regurgitation. An esophageal endoscopy report from April 2011 shows the Veteran’s gastroesophageal junction, stomach, and duodenum were all normal. At an April 2012 VA examination, the Veteran was diagnosed with GERD. His symptoms were reflux, recurrent nausea and mild vomiting. The examiner noted that the Veteran took continuous medication for treatment. In January 2016, the Veteran attended another VA examination. He was again noted to have a diagnosis of GERD. The Veteran reported that he had changed his diet, and elevated his bed to avoid reflux. His symptoms were pyrosis, reflux, regurgitation, substernal pain, and sleep disturbance. He stated that his symptoms recurred four or more times per year for a duration of less than one day. At the time, the Veteran required continuous medication to treat his symptoms. The Board finds that the preponderance of the evidence is against a finding that the Veteran is entitled to a rating in excess of 10 percent for GERD. The Veteran’s GERD has manifested has two or more symptoms listed under the 30 percent rating for Diagnostic Code 7346, thus meeting the 10 percent ratings requirement. To warrant a 30 percent rating, the Veteran’s symptoms would have to be accompanied by persistently recurrent epigastric distress and substernal, arm, or shoulder pain causing considerable impairment of health. At no point has the Veteran been assessed to have persistently recurrent epigastric distress. He reported that his symptoms occur four or more times per year, lasting for less than one day. Additionally, the Veteran’s GERD has not manifested as pain, vomiting, weight loss, hematemesis, melena with moderate anemia, or any other symptom combination causing severe impairment of health to warrant a 60 percent rating. Given these facts, the Board finds that a 10 percent rating adequately reflects the Veteran’s GERD disability, and the claim for an increased evaluation is denied. REASONS FOR REMAND 1. Entitlement to a compensable evaluation for left ear hearing loss is remanded. The results from the Veteran’s most recent VA audiology examination were not included in the examination report. Remand is required to obtain a new VA examination. The matter is REMANDED for the following action: 1. Obtain all outstanding treatment records related to the Veteran’s left ear hearing loss from any government or non-government medical provider and associate them with the claims file. 2. After any additional evidence is associated with the claims file, schedule the Veteran for a VA examination to determine the current severity of his left ear hearing loss. The claims file, to include a copy of this remand, must be made available to the examiner for review. The examination report should reflect that such a review was accomplished. The examiner should elicit a complete history from the Veteran. All appropriate tests, studies, and consultation, should be accomplished and all clinical findings should be reported in detail. Specifically, as to any reported worsening, the examiner must provide a complete explanation as to findings. 3. The examiner’s attention is drawn to the following: (a.) August 2010 VA Examination Report – Veteran noted to have mild sensorineural hearing loss in the left ear (b.) April 2012 VA Examination Report – Veteran noted to have sensorineural hearing loss in the left ear (c.) January 2016 VA Examination Report – Examiner did not report audiometric examination results, as he believed they were unreliable 4. After completion of the above and any other appropriate development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Miller, Associate Counsel