Citation Nr: 1307401 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 10-29 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a bilateral hip disability. 2. Entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine. ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from February 2004 to August 2008. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. Jurisdiction over the Veteran's claims file was subsequently transferred to the Denver, Colorado RO. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran's bilateral hip disability began during active service, was chronic during active service, and has been continuous since service separation. 2. Throughout the initial rating period on appeal, the Veteran's lumbar spine disability has been manifested by forward flexion to no less than 40 degrees, accounting for pain on motion and after repetition; no ankylosis; and no incapacitating episodes. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a bilateral hip disability have been met. 38 U.S.C.A. §§ 1101, 1110, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for an initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine have not been met for any period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243, 5003 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for a Bilateral Hip Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that he has a current bilateral hip disability that began during active service. After a review of all the evidence of record, lay and medical, the Board finds that the evidence is in equipoise on the question of whether a bilateral hip disability was chronic during active service. Service treatment records show that the Veteran had both back and bilateral hip pain during service that was often intertwined or associated as one disability. However, the Board finds that the evidence is at least in equipoise as to whether the Veteran had a separate bilateral hip disability during active service that was separate and distinct from his back disability. In December 2004, the Veteran reported seven months of low back pain that radiated down the right buttock and right leg. Examination and treatment was focused on the back, and the doctor assessed mechanical low back pain. An X-ray showed mild discogenic end-plate changes at L5-S1. In March 2005, the Veteran continued to report right buttock pain, and, on this occasion, the doctor assessed sacroiliitis as well as low back pain. In April 2005, the Veteran reported an ache in the right sacroiliac area, and there was tenderness over both sacroiliac joints. A steroid injection was administered into the right sacroiliac joint. In June 2005, the Veteran reported sacroiliac pain on the left side, as well. In October 2005, an MRI of the lumbar spine revealed a herniated disc at L5-S1 with a disc annular tear. A neurosurgeon opined that the Veteran's back pain was generated from the waxing and waning of the inflammatory component of this problem. In other words, the doctor assessed discogenic low back pain secondary to L5-S1 degenerative disc disease with mild herniation and a small disc annular tear. In January 2008, an MRI continued to show a disc herniation at L5-S1, as well as bilateral asymmetric sacroiliitis (demonstrated by bilateral sclerosis, multiple erosions, and inflammatory changes of the sacroiliac joints, right greater than left). It was noted that the sacroiliitis was most consistent with Reiters Disease or psoriatic arthritis, but was also seen with ankylosing spondylitis, inflammatory bowel disease, and, less likely, rheumatoid arthritis. In May 2008, the Veteran reported a four year history of pain in the bilateral sacroiliac and buttock regions. He stated that it started when he worked as a dental assistant and spent a lot of time bent over. It was noted that past treatment had focused on the L5-S1 herniated disc as the cause of the Veteran's pain, but he had not experienced relief in the sacroiliac region. The doctor, after reviewing the January 2008 MRI study, assessed sacroiliitis with clinical, radiologic, and laboratory evidence of spondyloarthritis. The doctor further noted that the presence of psoriatic lesions made psoriatic arthritis a possibility, but that ankylosing spondylitis was still possible as well. The Veteran was started on Humira. The June 2008 separation examination report lists diagnoses of sacroiliitis, ankylosing spondylitis, and psoriatic arthritis. The Veteran was afforded a VA examination in June 2008, two months prior to service separation. The VA examiner noted that the Veteran's back, bilateral hip, and buttock pain started around the same time in 2004 as a result of constant bending at work. The examiner further attributed both the bilateral hip and sacroiliac joint pain to severe, bilateral sacroiliitis, noting that the sacroiliitis had progressed to a diagnosis of ankylosing spondylitis. With regard to the Veteran's low back pain, the VA examiner attributed it to both the sacroiliitis and degenerative disc disease of the lumbar spine. The Board finds that the evidence is at least in equipoise on the question of whether the Veteran had chronic symptoms of a bilateral hip disability during active service that was separate and distinct from his already service-connected back disability. Specifically, the Board finds that the bilateral hip pain in service was a manifestation of his sacroiliitis (which progressed to ankylosing spondylitis), diagnosed during service, and that this pain was separate from, and not related to, the low back pain, diagnosed as a herniated disc at L5-S1 and degenerative disc disease of the lumbar spine. Moreover, the Board finds that the evidence is at least in relative equipoise on the question of whether a bilateral hip disability has been continuous since service separation in August 2008. Post-service VA treatment records show ongoing treatment for ankylosing spondylitis, with recurring complaints of bilateral hip pain. For instance, in September 2009, the Veteran reported that he had taken Humira for one year with a good response. However, he stopped taking the medication on his own several months prior, and his symptoms of severe low back, hip, and buttock pain and stiffness recurred. A February 2012 VA treatment note indicates bilateral sacroiliac and hip stiffness. The Veteran is competent to report a bilateral hip disability during active service and since service separation, and the Board finds the statements of the Veteran as to a chronic bilateral hip disability during active service and continuity of a bilateral hip disability since service separation to be credible. Resolving reasonable doubt in the Veteran's favor on these questions, the Board finds that a bilateral hip disability, diagnosed as sacroiliitis and ankylosing spondylitis, was chronic during active service and has been continuous since service separation in August 2008. In light of the documentation of an in-service bilateral hip disability separate and distinct from the service-connected back disability, and documentation of a continuous bilateral hip disability (sacroiliitis/ankylosing spondylitis) since service separation, with the resolution of reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for a bilateral hip disability are met. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The nature and extent of this problem is not before the Board at this time. Lumbar Spine Disability Rating Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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 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. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating 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 provided 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 disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2) (See also Plate V) provides that, 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 normal combined range-of-motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range-of-motion. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range-of-motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range-of-motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range-of-motion is normal for that individual will be accepted. Note (4) instructs to round each range-of-motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a. The Diagnostic Codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also DC 5003); 5243 Intervertebral disc syndrome. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (effective September 26, 2003) provides a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range-of-motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. 38 C.F.R. § 4.59. As above, in rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson, 7 Vet. App. at 39-40; Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469; see also Cartright, 2 Vet. App. at 25 ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno; 38 C.F.R. § 3.159(a)(2). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales, 218 F.3d at 1380-81; Timberlake, 14 Vet. App. at 128-30. In this case, the Veteran is in receipt of a 20 percent rating for service-connected degenerative disc disease of the lumbar spine for the entire initial rating period on appeal, under the provisions of 38 C.F.R. § 4.71a, DC 5236. He contends that his lumbar spine disability warrants a higher initial rating. Specifically, he avers that, during active service, he began the process of obtaining a medical discharge due to his back pain, but was told he would have to stay in active service for two additional years. Consequently, he contends that he was assured that he would be given a high rating upon separation from service. After a review of all the evidence, lay and medical, in this Veteran's case, the Board finds that a preponderance of the evidence is against the claim for an initial evaluation in excess of 20 percent for service-connected degenerative disc disease of the lumbar spine for the entire initial rating period on appeal. For the entire rating period, even with consideration of additional limitations of motion and function due to pain and other limiting factors, the Veteran's service-connected lumbar spine disability did not manifest forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine, as required for an evaluation in excess of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine, or incapacitating episodes of intervertebral disc syndrome of at least 4 weeks in duration, for an evaluation in excess of 20 percent under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. As noted above, the Veteran was afforded a VA examination prior to service separation in June 2008. On physical examination, there was no tenderness on palpation. Active lumbar flexion was to 40 degrees, extension was to 10 degrees, right lateral flexion was to 18 degrees, left lateral flexion was to 24 degrees, and bilateral rotation was to 30 degrees on each side. Taking Deluca factors into account, flexion remained at 40 degrees (with pain limiting further range of motion at a level of 8 out of 10), extension was to 12 degrees (with pain limiting further range of motion at 7 out of 10), and the remaining range of motion measurements remained the same, with pain limiting lateral flexion bilaterally at a level of 7 out of 10. Repeated movement did not reduce range of motion but caused subjective pain. Posture and gait were normal. There was no kyphosis, lordosis, or significant scoliosis. The Veteran reported that he had taken a number of pain medications and completed a physical therapy program with no relief. He denied pain, paresthesias, and weakness in the lower extremities, providing evidence against this claim. A June 2008 Medical Board report indicates the Veteran had back pain at a level of 5 out of 10 in severity, and that Naproxen was not controlling his pain at all. The Medical Board reviewed his records, noting that the Veteran's pain had ranged from a level of 5 to 10 out of 10 in severity over the last four years. Notably, much of the Medical Board report focused on the sacroiliitis and ankylosing spondylitis diagnoses rather than the degenerative disc disease. A December 2008 VA treatment note indicates the Veteran had experienced symptom relief after starting to take Humira four months prior. However, in January 2009, he reported a major worsening of symptoms, stating that, on the tenth or eleventh day after a Humira injection, he experienced the onset of night pain that lasted throughout the next day. He stated that the pain could be excruciating, and that even deep breathing could exacerbate the lower back pain. He further stated that he could barely move at times. The doctor noted the diagnosis of ankylosing spondylitis in relation to these symptoms, however, and did not mention the degenerative disc disease of the lumbar spine. In July 2009, the Veteran reported that he discontinued Humira two months prior, and that he was feeling well with minimal pain and good range of motion. He stated that he was working as a golf instructor. However, two months later, in September 2009, the Veteran stated that his symptoms had worsened, were debilitating, and that he had quit his job as a result. He requested to restart Humira. The doctor noted that examination findings were consistent with sacroiliitis and showed limited range of motion of the lumbar spine (specifically, decreased lateral rotation). The doctor further noted that the degree of subjective pain was somewhat inconsistent with examination findings, which only provides some evidence that does not support the Veteran's contentions. In October 2009, the Veteran had been taking Humira every ten days, although he still reported morning stiffness and night pain. He also stated that he felt as if he were addicted to pain medications, and admitted that he had been exaggerating reports of symptoms to doctors in order to get Vicodin and Percocet. He said he had also obtained pain medications from Mexico. The VA clinician noted lumbar lordosis, but no sacroiliac tenderness on direct palpation. Finger to floor distance was two inches (indicating good range of motion). In March 2010, the Veteran reported intermittent low back pain secondary to ankylosing spondylitis. He stated his pain was a level of zero out of ten, but increased at the end of his two-week Humira dosing intervals, and sometimes reached a level of ten out of ten. A May 2010 VA treatment note indicates normal spinal curvature, and intact active range of motion. The paraspinal muscle was without tenderness or rigidity. Straight leg raising was negative at 90 degrees. A June 2010 VA treatment note indicates very minimal morning stiffness and no pain, providing more evidence against this claim. Based upon these findings and the lay evidence of record, the Board finds the assignment of an initial rating in excess of 20 percent for a lumbar spine disability is not warranted for any period, as the requirements of forward flexion of the thoracolumbar spine 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of intervertebral disc syndrome of at least 4 weeks in duration, have not been met or more nearly approximated at any time during the rating period on appeal. 38 C.F.R. § 4.71a, DCs 5235-5243. Ankylosis, either favorable or unfavorable, is not demonstrated by the evidence. In addition, flexion, at worst, has been limited to 40 degrees, even with pain and following repetition. In reaching its finding that the evidence did not show flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine for any period, the Board has considered any additional functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint in determining that a rating in excess of 20 percent is not warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. Here, the Board notes the subjective evidence of pain on range of motion testing at the June 2008 VA examination, the Veteran's report that his pain sometimes reached a level of 10 out of 10 in severity, and has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). In this case, the June 2008 VA examiner noted subjective evidence of pain on active range of motion testing, but that function and motion were not additionally limited after repetition; thus, even if the pain on flexion is taken into consideration, the range of motion measurements still do not meet the criteria for the next higher rating category. Indeed, the flexion measurement of 40 degrees recorded at the June 2008 VA examination following repetition is well within the range of motion criteria for the currently assigned 20 percent rating. Moreover, when the Veteran reported pain to the Medical Board in June 2008 and to the VA clinician in December 2008, the focus was on his sacroiliitis and not his degenerative disc disease of the lumbar spine. Finally, the Board must unfortunately note that in October 2009, the Veteran admitted that he had been exaggerating his pain in order to obtain prescriptions for pain medications, which only provides evidence against this claim. The specific clinical measures of ranges of motion, including examiner's findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's statement that his pain sometimes reached a level of 10 out of 10 in severity. Thus, the overall evidence does not show that pain or other factors have resulted in additional functional limitation or limitation of motion (flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine) such as to enable a finding that the disability picture more nearly approximates the next-higher, 40 percent, evaluation under the General Rating Formula for Diseases and Injuries of the Spine. While the Board understands the Veteran's central concern that he has a debilitating back disability, it is important for the Veteran to understand that a 20 percent evaluation indicates a significant impact on the Veteran's functional ability. Such a disability evaluation by VA recognizes the Veteran's painful limited motion, indicating generally a twenty percent reduction in the Veteran's ability to function due to his back pain. The critical question in this case, however, is whether the problems the Veteran has believably cited meet the next highest level under the rating criteria. For reasons cited above, they do not, at this time. Without taking into consideration the problems associated with this disability, the current evaluation could not be justified, let alone a higher evaluation. As discussed above, the criteria for the currently-assigned 20 percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine is 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. Thus, based on the above findings, the preponderance of the evidence demonstrates the criteria for an initial evaluation higher than 20 percent are not met, as range of motion findings, even after repetition, do not meet the criteria for the next-higher, 40 percent, rating category - flexion to 30 degrees or less - even when taking into account additional loss of motion due to DeLuca factors. Even with such factors, the evidence does not show either favorable or unfavorable ankylosis of the thoracolumbar spine. For these reasons, the Board finds that an initial disability rating in excess of 20 percent is not warranted for any period. Next, the Board has considered whether an initial rating in excess of 20 percent is warranted under Diagnostic Code 5243 based on incapacitating episodes. As previously mentioned, Diagnostic Code 5243 deals with IVDS, which can include degenerative disc disease. However, in order to meet the criteria for a compensable rating under this diagnostic code, the evidence must show that a physician ordered bed rest to treat the disorder. In this case, in July 2009, the Veteran reported that he had to quit his job due to the severity of his symptoms; however, the clinician noted that examination findings were consistent with sacroiliitis, not the lumbar degenerative disc disease. Moreover, there are no physician's orders or other evidence in the claims file that the Veteran's doctors prescribed bed rest; therefore, he does not meet the criteria for a higher rating under DC 5243. The Board has also considered whether any alternate diagnostic codes might serve as a basis for an increased rating. In this regard, the RO rated the Veteran's back disability under Diagnostic Code 5236, which addresses sacroiliac injury and weakness. Disabilities evaluated under this code are evaluated under the General Rating Formula for Diseases and Injuries of the Spine, as discussed above. However, Diagnostic Code 5242, which addresses degenerative arthritis of the spine, is related to DC 5003, which also addresses degenerative arthritis. In this case, the maximum evaluation possible under DC 5003 is 10 percent, as only one major joint or group of minor joints is involved in this claim. Thus, it does not allow for a higher evaluation. There are no other applicable codes available for consideration. The Board has also contemplated whether any separate evaluations are applicable here for additional disability or neurological disorders associated with the service-connected back disability. However, the Veteran has denied any paresthesias, weakness, or other neurological symptoms in his lower extremities, and neurological examination has been negative. Moreover, there have been no other reports of other disabilities associated with the back disability. For these reasons, the Board finds that the weight of the evidence is against a finding of an initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine for any period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In addition to the foregoing, the Board has considered whether referral for an extraschedular evaluation is warranted for the Veteran's lumbar spine disability. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's lumbar spine disability has manifested in arthritis, disc disease, and painful movement. The schedular criteria for rating the lumbar spine disability (General Rating Formula for Diseases and Injuries of the Spine) specifically provide for ratings based on the presence of painful arthritis; limitations of motion of the spine (including due to pain and other orthopedic factors; see 38 C.F.R. §§ 4.40 , 4.45, 4.59; see also DeLuca); other clinical findings such as muscle spasm, guarding, abnormal gait, and abnormal spinal contours; and on the basis of incapacitating episodes. In this case, comparing the Veteran's disability level and symptomatology of the lumbar spine to the rating schedule, the degree of disability of the lumbar spine throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the lumbar spine disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Because the current appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for a back disability, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). The Board finds that all necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A. VA has obtained service treatment records, private treatment records, VA treatment records, and other records identified by the Veteran. The Veteran has been afforded an adequate examination on the issue of rating the back disability. VA provided the Veteran with an examination in June 2008. The Veteran's history was taken, and complete examinations with clinical measures were conducted, to include review of an MRI study. Conclusions reached and diagnoses given were consistent with the examination report, including notation of whether there were additional losses of ranges of motion due to factors such as painful motion and flare-ups. Therefore, the Veteran has been afforded an adequate examination on the issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a bilateral hip disability is granted. An initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs