Citation Nr: 1315258 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 09-46 572 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUES 1. Entitlement to service connection for a bilateral foot disorder. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an initial evaluation in excess of 20 percent for chronic low back strain. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from September 1984 to March 1989. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Wilmington, Delaware (RO). In the December 2007 rating decision, the RO denied service connection for a psychiatric disorder. The Veteran perfected appeals with respect to this issue. However, in a March 2013 rating decision, the RO granted service connection for generalized anxiety disorder. As this represents a total grant of benefit sought on appeal with respect to the Veteran's claim of entitlement to service connection for a psychiatric disorder, this issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). The issue of service connection for a bilateral foot disorder is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. Tinnitus was not incurred during service and is not etiologically related to active duty service, to include exposure to noise. 2. The evidence of record does not show that the Veteran's service-connected low back disability is primarily manifested by forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; the evidence of record also does not show that that the Veteran experienced any incapacitating episodes having a total duration of at least four weeks but less than six weeks due to her low back disability. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial disability rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the RO of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The Veteran's claim of entitlement to an increased rating for her low back disability arises from her disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. As for the tinnitus claim, the RO's May 2007 letter advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). This letter also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman, 19 Vet. App. at 486. Accordingly, with this letter, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. VA also has a duty to assist a Veteran in the development of her claims. This duty includes assisting her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained available service treatment records and identified VA and private treatment records. The Veteran also submitted written statements discussing her contentions and provided testimony at her hearing before the Board. Most recently, the claims were remanded so that the Veteran could be afforded VA examinations. The Board finds the VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claims. As for the tinnitus claim, the January 2012 and February 2013 VA examiners considered all of the pertinent evidence of record, to include service and post-military treatment records, and the statements of the Veteran, and provided a complete rationale for the opinions stated. Regarding the low back disability claim, the October 2007, January 2012, March 2012, and January 2013 VA examiners personally interviewed and examined the Veteran, including eliciting a history from her, and provided the information necessary to evaluate her service-connected disability under the applicable rating criteria. Additionally, there is also no objective evidence indicating that there has been a material change in the severity of the Veteran's low back disability since the most recent January 2013 VA examination. As the Veteran has been provided with adequate examinations with respect to her claims, the RO has substantially complied with the December 2012 remand directives. See D'Aires v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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). Service Connection for Tinnitus Service connection may be granted for disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence 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. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113 (West 2002); 38 C.F.R. § 3.303(d). Service connection for certain disabilities, including organic diseases of the nervous system, may be granted on a presumptive basis if manifested to a compensable degree within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Turning to the merits of the claim, the Veteran asserts that service connection is warranted for tinnitus due to in-service noise exposure. During the April 2011 Board hearing, the Veteran testified that she was primarily exposed to noise from aircrafts because her military duties required her to assist with events/meals for troops on the flight light. She also reported noise exposure from firing weapons on the shooting range with the benefit of hearing protection. The Veteran essentially claims that her tinnitus began during service and has continued following her discharge. The claims file includes the Veteran's DD 214, which reflects her military occupational specialties as a personnel programs officer, and morale, welfare, and recreation operations officer. The Veteran's service treatment records have been reviewed and are negative for reports or findings related to tinnitus. On an August 1988 report of medical history, the Veteran denied having any ear, nose, or throat trouble. There is no indication from these records that the Veteran's hearing was routinely monitored due to any in-service noise exposure. Post-military VA treatment records reflect the earliest evidence of reported tinnitus in February 2004. The Veteran reported having been exposed to loud sounds, but she did not specifically identify the source of this exposure. She reported that she had experienced tinnitus in each ear, but she stated that her tinnitus was now gone. The examiner noted that the audiologic examination revealed normal hearing thresholds and speech recognition. A February 2011 VA audiology consultation report documents her report of difficulty hearing for approximately six months; she made no reports of having tinnitus. She reported that she worked at an Air Force base, but indicated that this was not in high-noise areas. She also reported that she was exposed to loud noise from target shooting with various weapons for approximately two years. She stated that she was always provided hearing protection while on the range. The audiometric examination revealed hearing sensitivity within normal limits. The Veteran underwent a VA audiological examination in January 2012 to assess the etiology of her claimed tinnitus disorder. She reported experiencing occasional pulsating tinnitus in both ears for the past twenty years. Following the examination, the examiner opined that the Veteran's tinnitus was "less likely than not" caused by or a result of noise exposure. The examiner noted that an August 1988 in-service audiogram showed that her hearing sensitivity was within normal limits, bilaterally. While the examiner acknowledged the Veteran's report of frequent exposure to noise from aircrafts flying overhead, the examiner concluded that there was no significant effect on the Veteran's hearing. Regarding her hearing, the examiner noted the Veteran's report of fluctuating hearing levels, which the examiner stated was not consistent with long term exposure the loud noise. Additionally, the examiner noted that the Veteran's current audiogram showed a flat configuration, which was not usually associated with exposure to loud noise. As directed by the December 2012 Remand, the Veteran underwent an additional VA examination in February 2013 to assess the etiology her tinnitus disorder. On an associated audiologic history report, the Veteran describing having ringing in her ears and a sensation that her ears were plugged or blocked. She also reportedly experienced dizziness or balance problems, which she identified as " trip at [the] knees." The audiometric examination revealed normal hearing in both ears. Based on the examination results and a review of the claims file, the examiner rendered a diagnosis of tinnitus and opined that the disorder was "less likely than not" caused by or a result of military noise exposure. As the rationale for this opinion, the examiner highlighted that there were no significant noise hazards during military service. The examiner also highlighted that the Veteran's discharge audiogram was normal, bilaterally. Having carefully reviewed the evidence of record, the Board finds that the evidence weighs against the Veteran's claim for service connection for tinnitus. While the medical evidence shows a current diagnosis of tinnitus, such medical evidence does not demonstrate that the claimed disorder is etiologically related to the Veteran's period of active service. In this regard, the Veteran's service treatment records are negative for a report of ringing in the ears or a diagnosis of tinnitus. Indeed, the Veteran denied having any ear problems on the August 1988 report of medical history. Moreover, no examiner has attributed her current tinnitus to her military service, even with consideration of her claimed in-service noise exposure and onset of tinnitus. The Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1995). The only medical evidence of record assessing the relationship between the Veteran's current tinnitus and service are the January 2012 and January 2013 VA examiners' opinions. Even considering the Veteran's report of in-service noise exposure and continuing tinnitus symptomatology, and based on a review of the claims file and clinical examination of the Veteran, both examiners provide opinions against the claim for service connection. The Board finds the VA medical opinions to be highly probative and compelling evidence against the Veteran's claim that her tinnitus disorder is related to her military service. See Nieves-Rodriguez, 22 Vet. App. 295, 299- 301 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran has not provided any competent medical evidence to rebut the opinions against her claim or otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). In reaching this determination, the Board emphasizes that it has considered the Veteran's lay statements that her current tinnitus is related to and began during her military service. She is competent make such a report, as tinnitus is a disorder for which lay statements may be competent to establish medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran first reported having tinnitus in February 2004. Later, in February 2011, she did not report having tinnitus, but instead only reported having difficulty hearing for approximately six months. She reported a twenty year history of occasional tinnitus during the January 2012 VA examination; this would place the onset of her disorder as approximately 1992, years following her discharge from service. Accordingly, although the Veteran's statements may be competent evidence as to the date of the onset of her currently diagnosed tinnitus, the Board does not find the Veteran's statements of continued tinnitus symptomatology since service to be credible evidence, due to the inconsistency of the statements. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that credibility may be impeached by a showing of inconsistent statements, consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Thus, her statements of continued tinnitus since service do not support the grant of service connection for the claimed disorder. The Board acknowledges that the Veteran attributes her tinnitus disorder to in-service noise exposure. Her statements as to what is observable, in this case noise exposure, are competent evidence of such. As exposure to noise, at least to some extent, is consistent with her military service, these statements are credible. However, the Veteran's statements that the noise exposure she experienced in service caused her current tinnitus disorder are not competent evidence to establish service connection. Whether the Veteran's current tinnitus is related to or was caused by her military service does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge. See Jandreau, 492 F.3d at 1376-77; see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). It is not shown that the Veteran possesses the ability, knowledge, or experience to provide a competent etiological opinion that these disorders are the result of her military service. See Jandreau, 492 F.3d at 1376-77; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the Veteran's lay statements as to medical causation are not competent evidence to establish service connection for a bilateral hearing disorder and tinnitus. Id. In summary, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for tinnitus. Because the evidence preponderates against the claim, the benefit-of-the-doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Initial Increased Rating for Low Back Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Although all the evidence has been reviewed, only the most salient and relevant evidence is set forth below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). The Veteran contends that her low back disability is more severe than what is reflected by the initially assigned 20 percent disability rating. The RO granted service connection for the low back disability in the December 2007 rating decision and assigned an initial 20 percent disability effective from March 16, 2007. Thereafter, the Veteran perfected an appeal as to the initial rating assigned for her disability, which is the claim currently on appeal. Throughout the appeal, the low back disability has been rated under Diagnostic Code 5237, which pertains to a lumbosacral strain. See 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Rating Schedule indicates that disabilities of the spine under Diagnostic Codes 5235 to 5243 are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Diagnostic Code 5237 is used for the evaluation of a lumbosacral strain. 38 C.F.R. § 4.71a. The General Rating Formula assigns evaluations with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of the injury or disease. A 20 percent evaluation is for assignment when there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees, or with a combined range of motion 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. 38 C.F.R. § 4.71a, General Rating Formula. A 40 percent evaluation is for assignment when forward flexion of the thoracolumbar spine is 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is for assignment upon a showing of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). 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. 38 C.F.R. § 4.71a, General Rating Formula, Note (2). 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. Id. Another diagnostic code that is also considered in this case is Diagnostic Code 5243 for intervertebral disc syndrome. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Under Diagnostic Code 5243, intervertebral disc syndrome is evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based upon Incapacitating Episodes, whichever results in the higher rating. Id. The Formula for Rating Intervertebral Disc Syndrome Based upon Incapacitating Episodes provides for a 20 percent evaluation was assigned for incapacitating episodes having a total duration of at least two weeks, but less than four weeks during the past twelve months; a 40 percent evaluation was assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past twelve months; and a 60 percent evaluation was assigned for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based upon Incapacitating Episodes, Diagnostic Code 5243. An incapacitating episode as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based upon Incapacitating Episodes, Note (1). Separate evaluations are warranted if intervertebral disc syndrome is present in more than one spinal segment if the effects are distinct. Id. at Note (2). Moreover, degenerative arthritis, established by x-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. An October 2007 VA examination report documents the Veteran's report of achiness and stiffness affecting her back. She stated that her symptoms began in service during her pregnancy. The Veteran was independent with her daily activities, and she did not use any assistive devices. She reportedly exercised in an attempt to maintain her flexibility and mobility. The physical examination revealed lower back flexion from zero to 50 degrees; extension from zero to 15 degrees; and lateral rotation to 25 degrees, bilaterally. Three repetitions of the low back range of motion were painless, with the exception of pain that began at the end of the range of motion. The examiner noted that there was no additional loss of range of motion due to pain, fatigue, weakness, or incoordination. The neurological examination was normal, and there was no evidence of atrophy. The Veteran denied that she was bedridden during the previous twelve months due to her service-connected back disorder. The examination revealed a diagnosis of chronic lower back sprain/strain. At the time of the examination, she reported that she was employed as an university recruiter. During the April 2011 Board hearing, the Veteran testified that she experienced limited mobility due to her service-connected low back disability. She stated that she was unable to go to work on multiple occasions due to her low back, and she she had to sit behind her desk because of back pain. The Veteran reported that she wore a weight belt due to her condition and that she experienced back spasms. A January 2012 VA examination report reflects an additional assessment of the Veteran's low back disability. The Veteran described having daily back pain that increased with exertion. Her pain radiated down to her feet. She reported having flare ups of her symptomatology, which she described as increased back pain and spasms. On the physical examination, there was no evidence of tenderness, guarding, or muscle spasm. Range of motion testing of the thoracolumbar spine revealed flexion to 40 degrees, with pain beginning at 20 degrees, and extension to 15 degrees, with pain beginning at 10 degrees. Right and left lateral flexion and rotation was to 15 degrees, with pain beginning at 10 degrees. The Veteran performed repetitive use testing and demonstrated flexion to 40 degrees, extension to 15 degrees, right and left lateral rotation to 15 degrees, and right and left lateral flexion to 15 degrees. There was no additional limitation in the Veteran's thoracolumbar range of motion following repetitive use testing. The examiner determined that there was no function loss or functional impairment of the thoracolumbar spine. The muscle strength, reflex, and sensory examinations of the bilateral lower extremities were normal. Imaging studies of the thoracolumbar spine revealed arthritis. The examiner did not directly address the Veteran's report of pain radiating down to her feet and instead determined that there was no signs or symptoms of radiculopathy or signs of neurologic abnormalities related to the thoracolumbar spine. The examiner also determined that Veteran did not have intervertebral disc syndrome. The examiner opined that the Veteran's low back disability did not impact her ability to work. Based on the clinical findings, the examiner provided a diagnosis of lumbar spine strain and lumbar spine degenerative joint disease. In March 2012, the Veteran underwent an additional VA examination for her low back disability. The physical examination revealed flexion to 60 degrees, with pain from 45 degrees; extension to 15 degrees, with pain from 10 degrees; right and left lateral flexion to 15 degrees, with pain form 10 degrees; and right and left lateral rotation to 20 degrees, with pain from 15 degrees. Motor strength of the bilateral lower extremities was 5/5. Sensation of the bilateral lower extremities was intact, and there was no muscle atrophy. The VA examiner identified the Veteran's disability as degenerative joint disease of the lumbar spine. The examiner opined that the Veteran was able to do light duty work and should be allowed to frequently change positions. Her standing tolerance was one hour, and her walking tolerance was one mile/twenty-five minutes. The examiner stated that the Veteran was able to do occasional lifting of up to thirty pounds, but no heavy lifting or repetitive bending. As directed by the December 2012 Remand, the Veteran underwent a VA spine examination in January 2013. The Veteran reported having progressive back pain since her military service. She described her pain as sharp, intermittent, and not occurring on a daily basis. Her back pain worsened with prolonged standing and walking. The Veteran reported having flare ups of her symptomatology, which she treated with rest and medication. Range of motion testing revealed flexion to 60 degrees, with pain beginning at 50 degrees; extension to 10 degrees, with pain beginning at zero degrees; right lateral flexion to 20 degrees, with pain beginning at 10 degrees; left lateral flexion to 30 degrees or greater, with pain beginning at 20 degrees; and right and left lateral rotation to 25 degrees, with pain beginning at 20 degrees. There was no further change in range of motion due to weakened movement, fatigability, or incoordination. The examiner commented that the Veteran's back pain can limit her functional ability during a flare up; however, the examiner was unable to identify the exact limitation of her range of motion without resorting to speculation. Repetitive use testing revealed flexion to 60 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 30 degrees or greater; and right and left lateral rotation to 25 degrees. There was no additional limitation of motion following repetitive use testing. The Veteran had functional loss and/or impairment due to her low back disability, which the examiner identified as pain on movement. The examination did not reveal ankylosis. The associated imaging studies showed arthritis in the thoracolumbar spine. The physical examination revealed tenderness or pain to palpation, without evidence of guarding or muscle spasm. Muscle strength, reflex, and sensory examinations were normal. Straight leg raising testing was negative bilaterally. The Veteran did not have radicular pain or signs/symptoms due to radiculopathy. The examiner noted that the electromyography study (EMG) was normal, and the examiner concluded that there was no evidence of acute or chronic radicular or peripheral neuropathy. There were no neurological impairments attributable to the low back disability. There were no incapacitating episodes during the past twelve months. The examination confirmed the diagnosis of degenerative joint disease of the lumbar spine. The examiner noted the Veteran's report that her low back pain radiated down to her bilateral lower extremities. The examiner noted, however, that there was no clinical evidence of radiculopathy. The examiner highlighted that that the physical examination showed normal muscle strength testing, normal reflexes, normal sensory testing, and normal EMG study of the bilateral lower extremities. The examiner concluded that not all of the Veteran's subjective reports of her symptoms were consistent with the objective clinical findings. In light of the evidence of record, recounted above, the Board concludes that an evaluation in excess of 20 percent for the Veteran's low back disability is not warranted. The objective evidence of record does not show that the Veteran's lumbar spine flexion is primarily limited to 30 degrees or less. Moreover, there is no evidence showing ankylosis of the Veteran's lumbar spine. See 38 C.F.R. § 4.71a, General Rating Formula; see also Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing SAUNDERS ENCYCLOPEDIA AND DICTIONARY OF MEDICINE, NURSING, AND ALLIED HEALTH at 68 (4th Ed. 1987)). In so concluding, the Veteran's reports of low back pain on use is substantiated by the January 2012, March 2012, and January 2013 VA examination reports. The January 2012 physical examination revealed thoracolumbar flexion to 40 degrees, with the onset of pain at 20 degrees. However, the medical evidence of record does not show that this pain resulted in additional limitation in range of motion sufficient to warrant a 40 percent rating. Indeed, the Veteran also demonstrated flexion to 40 degrees following repetitive use, without any indication of pain during the January 2012 examination. Moreover, pain was taken into account by the January 2012 VA examiner, who specifically stated that there was no functional loss or impairment of the thoracolumbar spine. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based on loss of motion). The Veteran subsequently demonstrated flexion to at least 45 degrees, to include pain, during the subsequent March 2012 and January 2013 VA examinations. Accordingly, the preponderance of the evidence of record does not show that the Veteran ever experienced pain of the lumbosacral spine which caused additional functional loss beyond that contemplated by a 20 percent evaluation. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). As such, an evaluation in excess of 20 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's low back disability at any point during the pendency of her claim. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); 38 C.F.R. § 4.71a, General Rating Formula. Also, there is no evidence that the Veteran experiences incapacitating episodes as a result of her lumbar spine disability. Specifically, there is no evidence reflecting that the Veteran was prescribed bed rest by a physician, and the Veteran denied incapacitating episodes during the most recent January 2013 VA examination. Accordingly, a rating in excess of 20 percent is not warranted under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes during the pendency of the claim. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Diagnostic Code 5243. The Board has also considered whether an increased disability rating is warranted based upon the granting of a separate neurologic disability rating related to the low back disability at any point during the appeal. However, the evidence of record does not show the existence of any associated neurologic abnormalities, such as bladder or bowel complaints, that are related to the service-connected low back disability. Although the Veteran has consistently reported that she experiences pain that radiates down to her feet, there is no objective evidence of a diagnosed lower extremity neurological disorder associated with her low back. Indeed, the January 2013 VA examiner reported that an associated EMG study was normal. Thus, there is no objective medical evidence attributing the Veteran's reported bilateral neurologic abnormalities to the service-connected low back disorder. Therefore, a separate rating is not warranted for neurological impairment, as no such impairment is shown. The Board has also considered the Veteran's statements that her low back disability warrants a higher disability ratings. In this case, the Veteran is competent to report her symptoms because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). She is not, however, competent to identify a specific level of disability relating to a low back disability to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disability has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings, as provided in the examination reports, directly address the criteria under which her disability is evaluated. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned rating inadequate. The Veteran's service-connected low back disorder was evaluated as a disease or injury of the spine pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Id. The evidence of record does not show that the Veteran's service-connected low back disability is primarily manifested by forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; the evidence of record also does not show that that the Veteran experienced any incapacitating episodes having a total duration of at least four weeks but less than six weeks due to her low back disability. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by an initial 20 percent disability rating. Evaluations in excess of 20 percent are provided for certain manifestations of the Veteran's service-connected low back disorder , but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for a 20 percent rating reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Code 5237; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). The Board has also considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 56. Accordingly, an initial disability rating in excess of 20 percent for the Veteran's service-connected low back disability is not warranted. ORDER Service connection for tinnitus is denied. An initial disability in excess of 20 percent for a low back disability is denied. REMAND The Board most recently remanded the Veteran's claim for service connection for a bilateral foot disorder in December 2012 for a VA examination. Specifically, the Board ordered that an opinion be provided from a VA examiner regarding whether the Veteran's currently diagnosed pes planus is related to her active duty service. The Board requested that the examiner provide a complete rationale for the requested opinion, or otherwise explain, if applicable, why an opinion could not be provided. The Veteran was afforded VA examinations in January 2013, which revealed diagnoses of bilateral pes planus and plantar fasciitis. The examiner acknowledged the Veteran's report that she began to experience foot pain while pregnant when she was required to wear steel toe shoes. Highlighting that the claims file was reviewed, the examiner noted that there was no mention of pes planus in the military files and the physical examinations did not mention any feet problems. The examiner also noted the existence of "many appeals for feet problems." Despite this, the examiner failed to provide an opinion regarding whether the diagnosed bilateral foot conditions are related to the Veteran's military service. In this regard, the Board acknowledges that the examiner highlighted that the Veteran's medical history. However, the Board may not make a determination from the examiner's comments as to the etiology of the claimed bilateral foot disorder. Colvin v. Derwinski, 1 Vet. Ap. 191, 175 (1999) (finding that the Board is prohibited from exercising its own independent judgment to resolve medical questions). Therefore, as the September 2012 examination report is not adequate for adjudication purposes and as they are not in compliance with the Board's December 2012 remand directives, a further remand is required. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Moreover, once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford her the opportunity to identify or submit any additional pertinent evidence in support of her claims. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that she is ultimately responsible for providing the evidence. The Veteran and her representative must then be given an opportunity to respond. 2. An addendum opinion from the examiner who performed the January 2013 VA foot examination must be requested. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Based on the evidence of record, to include the results of diagnostic testing and the Veteran's reports of the onset of her symptomatology in the record, the examiner must provide an opinion as to whether the Veteran's diagnosed pes planus or plantar fasciitis disorders are related to her military service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, he or she must so state and provide the reasons why an opinion would require speculations. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 3. The examination report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, implement corrective procedures at once. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the RO must readjudicate the claim. If any benefit sought on appeal remains denied, the Veteran and her representative must be furnished a supplemental statement of the case and be given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. No action is required by the Veteran until she receives further notice; however, she may present additional evidence and argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs