Citation Nr: 1317643 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 05-07 395 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to a compensable disability rating for the period of November 13, 2002 to October 6, 2010, for the service-connected lumbosacral strain. 2. Entitlement to a disability rating in excess of 10 percent for the period of October 7, 2010 to August 15, 2012, for the service-connected lumbosacral strain. 3. Entitlement to a disability rating in excess of 20 percent as of August 16, 2012, for the service-connected lumbosacral strain. 4. Entitlement to service connection for a right knee disability, to include as secondary to the Veteran's service-connected lumbosacral strain. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from August 1986 to March 1994. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In October 2007, the Veteran testified before a Veterans Law Judge (VLJ) during a videoconference hearing. A transcript of the hearing has been associated with the claims file. In November 2008, the Veteran requested a personal hearing at the local RO before a VLJ; however, he cancelled such request in July 2009. In March 2008, February 2009, September 2009, and August 2011, the Board remanded the claims for additional development and adjudicative action. The previously-assigned VLJ who conducted the October 2007 hearing has retired from the Board. In March 2013, the Board sent the Veteran a letter offering him another hearing before a different VLJ. See 38 U.S.C.A. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2012) (the Board member who conducts the hearing will participate in making the final determination of the claim). The Veteran responded in April 2013 that he did not want another hearing, and asked the Board to consider the case on the evidence of record. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issue of entitlement to service connection for a right knee disability, to include as secondary to the Veteran's service-connected lumbosacral strain is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period of November 13, 2002 to July 2, 2003, the Veteran's service-connected lumbosacral strain is manifested by moderate limitation of motion of the lumbar spine. 2. For the period of July 3, 2003 to October 6, 2010, the Veteran's service-connected lumbosacral strain is manifested by subjective complaints of pain and limited range of motion, but objectively no limitation of motion. 3. For the period of October 7, 2010 to August 15, 2012, the Veteran's service-connected lumbosacral strain is manifested by a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees. 4. As of August 16, 2012, the Veteran's service-connected lumbosacral strain is manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. CONCLUSIONS OF LAW 1. For the period of November 13, 2002 to July 2, 2003, the criteria for a 20 percent disability rating, but no higher, for the Veteran's service-connected lumbosacral strain have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); Diagnostic Codes (DCs) 5292, 5293, 5295 (2002 & 2003); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237 (2012). 2. For the period of July 3, 2003 to October 6, 2010, the criteria for a compensable disability rating for the Veteran's service-connected lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); Diagnostic Codes 5292, 5293, 5295 (2002 & 2003); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 3. For the period of October 7, 2010 to August 15, 2012, the criteria for a disability rating in excess of 10 percent for the Veteran's service-connected lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); Diagnostic Codes 5292, 5293, 5295 (2002 & 2003); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 4. As of August 16, 2012, the criteria for a disability rating in excess of 20 percent for the Veteran's service-connected lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); Diagnostic Codes 5292, 5293, 5295 (2002 & 2003); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."); and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction; the Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). VA's Duty to Notify and Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of the VCAA letter from the RO to the Veteran dated in December 2002. The letter effectively satisfied the notification requirements of the VCAA consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by: (1) informing him about the information and evidence not of record that was necessary to substantiate his increased rating claim; (2) informing him about the information and evidence the VA would seek to provide; and (3) informing him about the information and evidence he was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Although the December 2002 VCAA notice letter did not contain the information regarding the assignment of ratings and effective dates required by Dingess v. Nicholson, 483 F.3d 1311 (2007), a follow-up letter with the necessary information was sent to the Veteran in August 2008. The August 2008 letter also advised the Veteran of the additional notice requirements for increased rating claims. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (minimum notice requirements pursuant to VCAA for an increased rating claim), rev'd in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to the effect on daily life and as to the assigned or cross-referenced diagnostic code under which the disability is rated). The outcome of these holdings is that VCAA notice for an increased rating claim does not have to be individually tailored to each Veteran's particular facts, but rather only a generic notice is required. The August 2008 letter advised the Veteran of both the generic and specific evidentiary and legal criteria necessary to substantiate a higher rating for his lumbar spine disability. As to timing, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If not timely or inadequate, such errors can be effectively "cured" by providing any necessary VCAA notice and then and readjudicating the claim. That is, a statement of the case (SOC) or supplemental SOC (SSOC) can readjudicate the claim so that the intended purpose of the notice is not frustrated and the appellant is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). As a matter of law, VA may cure a timing of notice defect by taking proper remedial measures, such as issuing a fully compliant VCAA notice followed by a subsequent SOC or SSOC. Prickett, 20 Vet. App. at 376. After providing the additional VCAA notice stated above, the RO readjudicated the Veteran's increased rating claim in an October 2008 SSOC. Any timing defect in the notice has been rectified. Prickett, 20 Vet. App. at 376; see Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). The Board finds that the duty to notify has therefore been met. With respect to the duty to assist, the RO has secured the Veteran's service treatment records (STRs), VA treatment records, as well as provided him with several VA medical examinations to rate the current severity of his service-connected lumbar spine disability. See 38 C.F.R. § 3.327(a); Palczewski v. Nicholson, 21 Vet. App. 174, 182-83. The examinations were provided in December 2002, July 2003, December 2004, October 2008, October 2010, and August 2012. These examinations are adequate, and a new VA examination to rate the severity of his low back disability is not warranted. The Veteran has submitted personal statements and representative argument. The Veteran testified at an October 2007 videoconference Board hearing before a VLJ. Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. The Court also observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). See id. at 498. Citing Sanders, 556 U.S. at 407, 410, the Court noted that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless. Id. Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly explain the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit. At the hearing, the Veteran testified as to the current severity of his lumbar spine disability. Any deficiencies in the October 2007 Board hearing under section 3.103(c)(2) were not prejudicial, and no deficiencies have been shown or alleged. Through numerous remands and notice letters, the Veteran has been advised of what evidence would substantiate his claims, and accorded opportunities to provide substantiating evidence. VA has otherwise developed this claim, including obtaining records on the Veteran's behalf and providing VA examinations which specifically address the outstanding issues in this case, as discussed above with regard to VA's duty to assist under the VCAA. Moreover, the Veteran did not raise any new issues relevant to his claim for an increased rating at the hearing, and there is also no indication of any outstanding evidence he might submit. See id. at 499. Thus, given the development undertaken by VA with respect to this claim, and in light of the Veteran's testimony at the hearing, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Id. at 498-99. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2). See id.; see also Sanders, 556 U.S. at 407, 410. The RO/AMC also substantially complied with the Board's March 2008, February 2009, September 2009, and August 2011 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). The RO/AMC secured additional VA treatment records, afforded the Veteran VA examinations to rate the current severity of his lumbar spine disability, and afforded the Veteran an additional Board hearing. The RO/AMC has substantially complied with the Board's instructions. In summary, the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2011). The Merits of the Increased Rating Claim The Veteran contends that his lumbar spine disability is more severe than is contemplated by the currently-assigned rating, and asserts that a higher rating is warranted. The Veteran filed an increased rating claim in November 2002. The Veteran's entire history is reviewed when assigning a disability evaluation per 38 C.F.R. § 4.1. However, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). That is to say, the Board must consider whether there have been times when his lumbar spine disability has been more severe than at others, and rate it accordingly. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness. Layno v. Brown, 6 Vet. App. 465, 469 (1994). During the course of this appeal, VA promulgated new regulations for the evaluation of disabilities of the spine twice, effective September 23, 2002 and September 26, 2003. See 67 Fed. Reg. 54,345-54,349 (August 22, 2002), 68 Fed. Reg. 51,454 (Aug. 27, 2003)(codified at 38 C.F.R. part 4). The amendments renumber the Diagnostic Codes and create a General Rating Formula for Diseases and Injuries of the Spine. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C.A. § 5110(g); VAOPGCPREC 3-2000. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Because the amendments discussed above have a specified effective date without provision for retroactive application, they may not be applied prior to the effective date. As of that effective date, the Board must apply whichever version of the rating criteria is more favorable to the Veteran. Prior to September 23, 2002, slight limitation of motion of the lumbar spine warranted a 10 percent evaluation. Moderate limitation of motion of the lumbar spine warranted a 20 percent evaluation and severe limitation of motion of the lumbar spine warranted a 40 percent evaluation. There was no higher evaluation available under DC 5292. 38 C.F.R. § 4.71a (2002). Prior to September 23, 2002, lumbosacral strain with slight subjective symptoms only warranted a 0 percent evaluation. Lumbosacral strain with characteristic pain on motion warranted a 10 percent evaluation. Lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral in a standing position warranted a 20 percent evaluation. A 40 percent evaluation was warranted when the disability was severe, with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. There was no higher evaluation available under Diagnostic Code 5295. 38 C.F.R. § 4.71a (2002). The words "slight," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Prior to September 23, 2002, under Diagnostic Code 5293, mild intervertebral disc syndrome (IDVS) warranted a 10 percent evaluation and moderate IDVS with recurring attacks a warranted a 20 percent evaluation. Severe IDVS with recurring attacks and intermittent relief warranted a 40 percent evaluation. A 60 percent evaluation was warranted when there was pronounced IDVS with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. 38 C.F.R. § 4.71a (2001). The Board notes that the regulations regarding IDVS were revised effective September 23, 2002. Under the revised regulations, IDVS (preoperatively or postoperatively) is evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 (the combined rating table) separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. Under these revised standards, IDVS warrants a 10 percent evaluation when the Veteran has incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent evaluation is warranted when the Veteran has incapacitating episodes having a total duration of a least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. These criteria are the same in the amendment effective September 26, 2003. 38 C.F.R. § 4.71a (2002-2012). The Board notes that while the regulations regarding IDVS were revised effective September 23, 2002, the criteria for Diagnostic Codes 5290, 5292, and 5295 remained unchanged. The Board notes that effective September 26, 2003, the schedule for rating spine disabilities was changed to provide for the evaluation of all spine disabilities under a General Rating Formula for Diseases and Injuries of the Spine, unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (renumbered as Diagnostic Code 5243). The pertinent criteria are as follows: Unfavorable ankylosis of the entire spine - 100 percent disabling. Unfavorable ankylosis of the entire thoracolumbar spine - 50 percent disabling. Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine - 40 percent disabling. Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 - 20 percent disabling. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 - 10 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242 (September 2003). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides a 60 percent rating for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). An incapacitating episode is defined 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. Id. at Note (1) (2012). 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 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. 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. Id. DC 5010 is for arthritis due to trauma, substantiated by X-ray findings and provides for rating as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. DC 5003 provides that 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 joint or joints involved (DC 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45 (2012). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, VA examination reports, and statements submitted in support of his claim. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claim for an increased rating for his service-connected lumbosacral strain. Specifically, the Board will focus on the evidence of record that describes the severity of his service-connected lumbosacaral strain disability. Entitlement to a Compensable Disability Rating for the Period of November 13, 2002 to October 6, 2010 In December 2002, the Veteran was afforded a VA examination to determine the severity of his service-connected lumbosacral strain. He reported having backaches and popping in the lumbar spine area. He denied having any peripheral radiation. Physical examination testing revealed an obese male with a normal gait. He was noted as not using a cane and could stand on his heels and toes easily. Range of motion testing reflected flexion to 60 degrees, extension to 20 degrees, side bending to 30 degrees bilaterally, and rotation to 30 degrees bilaterally. Straight leg raising test was negative, and his reflexes were normal bilaterally. X-rays of the lumbar spine showed mild degenerative changes. The VA examiner diagnosed the Veteran with lumbar strain. In July 2003, the Veteran underwent his second VA examination for his service-connected lumbosacral strain. He complained of chronic low back pain with no lower extremity symptoms associated with it. He reported that his back stiffens and gets worse when he stoops or coughs. Upon physical examination, the VA examiner noted that the Veteran's toe walking was normal, but he felt a sensation in his low back when heel walking. There were no muscle spasms or tenderness in the low back, but the Lasegue test was questionably positive on the right side. There was also a rocking reflex in the lower extremities and abdomen, as well as tightness in the low back. There was no weakness in either great toe, no loss of sensation to light touch over the right lower extremity, and deep tendon reflexes of the lower extremities were brisk and equal. The sciatic nerve stress test was negative. Range of motion testing showed flexion to 45 degrees, 30 degrees of hyperextension, 20 degrees of right lateral bending, 20 degrees of left lateral bending, and 40 degrees of bilateral rotation. X-ray testing revealed narrowing of most of the lumbar intervertebral disc spaces with mild degenerative changes. In an August 2003 VA addendum examination report, the VA examiner concluded that it is unlikely that the osteoarthritis and degenerative disc disease is related to the Veteran's service-connected lumbar strain, but the limitation of motion is at least as likely as not related to the service-connected lumbar strain. A third VA examination for the Veteran's service-connected lumbosacral strain was conducted in December 2004. He complained of aching in the back at the waistline and stiffness. He also indicated that coughing, sneezing, prolonged sitting or standing does not affect his back pain. Physical examination testing of the Veteran revealed an obese male with normal posture and gait. The VA examiner indicated that he could stand on his heels and toes easily and had normal reflexes. Straight leg raising test bilaterally was normal, and there were no spasms or tenderness of the back. Range of motion testing was flexion to 90 degrees, extension to 30 degrees, side bending to 45 degrees, and rotation to 45 degrees. X-rays and magnetic resonance imaging (MRI) testing results from November 2003 showed a mild bulge at L4-L5 on the left with no evidence of any secondary arthritic changes in that area, but some mild facet osteoarthritis on the right at L5-S1. The VA examiner diagnosed the Veteran with small herniated lumbar disk of fairly recent origin, and mild facet joint osteoarthritis of the right facet only at L5-S1, secondary to obesity. In October 2008, the Veteran underwent his fourth VA examination for his service-connected lumbosacral strain. He complained of daily pain located at the waistline, with a radiating stabbing pain down to his left posterior thigh. Upon physical examination of the Veteran, the VA examiner noted no signs of spasms, atrophy, guarding, tenderness, or weakness. The VA examiner indicated that there was only pain on motion. The Veteran's posture, head position, and gait type were all normal, and there was no gibbus, kyphosis, list, lumbar flattening, lumbar lordosis, or scoliosis. Motor testing revealed active movement against full resistance for bilateral elbow flexion, bilateral elbow extension, bilateral wrist flexion, bilateral wrist extension, finger flexors, finger abduction, thumb opposition, bilateral hip flexion, bilateral hip extension, bilateral knee extension, bilateral ankle dorsiflexion, bilateral ankle plantar flexion, and great toe extension. There was no muscle atrophy and muscle tone was normal. Sensory, reflex, and Lasegue's sign testing were normal with no evidence of thoracolumbar spine ankylosis. Range of motion testing revealed flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. There was no additional loss of motion on repetitive use. He was diagnosed with degenerative disc disease of the lumbosacral spine and spinal stenosis of the lumbosacral spine. An increased rating of 20 percent, and no higher, is warranted for the Veteran's service-connected lumbosacral strain under the pre-revision DC 5292, from November 13, 2002 to July 2, 2003. As previously reported, at the VA examinations dated December 2002 and July 2003, respectively, the Veteran's flexion was to 60 and 45 degrees. With regard to the pre-revision criteria, under DC 5292, a rating of 20 percent is assigned for moderate limitation of motion of the lumbar spine. The evidence shows moderate limitation of motion. As discussed above, the current rating criteria with regard to range of motion can be used as guidance in determining whether the Veteran's limitation of motion is moderate. Under the General Rating Formula, a 20 percent rating requires limitation of forward flexion greater than 30 degrees but not greater than 60 degrees. Resolving the doubt in the Veteran's favor, a 20 percent evaluation is warranted from November 13, 2002 to July 2, 2003 under DC 5292. However, a higher disability rating in excess of 20 percent is not warranted for the Veteran's service-connected lumbosacral strain from November 13, 2002 to July 2, 2003. Under the pre-revision criteria, under DC 5292, a rating of 40 percent is assigned for severe limitation of motion of the lumbar spine. The evidence does not shows severe limitation of motion. As the current rating criteria can be used as guidance in determining whether the Veteran's limitation of motion is severe, under the General Rating Formula, a 40 percent rating requires limitation of forward flexion to 30 degrees or less, indicating that severe limitation of motion would be one third of normal flexion, which is 90 degrees. See 38 C.F.R. § 4.71a, Plate V; see also 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (2). As mentioned above, at worst the Veteran's flexion was limited to 45 degrees. Thus, as the Veteran has always had at least 45 percent of forward flexion, severe limitation of motion has not been shown. A rating of 40 percent under the pre-revision DC 5295 from November 13, 2002 to July 2, 2003 is also not warranted. Although there is some evidence of marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, and narrowing of irregularity of joint space, there is no evidence of a positive Goldthwaite's sign. There is no evidence to show that the Veteran's service-connected lumbosacral strain has been characterized by medical professionals as severe. Therefore, a 40 percent rating under DC 5295 for a severe lumbosacral strain may not be assigned. Under the current General Rating Formula, a rating of 40 percent is assigned for limitation of forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Ratings in excess of 40 percent under the General Rating Formula require the presence of unfavorable ankylosis. See 38 C.F.R. § 4.71a. As discussed above, the Veteran's forward flexion has not been limited to 30 degrees or less from November 13, 2002 to July 2, 2003. There is no evidence of record indicating that he has favorable or unfavorable ankylosis of the lumbar spine. Therefore, a rating in excess of 20 percent is not warranted under the General Rating Formula from November 13, 2002 to July 2, 2003. Because the Veteran has not been diagnosed with intervertebral disc syndrome from November 13, 2002 to July 2, 2003, both under pre-revision criteria, DC 5293, and the new criteria, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, do not apply. A compensable rating is not warranted for the Veteran's service-connected lumbosacral strain from July 3, 2003 to October 6, 2010 under the pre-revision and current criteria. As mentioned above, at both the December 2004 and October 2008 VA examinations, the Veteran's flexion was to 90 degrees, which is considered normal. Also, his bilateral lateral flexion was to 45 degrees at the December 2004 VA examination and to 30 degrees at the October 2008 VA examination. Although the Veteran demonstrated pain on active range of motion testing at the October 2008 VA examination, there was no pain demonstrated at the December 2004 VA examination or the presence of muscle spasms at the October 2008 VA examination. There is no characteristic pain on motion, evidence of muscle spasm on extreme forward bending, or loss of lateral spine motion. Therefore, under the pre-revision criteria, a compensable rating is not warranted under DC 5295. The Board also finds that under the pre-revision criteria, DC 5292 does not apply. Using the current rating criteria with regard to range of motion as guidance in determining whether the Veteran's limitation of motion is slight, a compensable rating, in this case 10 percent, requires 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 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. At the December 2004 and October 2008 VA examinations, the Veteran demonstrated flexion to 90 degrees and a combined range of motion of 300 degrees at the December 2004 VA examination and 240 degrees at the October 2008 VA examination. Additionally, there was no evidence of localized tenderness at both VA examinations or vertebral body fracture with loss of 50 percent or more of the height. Thus, DC 5292 does not assist the Veteran in obtaining a compensable disability rating. The pre-revision DC 5293 does not apply because neither the December 2004 nor the October 2008 VA examiner found evidence of intervertebral disc syndrome. A compensable disability rating is also not warranted under the current criteria. There is no evidence of forward flexion of the thoracolubmar spine greater than 60 degrees but not greater than 85 degrees, a 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. As mentioned above, results from the December 2004 VA examination reflected flexion to 90 degrees with a combined range of motion of 300 degrees. Similarly, results from the October 2008 VA examination reflected flexion to 90 degrees with a combined range of motion of 240 degrees. The October 2008 VA examiner found no signs of spasms, guarding, or tenderness, and there were no signs of a vertebral body fracture with loss of 50 percent or more of the height. Thus, the Board finds that a compensable rating is not warranted under the current criteria from July 3, 2003 to October 6, 2010, for the Veteran's service-connected lumbosacral strain. A compensable rating is also not warranted under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, DC 5243. There is no evidence showing that the Veteran has been prescribed bed rest by a physician for his low back disability or that he has been diagnosed with intervertebral disc syndrome. Thus, a compensable rating from July 3, 2003 to October 6, 2010 is not warranted for the Veteran's service-connected lumbosacral strain on this basis. See id. The revised schedule provides for a separate rating for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The Board notes that the Veteran is currently service-connected for lumbar radiculopathy of the left lower extremity and right lower extremity radiculopathy. See the April 2011 and October 2012 rating decisions. The December 2002, July 2003, December 2004, and October 2008 VA examiners did not mention any other neurologic abnormalities or findings related to the service-connected lumbosacral strain. Thus, the medical evidence of record does not show associated objective neurologic abnormalities of bowel or bladder impairment so that a separate neurological disability rating, as it applies to his service-connected back disability is warranted. The Board has also considered the Veteran's service-connected lumbosacral strain in light of DC 5003, for degenerative arthritis. X-ray testing conducted during this time period showed mild degenerative changes, mild facet osteoarthritis on the right side at L5-S1, and degenerative disc disease of the lumbosacral spine. However, in an August 2003 VA addendum report, the VA examiner concluded that the Veteran's osteoarthritis and degenerative disc disease are not related to the Veteran's service-connected lumbosacral strain, and the December 2004 VA examiner attributed the Veteran's osteoarthritis to obesity. Therefore, 38 C.F.R. § 4.71a DC 5003 is not for application in this case. The Board has considered the Veteran's reports of pain during the VA examinations. Specifically, in July 2003, the Veteran complained of chronic low back pain, along with stiffness in the back. In December 2004, he complained of aching in the back along the waistline and stiffness. The Veteran again complained of pain along the waistline with radiating stabbing pain to the posterior thigh at the October 2008 VA examination. The presence of pain, fatigue, weakness, and lack of endurance are contemplated in the current rating criteria. What is of equal importance is the remaining functional use. See Deluca, 8 Vet. App. at 206-07. The October 2008 VA examiner determined that there was no additional loss of motion on repetitive use. Here, the evidence indicates that the Veteran did not experience functional loss of use of the lumbosacral spine during the increased rating period from November 13, 2002 to October 6, 2010. The evidence supports a finding that the Veteran's service-connected lumbosacral strain warrants a 20 percent rating and no higher from November 13, 2002 to July 2, 2003, and all reasonable doubt has been resolved in the Veteran's favor. However, from July 3, 2003 to October 6, 2010 the evidence does not support a compensable disability rating for the service-connected lumbosacral strain, and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 55. Entitlement to a Disability Rating in Excess of 10 percent for the period of October 7, 2010 to August 15, 2012 The Veteran was afforded a VA examination to determine the current severity of his service-connected lumbosacral strain in October 2010. He reported to the examiner that he has moderate pain in his back near the waistline that occurs approximately two to three times a week and lasts hours to days. He also indicated that the pain radiates to his bilateral posterior thigh and it is stabbing. He denied the use of any devices or aids for assistive purposes and admitted to only being able to walk one mill. Upon physical examination testing, the VA examiner noted that upon inspection of the spine, his posture and head position were both normal. There were no abnormal spinal curvatures, spasms, atrophy, guarding, pain with motion, tenderness, or weakness. Reflex testing was normal, and motor examination testing revealed active movement against full resistance for bilateral elbow flexion, bilateral elbow extension, bilateral wrist flexion, bilateral finger flexion, bilateral finger abduction, bilateral thumb opposition, bilateral hip flexion, bilateral hip extension, bilateral knee flexion, bilateral ankle dorsiflexion, bilateral ankle plantar flexion, and bilateral great toe extension. Muscle tone was normal, there was no muscle atrophy, and Lasegue's sign testing was negative. Range of motion testing showed flexion to 90 degrees, extension to 20 degrees, left lateral flexion to 20 degrees, left lateral rotation to 30 degrees, right lateral flexion to 20 degrees, and right lateral rotation to 30 degrees. There was no objective evidence of pain on active range of motion, objective evidence of pain following repetitive motion, or additional limitations after three repetitions of range of motion. X-ray testing revealed moderate to advanced multilevel degenerative disc disease with grade retrolisthesis of L2 on 3. The VA examiner diagnosed the Veteran with degenerative disc disease of the lumbosacral spine with stenosis and obesity. The VA examiner also noted that the Veteran has missed less than one week from work due to his low back pain and appears to have moderate intervertebral disc syndrome with recurrence based on work history with possible sciatica. A disability rating in excess of 10 percent is not warranted under the pre-revision or current rating criteria for the Veteran's service-connected lumbosacral spine disability. With regard to the pre-revision criteria, under DC 5292, a rating of 20 percent is assigned for moderate limitation of motion of the lumbar spine. The evidence does not show moderate limitation of motion. As discussed above, the current rating criteria with regard to range of motion can be used as guidance in determining whether the Veteran's limitation of motion is moderate. Under the General Rating Formula, a 20 percent rating requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. During this time period, the Veteran's flexion was 90 degrees, which is normal. Thus, as the Veteran has shown normal flexion of the thoracolumbar spine, the Board finds that moderate limitation of motion under DC 5292 has not been shown. Under the pre-revision DC 5295, a rating of 20 percent is assigned for muscle spasm on extreme forward bending, loss of lateral spine motion unilateral, in standing position. However, a rating of 20 percent under the pre-revision DC 5295 is also not warranted. At the October 2010 VA examination, the VA examiner found no evidence of muscle spasms, and there was no unilateral loss of lateral spine motion, as during range of motion testing, the Veteran was able to demonstrate right and left lateral flexion to 20 degrees. Therefore, a 20 percent rating under DC 5295 may not be assigned. As the Veteran has also been diagnosed with moderate intervertebral disc syndrome by the October 2010 VA examiner, the Board must also consider the pre-revision DC 5293. As mentioned above, the VA examiner reported that the Veteran has missed less than one week from work due to his low back pain, which appears to be due to his moderate intervertebral disc syndrome with possible sciatica. However, such findings do not warrant an increased rating under the pre-revision DC 5293. In order to warrant the next-higher 20 percent rating, the Veteran must have had incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Although the VA examiner has diagnosed the Veteran with IDVS, there is no evidence of incapacitating episodes, and even accepting that the Veteran has had incapacitating episodes, there is no objective evidence of them occurring at least for two weeks. Therefore, a higher rating is not warranted under the pre-revision DC 5293 for the Veteran's service-connected lumbosacral strain. A higher rating is also not warranted under the current criteria. As previously mentioned, under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. In this case, such as not been demonstrated. At the October 2010 VA examination, range of motion testing reflected forward flexion to 90 degrees, extension to 20 degrees, left lateral flexion to 20 degrees, left lateral rotation to 30 degrees, right lateral flexion to 20 degrees, and right lateral rotation to 30 degrees. The Veteran's forward flexion is greater than 60 degrees and in fact, is normal. Additionally, the combined range of motion is 210 degrees, more than 120 degrees. The VA examiner noted that his spine was normal with no abnormal spinal curvatures, spasms, atrophy, guarding, pain with motion, tenderness, or weakness. Thus, a higher rating is not warranted under the current criteria for the Veteran's service-connected lumbosacral strain. A higher rating is not warranted under the Formula for Rating Interverteral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, DC 5243. While the Board acknowledges the October 2010 VA examiner's finding of moderate intervertebral disc syndrome, there is no evidence showing that the Veteran has been prescribed bed rest by a physician for his low back disability. Even considering the Veteran has been diagnosed with moderate IVDS, and the October 2010 VA examiner indicated that he has missed less than one week from work due to his low back pain, such findings do not warrant an increased rating. The next-higher 20 percent rating requires incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Such as not been demonstrated and therefore a higher rating is not warranted for the Veteran's service-connected lumbosacral strain on this basis. See id. The revised schedule provides for a separate rating for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The Board notes that the Veteran is currently service-connected for lumbar radiculopathy of the left lower extremity and right lower extremity radiculopathy. See the April 2011 and October 2012 rating decisions. The October 2010 VA examiner did not mention any other neurologic abnormalities or findings related to the service-connected lumbosacral strain. Thus, the medical evidence of record does not show associated objective neurologic abnormalities of bowel or bladder impairment so that a separate neurological disability rating, as it applies to his service-connected back disability is warranted. The Board has considered whether an additional rating is available based on degenerative arthritis of the spine under DC 5003. X-ray testing revealed moderate to advanced multilevel degenerative disc disease with grade retrolisthesis of L2 on 3. See the October 2010 VA examination report. However, such is not warranted in this case. Indeed, to grant such an additional rating would violate the law against pyramiding, which specifically states that the evaluation of the same manifestations under various diagnoses is to be avoided. See 38 C.F.R. § 4.14. Here, the arthritis code directs that the disability be rated based on the particular limitation of motion codes; only if the disability does not warrant a rating under those codes is a rating solely for arthritis appropriate. As explained above, the Veteran's limitation of motion of the thoracolumbar spine has been found to be compensable at the 10 percent level under the General Rating Formula for Diseases and Injuries of the Spine. Therefore, a separate rating based on arthritis is not warranted in this case. The Board has considered whether a higher evaluation is warranted on the basis of functional loss due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The October 2010 VA examiner noted that there was no objective evidence of pain on active range of motion, no objective evidence of pain following repetitive motion, or additional limitations after three repetitions of range of motion testing. The evidence indicates that the Veteran's forward flexion is, at worst, to 90 degrees, which is normal and indicative of no functional loss. As the Veteran does not experience pain on active range of motion and there is no functional loss, a higher rating is not possible under DeLuca. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. The evidence does not support an evaluation in excess of 10 percent for service-connected lumbosacral strain from for the period of October 7, 2010 to August 15, 2012, and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. Entitlement to a Disability Rating in Excess of 20 percent as of August 16, 2012 In August 2012, the Veteran was given a VA examination for his service-connected lumbosacral strain. He reported daily, throbbing back pain with stiffness most of the time. He rated the pain at a 6 out of 10 in terms of severity. He also admitted to having flare-ups. The Veteran described the flare-ups being worse in bad weather or coldness. The pain shoots down to both legs with the right leg being worse than the left. He indicated that the pain is so severe that he gets tears in his eyes. The pain, which he rated at a 10 out of 10 in terms of severity, can last from one day to a week. The Veteran admitted to using the presence of a can occasionally for assistive purposes. Range of motion testing revealed forward flexion to 60 degrees with painful motion, extension to 25 degrees with painful motion, right lateral flexion to 30 degrees or greater with painful motion at 25 degrees, left lateral flexion to 20 degrees with painful motion at 20 degrees, right lateral rotation to 25 degrees with painful motion at 25 degrees, and left lateral rotation to 20 degrees with painful motion at 20 degrees. The VA examiner noted that the Veteran is able to perform repetitive-use testing with three repetitions with post-test forward flexion to 45 degrees, extension to 15 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. The VA examiner indicated that the Veteran has additional limitation in range of motion of the thoracolumbar spine, as well as functional loss and/or functional impairment. The VA examiner noted that the contributing factors are less movement than normal and pain on movement. There was also localized tenderness or pain to palpation for joint and/or soft tissue of the thoracolumbar spine, along with guarding or muscle spasm of the thoracolumbar spine. However, the VA examiner reported that while the guarding and/or muscle spasms are present, they do not result in an abnormal gait or spinal contour. Muscle strength testing was normal for the Veteran's bilateral hip flexion, bilateral knee extension, bilateral ankle plantar flexion, bilateral ankle dorsiflexion, and bilateral great toe extension. There was no muscle atrophy present and reflex testing for the bilateral ankles was normal and hypoactive for the knees. Sensory testing was normal, and straight leg raising test was negative. On physical examination testing, the VA examiner also noted the presence of intervertebral disc syndrome, but determined that the Veteran has not had any incapacitating episodes over the past 12 months. Diagnostic testing documented arthritis, and the VA examiner diagnosed the Veteran with chronic lumbosacral strain. A rating in excess of 20 percent is not warranted under the pre-revision or current rating criteria for the Veteran's service-connected lumbosacral spine disability. With regard to the pre-revision criteria, under DC 5292, a rating of 40 percent is assigned for severe limitation of motion of the lumbar spine. The evidence does not show severe limitation of motion. As discussed above, the current rating criteria with regard to range of motion can be used as guidance in determining whether the Veteran's limitation of motion is moderate. Under the General Rating Formula, a 40 percent rating requires limitation of forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. During this time period, the Veteran's forward flexion well-exceeded 30 degrees. In fact, at the August 2012 VA examination, range of motion testing revealed forward flexion to 60 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 20 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 20 degrees. Additionally, while the August 2012 VA examiner diagnosed the Veteran with chronic lumbosacral strain, he did not characterize it as severe. Thus, as the Veteran has demonstrated forward flexion to 60 degrees and there is no sign of anklylosis of the thoracolumbar spine, severe limitation of motion has not been shown and an increased rating is not warranted under the pre-revision DC 5292. A higher rating of 40 percent under the pre-revision DC 5295 is not warranted as well. The Veteran's service-connected lumbosacral strain has never been characterized as severe, but only chronic in nature. Although the Veteran may have some symptoms associated with a 40 percent rating under DC 5295, which includes loss of lateral motion with osteo-arthritic changes, his service-connected low back disability is not approximately characterized as severe and the criteria for a higher rating are not met or approximated. Therefore, a 40 percent rating under DC 5295 for a severe lumbosacral strain may not be assigned. While the August 2012 VA examiner noted the presence of intervertebral disc syndrome, it was concluded that the Veteran had not endured any incapacitating episodes over the past 12 months. Such findings do not warrant an increased rating under the pre-revision DC 5293, intervertebral disc syndrome, as the next-higher 40 percent rating requires incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Without any evidence of incapacitating episodes within the past 12 months, the Veteran's intervertebral disc syndrome cannot be appropriately rated under the pre-revision DC 5293. A higher rating is also not warranted under the current criteria. As previously mentioned, under the General Rating Formula for Diseases and Injuries of the Spine, a 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable anklyosis of the entire thoracolumbar spine. In this case, such as not been demonstrated. At the August 2012 VA examination, range of motion testing reflected forward flexion to 60 degrees, extension to 25 degrees, left lateral flexion to 20 degrees, left lateral rotation to 20 degrees, right lateral flexion to 30 degrees, and right lateral rotation to 25 degrees. The Veteran's forward flexion is greater than 30 degrees, and there is no objective evidence of anklyosis as he demonstrated range of motion in all planes of excursion. Thus, a higher rating is not warranted under the current criteria for the Veteran's service-connected lumbosacral strain. A higher rating is not warranted under the Formula for Rating Interverteral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, DC 5243. While the August 2012 VA examiner's found intervertebral disc syndrome, there is no evidence showing that the Veteran has had incapacitating episodes within the past 12 months and has been prescribed bed rest by a physician for his low back disability. The next-higher 40 percent rating requires incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Such as not been demonstrated and therefore a higher rating is not warranted for the Veteran's service-connected lumbosacral strain on this basis. See id. The revised schedule provides for a separate rating for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The Veteran's lumbar radiculopathy of the left lower extremity and right lower extremity radiculopathy are service connected. See the April 2011 and October 2012 rating decisions. The August 2012 VA examiner did not mention any other neurologic abnormalities or findings related to the service-connected lumbosacral strain. Thus, the medical evidence of record does not show associated objective neurologic abnormalities of bowel or bladder impairment so that a separate neurological disability rating, as it applies to his service-connected back disability is warranted. Additionally, the Board has considered whether an additional rating is available based on degenerative arthritis of the spine under DC 5003. X-ray testing revealed the presence of arthritis. See the October August 2012 VA examination report. However, such is not warranted in this case. Indeed, to grant such an additional rating would violate the law against pyramiding, which specifically states that the evaluation of the same manifestations under various diagnoses is to be avoided. See 38 C.F.R. § 4.14. Here, the arthritis code directs that the disability be rated based on the particular limitation of motion codes; only if the disability does not warrant a rating under those codes is a rating solely for arthritis appropriate. As explained above, the Veteran's limitation of motion of the thoracolumbar spine has been found to be compensable at the 10 percent level under the General Rating Formula for Diseases and Injuries of the Spine. Therefore, a separate rating based on arthritis is not warranted in this case. The Board has considered whether a higher evaluation is warranted on the basis of functional loss due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The August 2012 VA examiner noted that the Veteran demonstrated additional limitation in range of motion of the thoracolumbar spine, as well as functional loss and/or functional impairment. The VA examiner indicated that the contributing factors were less movement than normal and pain on movement. Upon repetitive-use testing with three repetitions the Veteran's range of motion was forward flexion to 45 degrees, extension to 15 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. Thus, at its worst, the Veteran's forward flexion is to 45 degrees. However, this falls within the criteria for the current assignment of a 20 percent rating. The evidence does show that the Veteran experiences painful motion; however it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. Overall, the evidence does not support a disability rating in excess of 20 percent for service-connected lumbosacral strain as of August 16, 2012, and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has also considered whether referral for an extraschedular rating is appropriate. Ratings are generally based on average impairment, and that the rating schedule represents, as far as is practicable, the average impairment of earning capacity. See 38 C.F.R. § 3.321(a), (b) (2012). However, to afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.3211 (b) (2012). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. at 115-16. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, and is therefore found to be 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. Id. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. There is no evidence either submitted by the Veteran or otherwise obtained which suggests that his low back disability has markedly interfered with his employment status beyond that interference contemplated by the assigned evaluation, and there is also no indication that this disorder has necessitated frequent, or indeed any, periods of hospitalization during the pendency of this appeal. Rather, all symptoms described above have been fully contemplated by the criteria of Diagnostic Code 5237, taking into account 38 C.F.R. §§ 4.40 and 4.45 as well. As such, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Thun v. Peake, 22 Vet. App. 11 (2008). ORDER For the period of November 13, 2002 to July 2, 2003, the criteria for a 20 percent disability rating, but no higher, for the service-connected lumbosacral strain is granted, subject to the regulations applicable to the payment of monetary benefits. For the period of July 3, 2003 to October 6, 2010, a compensable disability rating for the service-connected lumbosacral strain is denied. For the period of October 7, 2010 to August 15, 2012, a disability rating in excess of 10 percent for the service-connected lumbosacral strain is denied. As of August 16, 2012, a disability rating in excess of 20 percent for the service-connected lumbosacral strain is denied. REMAND The Board's August 2011 remand directed that the claims file be returned to the VA examiner who drafted the January 2011 opinion regarding the etiology of the Veteran's right knee disorder for was an addendum as to whether it is at least as likely as not that any diagnosed right knee disorder or disorder is/are aggravated beyond the natural progression by symptoms caused by the service-connected lumbar spine disorder. The VA examiner was also asked to opine as to whether it is at least as likely as not that any diagnosed right knee disorder(s) was/were aggravated as a result of the Veteran's service. The Board also noted that a new VA examination is not warranted unless deemed so by the VA examiner. See the August 2011 Board remand. In August 2012, the Veteran was afforded a VA knee and lower leg disability benefits questionnaire (DBQ) examination. However, the August 2012 examiner did not provide an opinion as to whether the Veteran's right knee disability is aggravated beyond the natural progression by symptoms caused by the service-connected lumbar spine disorder. To ensure that VA has met its duty to assist the Veteran in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is again REMANDED for the following action: 1. Return the claims file to the examiner who conducted the August 2012 VA examination. IF THE AUGUST 2012 EXAMINER IS AVAILABLE, HE MAY CONDUCT A RECORDS REVIEW AND RESPOND TO THE QUESTIONS BELOW. IF THE AUGUST 2012 EXAMINER OTHERWISE FINDS IT NECESSARY, HE SHOULD CONDUCT FURTHER EXAMINATION OF THE VETERAN TO RESPOND TO THE QUESTIONS BELOW. If that examiner is not available, schedule the Veteran for a VA orthopedic or similarly specialized examination, to be conducted by a qualified examiner. Issue an opinion that specifically addresses the questions below with a full explanation for any conclusions. The following considerations will govern the examination: a. The claims file MUST be made available to and thoroughly reviewed by the examiner in connection with the examination, and the examiner must acknowledge such receipt and review in any report generated as a result of the examination. b. The examiner must review the Veteran's statements, as well as service treatment records in conjunction with the examination. Any special diagnostic studies deemed necessary must be performed. c. The examiner must obtain from the Veteran a full in-service and post-service history pertaining to the onset, symptoms, and treatment of his right knee disability. d. With respect to the review of the claims file, the Board calls the examiner's attention to the following: (i) The examiner is referenced to the Veteran's service treatment records - at the time of this writing are absent for any right knee symptoms. (ii) With respect to the current disability, the August 2012 VA examiner has diagnosed the Veteran with retropatellar pain syndrome and degenerative joint disease of the right knee. (iii) The examiner is also referenced to the history provided by the Veteran, who alleges that during service he had knee problems after a long run. At the October 2007 Board hearing, he admitted to being treated in service and continued to have problems after service. e. After reviewing the records, examining the Veteran, and identifying all appropriate symptoms and diagnoses, the examiner must provide medical findings or opinions responsive to the following questions: (i) Given the Veteran's account and the current lack of contemporaneous medical documentation of right knee symptoms from the time of discharge from active service through the present, is there a clinical or medical basis to support the Veteran's assertions. Please provide a fully reasoned explanation. (ii) Were the Veteran's right knee disabilities caused by or are they a result of the Veteran's active service, and to also include whether any of the right knee disability manifested as arthritis within one year after discharge from service? (iii) DID THE VETERAN'S SERVICE-CONNECTED LUMBAR SPINE DISABILITY CAUSE OR AGGRAVATE (CHRONICALLY WORSEN) HIS RIGHT KNEE DISABILITIES? (iv) IS IT AT LEAST AS LIKELY AS NOT THAT THE RIGHT KNEE DISABILITIES WERE AGGRAVATED BEYOND THE NATURAL PROGRESSION BY SYMPTOMS CAUSED BY THE SERVICE-CONNECTED LUMBAR SPINE DISABILITY? The examiner is also informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. f. The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established principles. g. If the examiner is unable to render the requested opinion(s) without resort to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the examiner to use his or her medical expertise and training to render an opinion. 3. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefit sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs