Citation Nr: 1328745 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 08-02 856 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased rating for residuals of a lower back injury with chronic lower back pain and degenerative disc disease L5-S1, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: John S. Berry, Esq. ATTORNEY FOR THE BOARD N. J. Nardone, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1979 to January 1982 and from November 1982 to November 1993. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied entitlement to the benefit sought on appeal. The March 2007 rating decision also denied a compensable rating for left ear hearing loss. The appellant appealed the decision to the Board, and the case was referred to the Board for appellate review. When the case was before the Board in May 2009, the Board denied the Veteran's claim for a compensable rating for left ear hearing loss and remanded the Veteran's claim for a rating in excess of 20 percent for residuals of a lower back injury with chronic lower back pain and degenerative disc disease L5-S1 for additional development. Thereafter, in a June 2010 decision, the Board denied the claim for a rating in excess of 20 percent for residuals of a lower back injury with chronic lower back pain and degenerative disc disease L5-S1. The Veteran appealed the June 2010 denial to the United States Court of Appeals for Veterans Claims (Court). In a March 2012 Memorandum Decision, the Court vacated the Board's June 2010 decision and remanded the matter back to the Board for further proceedings consistent with the Memorandum Decision. In January 2013, the Board again remanded the claim for additional development. The case has been returned to the Board for further appellate consideration. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. FINDINGS OF FACT 1. The Veteran's lumbar spine disorder is manifested by functional forward flexion limited by pain to 50 degrees and extension limited to 25 degrees; there is no objective evidence of functional flexion limited to 30 degrees of motion or less, incoordination, weakness of the lumbar spine, lack of endurance, ankylosis or incapacitating episodes having a total duration of at least four weeks in a twelve-month period. 2. While the Veteran reports low back pain affecting the lower extremities, the service-connected disability does not result in any associated objective neurological abnormalities. CONCLUSION OF LAW The criteria for an evaluation in excess of 20 percent for residuals of a lower back injury with chronic lower back pain and degenerative disc disease L5-S1 have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. The Veterans Claims Assistance Act of 2000 (the VCAA) With respect to the Veteran's claim decided 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). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claims. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. Prior to initial adjudication of the Veteran's claim, a letter dated in November 2006 fully satisfied the duty to notify provisions regarding the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records are in the claims file. The Veteran identified relevant VA records for the claimed disability and those records have been obtained and associated with the claims file. He has not referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran was provided VA examinations in December 2006, December 2008, July 2009, and March 2013. The examination reports reference the Veteran's past medical history, recorded his current complaints, conducted an appropriate physical examination, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board therefore concludes that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 38 C.F.R. § 4.2 (2012). In addition, pursuant to the Board's May 2009 and January 2013 remand directives, the March 2013 examination included a neurological examination to help determine whether the Veteran had a neurologic disability secondary to his service-connected low back disability. Further, additional VA treatment records dated through March 2013 have been obtained and associated with the Veteran's electronic Virtual VA claims file, as directed in the January 2013 remand. Accordingly, the Board finds that there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance 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). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Background and Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The Veteran's lumbar spine disability is evaluated as 20 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5243, relating to intervertebral disc syndrome. Intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, unfavorable ankylosis of the entire spine warrants a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent rating. 38 C.F.R. § 4.71a. Finally, 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 spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent rating. Id. Note (1): Evaluate any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes contained in Diagnostic Code 5243 provides for a 20 percent evaluation when there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent evaluation is contemplated when there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent evaluation is contemplated for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. Note (2). The Veteran has been assigned a 20 percent evaluation for his lumbar spine disability. Having considered the evidence of record, the Board finds that the Veteran is not entitled to an evaluation in excess of 20 percent for his lumbar spine disability at any point during the appeal period. In this regard, the Board notes that the Veteran's lumbar spine disability is manifested by subjective complaints of dull pain with periodic episodes of brief intense pain. VA treatment records dated during the course of this appeal reveal complaints of low back pain, but do not contain range of motion measurements or other objective findings that would support an evaluation in excess of 20 percent for the Veteran's lumbar spine disability. On physical examination in December 2006, there was no evidence of spasm, atrophy, guarding, tenderness, or weakness. With regards to range of motion testing, the Veteran was able to flex from 0 to 90 degrees with pain starting at 50 degrees. He was able to extend from 0-30 degrees with pain, rotate 0-30 degrees without pain, and perform lateral motion from 0-30 degrees without pain. There was no limitation on repetition of range of motion due to fatigue, weakness, incoordination, or pain. Applying the range of motion measurements to the general ratings formula, the above evidence demonstrates the Veteran is not entitled to an evaluation greater than 20 percent for orthopedic manifestations of his lumbar spine disability. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. An evaluation greater than 20 percent is not warranted as there is no medical evidence of forward flexion of the lumbar spine limited to 30 degrees or less. In addition, there is no objective evidence of ankylosis of the lumbar spine or of the entire spine during this period, nor is there evidence of incapacitating episodes having a total duration of at least four weeks during a twelve-month period. Turning to the December 2008 examination, again there was no evidence of spasm, atrophy, guarding, or weakness. There was evidence of pain on motion and tenderness on the left side. Range of motion studies again revealed active flexion from 0-90 degrees with pain beginning at 50 degrees. Extension was from 0-25 degrees with pain beginning at 15 degrees. Lateral flexion and lateral rotation both yielded active motion from 0-30 degrees. There was no additional loss of motion on repetitive use. Applying the range of motion measurements to the general ratings formula, the above evidence demonstrates the Veteran is not entitled to an evaluation greater than 20 percent for orthopedic manifestations of his lumbar spine disability. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Turning to the July 2009 VA examination, again there was no evidence of spasms, weakness, atrophy, or guarding. There was pain with motion and tenderness. Active range of motion was from 0-90 degrees flexion, extension was from 0-25 degrees, bilateral lateral rotation was from 0-30 degrees, and bilateral lateral flexion was from 0-30 degrees. While there was objective evidence of pain on motion, there was no additional limitation after three repetitions of range of motion. These findings again do not support the assignment of an evaluation greater than 20 percent for orthopedic manifestations of his lumbar spine disability. Upon examination in March 2013, the Veteran endorsed intermittent numbness and tingling of the left upper outer thigh which occurs for no apparent reason and comes and goes. The Veteran also reported that flare-ups impact the function of the thoracolumbar spine due to increased pain. Range of motion measurements revealed that forward flexion was to 90 degrees or greater, with no objective evidence of painful motion. Extension was to 25 degrees, with painful motion beginning at 25 degrees. Right and left lateral flexion were to 30 degrees or greater, with painful motion beginning at 30 degrees or greater. Right and left lateral rotation were to 30 degrees or greater, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions. The Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing. However, the Veteran did have functional loss and/or functional impairment of the thoracolumbar spine after repetitive use, with less movement than normal and pain on movement. There was no atrophy. Further the examiner indicated that the Veteran did have intervertebral disc syndrome of the thoracolumbar spine, although there were no incapacitating episodes over the past 12 months due to such. These findings do not demonstrate that the Veteran is entitled to an evaluation greater than 20 percent for orthopedic manifestations of his lumbar spine disability. The objective medical evidence of record does not establish that an increased rating is warranted based on evidence of functional loss. The February 2007 VA examiner noted no limitation on repetition of range of motion due to fatigue, weakness, incoordination, or pain. Similarly, the December 2008 VA examiner noted no additional loss of motion on repetitive use. Likewise, the July 2009 VA examiner noted no additional limitation after three repetitions of range of motion. In March 2013, the Veteran endorsed flare-ups with increased pain, and the examiner found that the Veteran did have functional loss and/or functional impairment of the thoracolumbar spine after repetitive use, with less movement than normal and pain on movement. However, the Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing with 3 repetitions. The Board concludes that the 20 percent rating which is currently assigned adequately compensates the Veteran for the degree of functional impairment shown. There is objective evidence of pain. However, the Board finds that even after consideration of such, the disability does not nearly approximate the criteria for a higher rating. Accordingly, there is no basis on which to assign a higher level of disability based on 38 C.F.R. §§ 4.40 and 4.45. Nor is the Veteran entitled to an increased disability rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Despite the Veteran's contentions to the contrary, there is no indication in the objective medical evidence that he has experienced an "incapacitating episode", as defined by VA, as a result of the service-connected low back disability, let alone incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. No health care provider has prescribed bed rest. The Board has also considered whether a separate evaluation for neurological disability is warranted. In this regard, the Board notes that the Veteran has complained of intermittent numbness, tingling and radiating pain through his lower extremities. Even after considering such, however, the Board finds that a separate rating for neurological impairment is not warranted. In this respect, a February 2007 magnetic resonance imaging (MRI) examination of the lumbar spine revealed "no neural impingement." In addition, a July 2009 electromyography (EMG) study revealed "no electro diagnostic evidence of diffuse peripheral neuropathy or lumbar radiculopathy in the muscles tested." The report of the May 2009 examination notes that there was a history of numbness and paresthesias, as well as a sharp, dull, and numbing pain which radiated to the legs. Sensory examination of the lower extremities was normal to vibration, light touch, and position sense. Reflexes were normal for knee jerk, ankle jerk, and plantar (Babinski). The examination report also referenced a July 23, 2009 neurology consult, which revealed normal EMG and nerve conduction studies of both lower extremities with no evidence of diffuse peripheral neuropathy or lumbar radiculopathy in the muscles tested. The examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine without objective evidence of radiculopathy. Further, in March 2013, reflex and sensory examination in the lower extremities yielded normal results, and straight leg raising testing was negative, bilaterally. The examiner indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Further, the Veteran did not have any other neurologic abnormalities or diagnoses related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes). Pursuant to the January 2013 remand directives, the March 2013 examiner opined that the Veteran does not have any neurological condition related to his lumbar spine. The examiner indicated that all records were reviewed, to include the July 2009 VA examination report which notes a history of numbness and paresthesias; the July 2009 VA neurology consult containing the EMG and nerve conduction studies; the December 2006 VA examination report, which reflects the Veteran's complaints of numbness and tingling in the left lower extremity; the December 2006 VA treatment record, which reflects the Veteran's treatment for radiating pain and numbness into the left thigh; the March 1999 VA examination report, which reflects a finding that sensation in the left foot was impaired and indicates that lumbar radiculopathy could not be ruled out; the July 1997 VA examination report, which reflects a diagnosis of paresthesia in the left leg; and the October 1996 VA examination report which notes a sluggish left Babinski. The examiner stated that on that date, the neurologic examination was completely normal, and the Veteran described intermittent sensory changes involving only the left upper outer thigh, which is characteristic of and diagnostic of meralgia paresthetica, a condition described below that is not related to any lumbar spine condition. The examiner explained that the EMG done in July 2009 ruled out any lumbar radiculopathy and EMGs are the gold standard for testing such neurologic disorders. Negative EMG results as in the Veteran's case, are useful in making the diagnosis of meralgia paresthetica by ruling out radiculopathy. The examiner explained that burning pain, paresthesia (numbness and tingling), and hypesthesia (diminished sensation) over the upper outer thigh is the classic presentation of meralgia paresthetica. The onset of pain is typically subacute. Sensory loss is quite discrete, and it is often possible to clearly demarcate the area of numbness. The patient often rubs the outer thigh when describing the symptoms. Neurologic symptoms are restricted to sensory changes since the lateral femoral cutaneous nerve does not contain motor fibers. The majority of meralgia paresthetica cases result from entrapment of the lateral femoral cutaneous nerve as it passes under the inguinal ligament. The most frequent associated conditions are obesity, diabetes mellitus, and older age. Additional associations include large abdomens with overlying panniculus, tight belts or garments around the waist, scar tissue near the lateral aspect of the inguinal ligament, and pregnancy. The examiner said that sensory nerve condition studies have been described for the lateral femoral cutaneous nerve. However, responses are extremely variable, and it is often difficult to perform this study in overweight individuals. Therefore, if this nerve conduction study is to be performed, it is essential that the contralateral side be studied as well. EMG has no role in the diagnosis, as there are no motor manifestations. However, EMG and nerve conduction studies are occasionally useful to rule out radiculopathy or plexopathy. The Board acknowledges the Veteran's assertions of pain, numbness, and tingling radiating from his low back to his lower extremities. Certainly, the Veteran can attest to factual matters of which he had first-hand knowledge, such as subjective complaints of pain radiating from the back to the lower extremities. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board finds the Veteran's statement regarding the symptoms manifesting in the lower extremities to be competent and credible. The Board notes, however, that objective physical examinations and diagnostic testing have not supported any relationship between such symptoms and the Veteran's service-connected low back disability. As noted, the March 2013 VA examination included neurologic testing that was wholly negative. Further, the March 2013 VA examiner attributed the Veteran's lower extremity symptoms to meralgia paresthetica. Thus, the objective evidence does not support any relationship between the Veteran's radiating pain to the lower extremities and his service-connected back disability. Given the foregoing, the Board finds that a separate rating for neurological impairment related to the Veteran's lumbar spine disability is not indicated. The Board has considered the Veteran's reports of radiating pain. In that regard, while the Veteran may be competent to describe symptoms, as a lay person he has not been shown to be capable of offering conclusions on complex medical matters, such as diagnosing peripheral neuropathy or radiculopathy or linking any such symptomatology to his service-connected low back disability. Thus, the Board finds the objective evidence of record showing no evidence of neurological impairment related to the Veteran's lumbar spine disability of greater probative value than the Veteran's statements. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Consequently, the Board finds that the preponderance of the evidence is against granting a separate evaluation for neurological impairment related to the Veteran's lumbar spine disability. Finally, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 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. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability on appeal with the established criteria found in the rating schedule show that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, with respect to the low back, the Veteran reports primarily pain. As discussed above, the current 20 percent rating under Diagnostic Code 5243 is adequate to fully compensate the Veteran for these symptoms. As discussed above, the Board finds the objective medical evidence regarding the Veteran's radiating pain, numbness, and tingling to the lower extremities does not warrant a separate rating for neurological impairment related to the Veteran's lumbar spine disability. Thus, the Veteran's current schedular rating under Diagnostic Code 5243 is adequate to fully compensate him for his disability on appeal. As the first prong of Thun has not been satisfied, the Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In reaching this decision the Board considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim the doctrine is not for application. 38 U.S.C.A. § 5107. ORDER An evaluation in excess of 20 percent for residuals of a lower back injury with chronic lower back pain and degenerative disc disease L5-S1 is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs