Citation Nr: 1329803 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 09-03 677 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for degenerative disc disease L3-5 to L5-S1, residuals of compression fracture at T12 and L1 with intervertebral disc syndrome (lumbar spine disability). 2. Entitlement to an evaluation in excess of 10 percent for radiculopathy of the left lower extremity. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from March 1976 to July 1980. This case comes before the Board of Veterans Appeals (the Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which continued a 20 percent evaluation for lumbar spine disorder and a 10 percent evaluation for radiculopathy of the left lower extremity. In July 2012, the Veteran presented testimony in a Travel Board hearing before the undersigned Veterans Law Judge. The Veteran was provided an opportunity to set forth his contentions at the hearing. The record reflects that at this hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Veterans Law Judge has to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). A copy of the transcript has been associated with the claims folder In October 2012, the Board remanded these claims as well as a claim of entitlement to service connection for a right hip disability to the Appeals Management Center (AMC)) for further development. In March 2013, the AMC granted entitlement to service connection for a right hip disability effective August 8, 2006, and assigned a 10 percent disability rating effective that same date. The Veteran has not expressed disagreement with either the effective date of the grant of service connection or the disability rating. Therefore, no issue involving the now-service-connected right hip disability is in appellate status. In May 2013, the Board again remanded to the AMC for additional development, to include obtaining any outstanding records of pertinent VA treatment and to obtain a copy of a handwritten November 2012 DBQ form. A review of the claims folder reflects that additional VA treatment records were associated with the Veteran's paperless claims folder. While the AMC attempted to obtain a copy of the handwritten November 2012 DBQ form, the VA Medical Center responded that the document was no longer available. Since the record reflects that there has been substantial compliance with the Board's 2011/2012 remand directives, the Board may precede with adjudication of the claim. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). A review of the records contained in the Veteran's paperless claims folder and VA Virtual claims folder have been considered in this case. FINDINGS OF FACT 1. Throughout the entire period under appeal, the Veteran's lumbar spine disability has been manifested by no more than forward flexion to 40 degrees, with evidence of painful motion, tenderness, and muscle spasms, but no further limitation of motion on repetitive motion. There is no evidence of favorable or unfavorable anklyosis or evidence of incapacitating episodes of Intervertebral Disc Disease. 2. Throughout the entire period under appeal, the Veteran's disability due to radiculopathy in the left lower extremity more closely approximates moderate functional loss. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5242, 5243 (2012). 2. The criteria for a rating of 20 percent, and not higher, for the radiculopathy in the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.25, 4.26, 4.71a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, as well as what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). Importantly, the VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom., Hartman v. Nicholson, 483 F.3d 1311 (2007). VA sent letters to the Veteran in August 2006 that addressed the notice elements concerning his claims. The letters informed the Veteran of what evidence is required to substantiate the claim, and apprised the Veteran as to his and VA's respective duties for obtaining evidence. VA also informed the Veteran how it determined the disability rating and the effective date for the award of benefits if service connection was to be awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that all notices required by VCAA and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. In addition to its duty to notify, or inform, the Veteran with regard to his claim, VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the available record includes service treatment records, service personnel records, post-service VA medical treatment reports, and the Veteran's own statements. To the extent that any more recent records may remain outstanding, there is no indication that they are necessary for a fully informed adjudication of the Veteran's claims. The Board finds that the notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to the matters have been requested or obtained. There is no evidence that any additional relevant treatment records exist, and the Veteran has not so alleged. VA provided the Veteran with VA spine and neurologic examinations in January 2007, November 2010, and November 2012, in which the examiners identified the nature and severity of the Veteran's lumbar spine and left radiculopathy disabilities, and the examiners reported the clinical findings from the examination. The Board acknowledges the Veteran's assertions that the January 2007 VA examination report is inadequate because of the "abbreviated" amount of taken to perform the examination, which she feels result in "lack of information" in the examination report. See February 2009 substantive appeal, VA Form-9. While the Board notes the Veteran's concerns on the time frame in which the examination was conducted, upon review of the two-page, single spaced examination report, the Board finds that it is adequate for VA adjudication purposes. In this regard, the Board notes that the examination report is very thorough and detailed in regards to the Veteran's reported medical history, subjective complaints, and clinical findings as well as contains findings consistent with factors regarding additional functional loss pursuant to 38 C.F.R. § §§ 4.40, 4.45, and DeLuca v. Brown, 8 Vet. App. 202 (1995). While the duration of the examination may have seemed short to the Veteran, it appears to the Board that the VA examiner was still able to create a comprehensive report based on a review of the claims folder and interview with the Veteran. Thus, although the Board has considered the Veteran's concerns, the Board finds the January 2007 VA examination report is adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2011); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to VCAA. See 38 U.S.C.A. §§ 5102 and 5103; 38 C.F.R. §§ 3.159(b), 20.1102; Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). 2. Increased Rating Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). When the veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Any reasonable doubt will be resolved in favor of granting the veteran's claim. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. § 3.102. Lumbar Spine Disability The Veteran seeks a higher evaluation for her disability due to degenerative disc disease L3-5 to L5-S1, residuals of compression fracture at T12 and L1 with intervertebral disc syndrome (lumbar spine disability). She contends that the severity of his symptomatology is more severe than reflected by the currently assigned 20 percent evaluation. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Painful motion with the joint or particular pathology, which produces a disability, warrants the minimum compensation. DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (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, 33, 43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court 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 (38 C.F.R. §§ 4.40), 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 (38 C.F.R. § 4.45). 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. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Veteran's lumbar spine disability was previously rated as 20 percent disabling under Diagnostic Code 5293-5292, which pertains to limitation of motion of the lumbar spine, and under current the Rating Schedular, her disability corresponds to rated under Diagnostic Code 5242, which pertains to degenerative arthritis of the spine and loss of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5293-5292 (2002), and 5242 (2012). The Veteran filed her claim for increased rating in August 2006, so only the current regulations are relevant. The General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243 provides for the rating of disabilities of the spine. Under the General Rating Formula for Diseases and Injuries of the Spine, where the disability is 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, a 20 percent disability 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. A 40 percent disability rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. The maximum 100 percent disability rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. It is noted that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. It is also noted that for VA compensation purposes, normal flexion of the thoracolumbar 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 (see also 38 C.F.R. § 4.71, Plate V). 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 criteria for Intervertebral Disc Syndrome (IVDS) also potentially apply. Under the rating criteria, IVDS may be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or otherwise based upon the frequency and severity of its incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The specific formula for IVDS provides: If there are incapacitating episodes having a total duration of at least 1 week but less than 2 weeks, a 10 percent rating is warranted; if at least 2 weeks but less than 4 weeks, a 20 percent rating; if at least 4 weeks but less than 6 weeks, a 40 percent rating is warranted; and where there are incapacitating episodes with a total duration of at least 6 weeks during the past 12 months, the assignment of a maximum 60 percent rating is warranted. Note (1) to the rating criteria provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, for Intervertebral Disc Syndrome. The Veteran filed her claim for an increased disability rating for her service-connected lumbar spine disability in August 2006. She described experiencing increased pain and worsening of her disability over the past few years which necessitated additional medical treatment, including physical therapy. The Veteran's private treatment records show her lumbar spine and radiculopathy disabilities were treated with pain medications, muscle relaxers, nerve block injections, and physical therapy. A June 2006 from Franciscan Spine Center shows the Veteran had a history of left side radiculopathy and diagnostic imagining reports reflected findings of spondylolysis with associated spondylolisthesis at L5-SI and degenerative disc disease from L3-4 to L5-SI. A May 2006 private treatment note shows the Veteran had forward flexion limited to 45 degrees, but no objective evidence of tenderness, and she had normal muscle strength, reflexes and sensation in her lower extremities. A June 2006 private physical therapy noted shows she had forward flexion limited to 80% of forward flexion (or limitation to 72 degrees). She was noted to have decreased trunk mobility, lateral swaying gait, and muscle spasms. In January 2007, the Veteran was afforded a VA examination to evaluate the severity of her lumbar spine disability. In the examination report, the examiner noted that the Veteran complained of stiffness and weakness in her left leg, constant lumbar pain, and with radiating pain, which she described as crushing, burning, aching, and sharp in nature. She stated that she has difficulty with bending and lifting because of her disability. She reported that her symptoms were exacerbated by physical activities and relieved with pain medication. She has had epidurals and nerve root injections in past with transient relief. She denied any incapacitating episodes because of her lumbar spine disability. On physical examination, the examiner observed that the Veteran had normal gait and posture, with normal curvature of the spine. There was no objective evidence of muscle spasms, tenderness, or radiating pain on movement. Straight leg test was negative, bilaterally. Range of motion testing revealed that the Veteran had forward flexion limited to 70 degrees, when pain begins, and total limitation of thoracolumbar motion to 183 degrees, when pain begins. There was no evidence of anklyosis. The examiner noted that there was evidence of additional limitation of motion due to pain and tenderness, but it did not result in any additional loss of motion. Neurologic examination revealed findings of decreased sensation in the left lower extremity, but normal reflexes and muscle strength evaluations. It was felt that the peripheral nerve involved in the left lower extremity was the sciatic nerve. There was no evidence of bowel or bladder problems. Diagnoses of degenerative disc disease from L4-L5, residuals of compression fracture at T12- L1, and radiculopathy in the left lower extremity were provided. Subsequent VA and private treatment records show that the Veteran continued to seek treatment for lumbar spine pain and radicular problems, for which she received pain medication, nerve block injections, and physical therapy. These records show her lumbar spine disability resulted in difficulty with sitting and walking, and decreased range of motion, as well as muscle spasms. A December 2008 VA treatment record shows clinical findings of mild kyphosis in lower thoracic region, lumbar paraspinal tightness, and limitation of flexion to 90 degrees, and with decreased sensation in the left lower extremity. . A January 2009 VA electrodiagnostic consultation report show the Veteran was referred for evaluation of low back pain with left lower extremity paresthesias. It was noted that she had a history of foot drop in 2003, but this symptomatology resolved over time, and she complained of tingling and numbness in her calf and foot. Nerve conduction studies and electromyography revealed no abnormalities. The examining physician noted that there was no electro diagnostic evidence for a lumbosacral radiculopathy of the left lower extremity, but the study cannot exclude a purely sensory radiculopathy. The Veteran underwent another VA spine and neurologic examination in November 2011. The examination report shows the Veteran complained of pain, stiffness, weakness, fatigue, muscle spasms and decreased motion in her lumbar spine, as well as paresthesias, numbness and weakness in her left lower extremity. She reported having difficulty with prolonged walking and standing. The Veteran reported that her lumbar spine and radicular pain were exacerbated by physical activities and relieved with immobilization. She denied any incapacitating episodes due to her lumbar spine disability. She also denied any bladder or bowel problems. On physical examination, the examiner observed that the Veteran had a normal gait and steady walk, and she did not require the use of an assistive device. There was no evidence of radiating pain on movement, weakness, decreased muscle strength or muscle atrophy. Straight leg test was negative, bilaterally. There was objective evidence of muscle spasms, tenderness, and guarding. Range of motion testing revealed forward flexion was limited to 75 degrees, when pain begins, and total limitation of thoracolumbar motion to 190 degrees, when pain begins. There was no evidence of additional limitation of motion due to pain, weakness, fatigue, or incoordination after repetitive use. Neurologic evaluation was normal. The examiner noted that there was no evidence of left sciatica on clinical examination or diagnostic imagining. Subsequent VA and private treatment records show that the Veteran sustained injuries from a motor vehicle accident in January 2012 and she exacerbated her lumbar spine disability. She continued to receive treatment for lumbar spine and left radiculopathy. In July 2012, the Veteran testified before the undersigned during a Board hearing at the RO. She reported that her lumbar spine and radicular pain affected her ability to perform her duties at work and impacted her activities of daily living. She stated that she was able to maintain her employment, but her disabilities impact her ability to perform her job and she has required occupational modifications at the workplace. She reported that she continues to use physical therapy and steroid injections to treat her symptomatology, but she was no longer able to take pain medication because of her work. The Veteran underwent her most recent VA spine and neurologic examination in November 2012. The examination report shows that the Veteran complained of constant pain, weakness, stiffness, and occasional muscle spasms in her lumbar spine, as well as weakness and tingling in her left lower extremity. She denied any recent incidents of dropped foot. The Veteran reported that her disabilities affect her ability to work and she has missed approximately five days from work over the past year because of her lumbar spine disability. She also reported that she has work modifications of light duty at times at her job and she can adjust the table at any height in the gastroenterology clinic during a procedure. She experiences increases in pain with activity, and she reported that treatment for episodes of severe pain is to stop the activity and sit down or lie down for five or six hours. The Veteran indicates that she stopped participated in recreational sports in 2012, because of her back and right hip conditions. She indicated that she could walk approximately a mile but has increased back pain after a half mile. She also has difficulty with prolonged sitting and standing. The Veteran felt that over the past year the frequency, duration, and intensity of pain in her back worsened, and there has been decreased activity tolerance and also an increased need for medications and difficulty getting a good night's sleep. She denied any incapacitating episodes. The Veteran denied any bladder or bowel problems due to her lumbar spine disability. On physical examination, the November 2012 VA examiner observed that the Veteran had a slow and steady, and there was objective evidence of pain when she raised herself from a seated position. There was evidence of tenderness, but no objective findings of swelling, muscle spasms or decreased muscle tone. The November 2012 VA examination report only shows findings from range of motion testing after four repetitions. The examiner noted that the results from range of motion were recorded on the database questionnaire (DBQ) for the thoracolumbar spine and it would be "faxed." However, as noted above, attempts to obtain a copy of the original November 2012 DBQ have been unsuccessful. Regardless, the examination report does contain sufficient range of motion results to adjudicate the Veteran's claim, especially since it contains range of motion findings after repetitive use test, which are usually reflect the most reduction in range of motion. Range of motion testing after four repetitions revealed the Veteran had forward flexion limited to 45 degrees, when pain begins, and after the fourth repetition, there was an additional loss of 5 degrees of forward flexion (or limitation to 40 degrees), because of pain, but there was no additional limitation of motion due to weakness and total thoracolumbar motion was limited to 195 degrees. The examiner noted lack of endurance, or any incoordination on clinical examination. Neurologic evaluation revealed findings of decreased sensation with L5 numbness in the left calf and left foot, which was assessed as mild. There was evidence of muscle atrophy in the left calf, where it measured 8 millimeters less than the right calf. There was positive findings on straight leg test on the left, but negative findings on the right. The November 2012 VA examiner assessed the Veteran with mild left sciatica and mild left L-5 numbness, and the examiner opined that there was no evidence of sciatica in the right lower extremity. Subsequent VA treatment records show that the Veteran continued to seek treatment for her lumbar spine and left radiculopathy disabilities. Pertinently, in a May 2013 VA treatment record the Veteran informed her provider that she experiences loose stool, but she believed that the symptoms were related to her medication for another condition. In considering the rating criteria, set forth above, in order for the Veteran to receive the next higher 40 percent disability rating pursuant to the General Rating Formula for Diseases and Injuries of the Spine for a disability of the thoracolumbar spine, there must be evidence of forward flexion of the thoracolumbar spine of 30 degrees or less; or favorable anklyosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The January 2007 and November 2010 VA spine examination reports specifically set forth that forward flexion was limited to no more than 70 degrees, with evidence of painful motion, with no further additional loss of motion after repetitive use or due to pain. In November 2012, forward flexion was limited at most to 40 degrees after the fourth repetition because of pain. The medical evidence of record shows that the Veteran's forward flexion of the thoracolumbar spine is well above the required limitation of flexion to 30 degrees or less, even after repetitive motion. Also, the Veteran is not shown to have had anklyosis of the thoracolumbar at any point up to present, even when taking into consideration functional loss due to pain. See Mitchell, 25 Vet. App. at 33, 43; DeLuca, 8 Vet. App. 202. Therefore, a disability rating higher than the currently assigned 20 percent does not apply under the general rating formula for spine disabilities. See 38 C.F.R. § 4.71a, Diagnostic Code 5235. Additionally, a disability rating higher than that already assigned, based on functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint is not warranted. See 38 C.F.R. §§ 4.40, 4.45, and 4.59; DeLuca, 8 Vet. App. at 202. Although each VA examiner noted that the Veteran's range of motion was additionally limited by pain, this has already been contemplated by the 20 percent disability rating for limitation of motion. Moreover, the November 2012, the VA examiner specifically indicated that the 40 degrees of limitation of flexion was demonstrated after the fourth repetition and there was no further additional limitation of motion after repetitive use. Thus, the Veteran's functional loss has already been considered in the determination of the proper rating assigned in this case. Moreover, the Veteran has not asserted and none of the medical evidence of record suggests that she has had any incapacitation in the preceding 12 months. The medical evidence does not demonstrate that she was prescribed bed rest by a physician at any point. As such, a disability rating higher than the currently assigned 40 percent under the rating criteria for intervertebral disc syndrome, also, would not be appropriate. Id. The Board acknowledges that the Veteran's contention that she should be awarded a separation evaluation for spondylolisthesis L-5 and degenerative arthritis of spine. However, the Veteran's current lumbar spine disability already considers the limitation of motion of the thoracolumbar spine due to degenerative disc disease, including the degenerative changes at L5 to SI. Evaluations for distinct disabilities resulting from the same injury may be separately rated as long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban, 6 Vet. App. at 261-62. Limitation of motion of the thoracolumbar spine has been considered and compensated under the 20 percent disability rating already assigned. To assign a separate disability rating for limitation of the motion of the spine due to spondylolisthesis at L-5 and degenerative arthritis is not permitted under the criteria. See 38 C.F.R. §§ 4.14 and 4.71a, Diagnostic Code 5003 and following notes. Nevertheless, the Veteran maintains that her spine disability warrants a higher disability rating, and the Board has considered the statements of the Veteran as to the extent of her current symptoms. She is certainly competent to report on the subjective severity of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208(1994). To the extent that the Veteran argues or suggests that the clinical data supports an increased disability rating or that the rating criteria should not be employed, she is not competent to make such an assertion. While the Veteran is a registered nurse (currently working in gastroenterology clinic), and thus, her opinions regarding medical matters carry weight beyond that of a mere lay person, she is not an orthopedic medical professional with the specialized training for evaluating lumbar spine disability. Furthermore, although her symptoms may indeed be worse, the medical evidence of record does not show that they rise to the level that would warrant the assignment of the next higher, 40 percent disability rating. The schedule provides for a separate disability 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 has already been awarded a separate compensable rating for radiculopathy in her left lower extremity, which is discussed below. There is no evidence of neurologic involvement in the right lower lower extremity. Pertinently, the Veteran received normal neurologic evaluations in her right lower extremity throughout the period under appeal and the November 2012 VA examiner concluded that there was no evidence of right sciatica on clinical evaluation. Although the recent VA treatment records show that the Veteran complained of bladder dysfunction, she attributed those problems with medication that he takes for other conditions at that time. See May 2013 VA treatment record. She has consistently denied any bladder or bowel problems associated with her lumbar spine disability and none of the VA treatment records references objective bladder dysfunction impairments associated with her lumbar spine disability. The Board finds that the preponderance of the medical evidence is against a finding that the Veteran has any additional objective neurologic abnormalities. As such, there is no other provision under which any other additional separate disability rating may be assigned for the Veteran's disability. The Veteran is entitled to be rated under the code that allows the highest possible disability rating. After reviewing all pertinent provisions, however, there is no basis on which to assign a higher or separate disability rating. The preponderance of the evidence is against a disability rating higher than 20 percent for the Veteran's lumbar spine disability. The Veteran's disability rating has been staged as captioned above. An additional staged rating is not appropriate in the present case because the Veteran's symptoms remained constant throughout the course of the period. Thus, the benefit-of-the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Left Radiculopathy Disability The Veteran is currently assigned a 10 percent evaluation for the severity of the disability due to radiculopathy in her left lower extremity associated with the lumbar disc disease under the criteria associated with Diagnostic Code 8620, for neuritis of the sciatic nerve. Under Diagnostic Code 8620, complete paralysis of the sciatic nerve warrants an 80 percent evaluation; with complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. Incomplete paralysis of the sciatic nerve warrants a 60 percent evaluation if it is severe with marked muscular dystrophy, a 40 percent evaluation if it is moderately severe, a 20 percent evaluation if it is moderate or a 10 percent evaluation if it is mild. 38 C.F.R. § 4.124a, Diagnostic Code 8620. Disability involving a neurological disorder is ordinarily to be rated in proportion to the impairment of motor, sensory, or mental function. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. 38 C.F.R. §§ 4.120, 4.124a. The Board finds that the evidence of record shows that the severity of the Veteran's radiculopathy in the left lower extremity more closely approximates the criteria associated with an evaluation of 20 percent, but not higher, under Diagnostic Code 8620. See 38 C.F.R. § 4.124a. The Veteran has consistently complained of radiating pain with symptoms of tingling and numbness in her left lower extremity and there are objective symptoms of radiculopathy on clinical examination. Clinical evaluation has consistently showed evidence of sensory deficits in the left lower extremity. At the most recent VA examination in November 2012, the Veteran complained radiating pain, numbness, and tingling down her left leg, and there was evidence of decreased sensation and muscle atrophy. Although the November 2012 VA examiner specifically characterized the Veteran's radiculopathy in the left lower extremity as mild in severity, the Board believes that the Veteran's disability is more closely approximates a moderate disability picture warranting the current 20 percent rating under Diagnostic Code 8620 for moderate neuritis of the sciatic nerve. See 38 C.F.R. § 4.124a, Diagnostic Code 8620. At no point during the period under appeal does the evidence of record demonstrate moderately severe or severe disability to warrant an evaluation in excess of 20 percent. See 38 C.F.R. § 4.124a, Diagnostic Code 8620. In this regard, the medical findings only demonstrate sensory and muscle involvement, which is described as slight, and there is indication of motor involvement to warrant a higher evaluation in the left lower extremity. Her January 2010 nerve studies revealed normal findings in the left lower extremity. 38 C.F.R. § 4.124(a). Although the Veteran has reported a history of dropped foot, she denied any occurrences during the applicable period under appeal. See July 2012 Travel Board hearing transcript, page 5. Moreover, at no point has there been objective evidence of limitation of motion or weakness in the left foot so as to be characterized as more than moderate symptomatology in other to warrant an evaluation in excess of 20 percent rating under Diagnostic Code 8620. See 38 C.F.R. § 4.124a. In short, after a review of all the evidence of record for the entire period under consideration, the Board finds that a rating of 20 percent, and no more, is warranted for radiculopathy in the left lower extremity. See 38 C.F.R. § 4.124a, Diagnostic Code 8620. Extraschedular Consideration The above determinations are based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. However, the regulations also provide for exceptional cases involving compensation. Ratings shall be based, as far as practicable, upon the average impairments of earning capacity with the additional proviso that VA shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in exceptional cases is 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Here, the Board is cognizant of the Veteran's assertions that her lumbar spine and left radiculopathy disabilities impact occupational functioning because of decreased mobility, problems with prolonged standing and walking, and weakness or fatigue. Nevertheless, the Board considers it unnecessary to refer the Veteran's disabilities for an extraschedular rating as the regular schedular standards obviously address this manifestation loss of motion in the lumbar spine due to pain, weakness, and tenderness as well as neurologic impairment in the left leg due to pain, numbness, tingling and mild sciatic involvement. The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Moreover, the competent and credible evidence of record does not otherwise show that the Veteran's lumbar spine and left radiculopathy disabilities result in a marked functional impairment to a degree other than that addressed by VA's Rating Schedule. The Veteran has maintained his employment as a nurse, despite her disability that results in loss of motion and radicular pain. Also, the Board considers it significant that the particular regulatory criteria used to rate the Veteran's service-connected disabilities expressly contemplate functional loss in the assignment of a schedular evaluation. 38 C.F.R. §§ 4.59, 4.71a. Also, Accordingly, the Board finds that the Veteran has been reasonably compensated for the impairment attributable to that disability. See Van Hoose v. Brown, 4 Vet. App. 361 (1993) (disability rating is recognition that industrial capabilities are impaired). In light of the above, the Board finds that remand for referral for consideration of an extraschedular rating is unwarranted in this instance. See 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Total Disability Rating Based Upon Individual Unemployability (TDIU) The Board also notes that this case does not raise a claim for a TDIU rating. At no point during the period under appeal has the Veteran asserted that she is unable to obtain or maintain substantially gainful employment. She has asserted that her disability causes her significant functional impairment, but this does not amount to claiming unemployable. Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). Pertinently, the evidence of record shows that the Veteran has maintained employment as a registered nurse. ORDER Entitlement to an evaluation in excess of 20 percent for degenerative disc disease L3-5 to L5-S1, residuals of compression fracture at T12 and L1 with intervertebral disc syndrome (lumbar spine disability) is denied Entitlement to an evaluation of 20 percent, and not higher, for radiculopathy of the left lower extremity is granted. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs