Citation Nr: 1509785 Decision Date: 03/09/15 Archive Date: 03/17/15 DOCKET NO. 06 07-596 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an increased disability rating for lumbar strain with degenerative joint and degenerative disc disease , rated as 10 percent disabling prior to May 23, 2011, and 40 percent disabling thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from June 1976 to June 1996. This appeal to the Board of Veterans' Appeals (Board) arose from a February 2007 rating decision in which the RO continued a 10 percent rating for lumbosacral strain with degenerative joint and disc disease. Entitlement to a total disability rating based on individual unemployability (TDIU) was granted in September 2007, effective April 13, 2006. The Board has reviewed the Veteran's electronic records (Virtual VA and VBMS) prior to rendering a decision in this case. FINDING OF FACT For the entire increased rating period, the Veteran's low back disability has been manifested by symptomatology more nearly approximating limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; ankylosis of the spine has not been shown at any time relevant to the appeal. CONCLUSION OF LAW For entire period of appeal, the criteria for an increased rating of 40 percent, but no greater, for a low back disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION Introductory Matters In this decision, the Board will discuss the relevant law that 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 United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues 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) (West 2014 & Supp. 2013); see also 38 C.F.R. § 19.7 (2013) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the 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). Duties to Notify and Assist VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). In a claim for an increased rating, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). After the claims were received, the RO advised the Veteran by letter of the requirements for substantiating the claims, and informed him of his and VA's respective responsibilities for obtaining relevant records and other evidence in support of his claims. VA's duty to assist under the VCAA includes helping claimants to obtain pertinent records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's VA and private treatment records. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). On his VA form 9 submitted in December 2009, the Veteran asserted that the range of motion findings recorded by the January 2007 VA compensation and pension examiner were incorrect. He said that the examiner recorded findings that the Veteran was not able to perform. A long line of cases indicates that "there is a presumption of regularity which holds that government officials are presumed to have properly discharged their official duties." Ashley v. Derwinski, 2 Vet. App. 307, 308 (1992) (quoting United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15, 71 (1926)). The January 2007 VA examination report appears complete on its face, showing the results of a physical examination, to include limitation of motion findings, and a review of the claims file. The examination contains sufficient information to allow for the rating of the Veteran's service-connected disabilities. Therefore, the Veteran's statements suggesting that the March 2010 VA medical examination was inadequate are insufficient to overcome the presumption of regularity. See id.; see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). Even if the January 2007 VA examination were to be inadequate, additional VA examinations were performed in May 2011 and January 2014, and the Board has not relied solely on any single examination report in the present adjudication. Appropriate VA medical inquiry has been accomplished, and the VA medical examination reports are factually informed, medically competent, and responsive to the issues under consideration. Monzingo v Shinseki, 26 Vet. App. 97 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). In March 2009, January 2011, and April 2012, the Board remanded the claims to the AOJ, in pertinent part, to provide adequate notice under the VCAA, obtain any additional records identified by the Veteran; and the provision of VA medical examinations to determine the respective severity of the service-connected low back disability. The AOJ complied with the Board's Remand directives regarding the issue of an increased rating. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). General Law and Regulations-Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2014). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21 (2014). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3. A veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue (i.e., an increased rating claim), the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). 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. See Hart v. Mansfield, 21 Vet. App. 505 (2007). "The relevant temporal focus for adjudicating an increased rating claim [as opposed to a higher initial rating claim] is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Id. at 509. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent medical evidence is 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 include 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). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curium) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered all evidence of record as it bears on the question of increased ratings. See 38 U.S.C.A. § 7104(a) (West 2014) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeals. Analysis of the Claim 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 portrays the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other 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 (2014). Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45 (2014). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2014); Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Disabilities of the spine usually are rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243). 38 C.F.R. § 4.71a. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with regard to the presence or non-presence of symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; 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 assigned for forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Id. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id.; see also Plate V, 38 C.F.R. § 4.71a. The Formula for Rating Intervertebral Disc Syndrome (IVDS) based on incapacitating episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least two weeks, but less than four weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 defines an incapacitating episode as 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. The present claim for an increased rating was received in November 2005. An X-ray taken in August 2005 revealed degenerative disc disease between L5 and S1 and slight narrowing posteriorly between L3 and L4. A December 2005 VA treatment record reflects that the Veteran experienced muscle spasms. Pain was elicited by motion. The examiner noted that lumbosacral spine and thoracolumbar spine ranges of motion were normal and full. In December 2005, the Veteran was treated at a private hospital for lower back pain. He reported that his job at the post office required him to stand on his feet for many hours during the day. The Veteran was continent. An MRI revealed a lumbar disk protrusion at the L5-S1 level. The assessment given was history of chronic low back pain with MRI evidence of an L5 nerve root irritation. Private treatment records from January 2006 and March 2006 indicate that the Veteran's back ranges of motion were limited. Extension was to 5 degrees, and flexion was to 10 degrees. A March 2006 private physical therapy note reflects that the Veteran had an antalgic gait. Range of motion measurements were recorded as percentages. Forward flexion was noted to be 50 percent and later as 25 percent. Left rotation was noted to be 50 percent and later as 75 percent. Right rotation was 75 percent. Extension was 50 percent. In April 2006, the Veteran told a private treatment provider that his severe back pain made him unable to work. The examiner felt that his complaints were very subjective and poorly localized. Another treatment provider noted range of motion findings of extension to 5 degrees and flexion to 10 degrees. A private treatment record from May 2006 indicates that the Veteran had normal range of motion of his spine. A VA medical record from May 2006 reflects that flexion, extension, and lateral bending were limited for the back. In October 2006, the Veteran underwent a functional capacity evaluation. The examiner concluded that the Veteran was currently functioning between a "sedentary" and "light" physical demand level, and any occupation the Veteran performed in would need to allow sitting for the majority of the day. On VA compensation and pension examination in January 2007, the examiner noted that the Veteran stood bent about 15 degrees forward from vertical while at rest. The Veteran could bend backwards to about 20 degrees with pain. He could bend laterally about 20 degrees with pain. Forward flexion was to 90 degrees with pain. Repetitive motion did not change any ranges of motion. There was normal strength in both legs and normal reflexes at the knee and ankles. Peripheral nerve conduction studies and an electromyelogram done within the past year on the lower extremities elicited no evidence of neuropathy, but radiographic studies showed some degenerative disk disease and spondylolisthesis of the lumbosacral spine. A private examiner indicated on July 2, 2007 that the Veteran used a simple cane for walking. The cane was not prescribed by a physician. The examiner felt that the Veteran's ability to stand and move was moderately impaired. Forward flexion of the thoracolumbar spine was to 15 degrees. Extension was to 10 degrees. Lateral flexion was to 15 degrees bilaterally. On his VA form 9 submitted in December 2009, the Veteran asserted that the range of motion findings recorded by the January 2007 VA compensation and pension examiner were incorrect. He said that the examiner recorded findings that the Veteran was not able to perform. He remarked that the findings of the January 2007 were in contradiction with the findings of the October 2006 functional capacity evaluation. On VA compensation and pension examination in May 2011, the Veteran denied experiencing bladder incontinence, but he said he had bowel incontinence for at least the prior three months. He had not informed his primary care physician about the bowel incontinence. Concerning incapacitating episodes, he said that his primary care physician told him to lie in bed "after injections," which he had received five times during the previous year. The Veteran could not recall how long he was told to lie in bed for. The C and P examiner could find no written documentation of physician-prescribed bedrest. He reported radiating pain and lower extremity weakness. He used a cane. He was last employed in 2006, and he reported that he missed nearly all of his last year of work due to back pain. Forward flexion of the thoracolumbar spine was to 20 degrees. Extension was to 0 degrees. Bending to both sides was to 20 degrees. The Veteran declined to rotate to either side and said that rotating would be "too painful." There were no changes in the ranges of motion with repetition. No objective signs of spasm or deformity were found. There was no ankylosis of the lumbar spine. On VA compensation and pension examination in January 2014, the Veteran reported continual pain that flared daily. Although he experienced occasional, inconsistent bouts of fecal incontinence, he denied experiencing urinary incontinence or sexual dysfunction. Forward flexion of the thoracolumbar spine was to 70 degrees with pain. Extension was to 20 degrees with pain. The examiner indicated that the Veteran refused to perform lateral flexion and rotation testing. The examiner further observed that the Veteran was able to sit upright without difficulty. The examiner noted that the Veteran was able to dress and undress himself in the office that day, and he was able to bend down more than 70 degrees from a sitting position to put his socks and shoes on. On repetitive use testing, extension was reduced to 15 degrees; all other range of motion findings remained the same. Muscle spasms of the thoracolumbar spine resulted in an abnormal gait or spinal contour. No muscle atrophy was present. There was no ankylosis of the spine. Moderate radicular pain radiating into the lower extremities was present; no other neurological abnormalities attributable to the thoracolumbar spine condition were found. The examiner specified that the Veteran had no incapacitating episodes during the prior 12 months due to intervertebral disc syndrome. The Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of height. The examiner specifically commented on his review of the Veteran's history from 2005 through the present. He said that the Veteran's complaints of back pain have been consistent; however, there were no noticeable changes with the Veteran's neurological complaints until he complained of bowel incontinence. The examiner noted that the Veteran's lumbo-sacral nerve root involvement consisted L5-S1, and although the Veteran reported occasional bouts of fecal incontinence, he denied any other symptoms related to his sacrum. As such, the examiner opined that the Veteran's reports of occasional fecal incontinence were not consistent with the affected nerve roots in question. The examiner explained that the nerve roots that are involved in urinary and fecal incontinence and sexual dysfunction are S2, S3, and S4, whereas the Veteran's affected nerve roots were L5-S1. The examiner further explained that on review of the claims file, the Veteran had been seen multiple times for his back condition, but it would be mere speculation to comment on where there was objective evidence of when the condition worsened, as his symptoms waxed and waned since 2005. The Veteran's low back disability is currently rated as 10 percent disabling prior to May 23, 2011, and 40 percent disabling thereafter. The Board finds that throughout the period of appeal, the Veteran's low back disability more nearly approximated the criteria for a 40 percent rating, but no higher, under Diagnostic Code 5237. The medical evidence for the period prior to May 23, 2001 is contradictory. Within a matter of months, private and VA examiners found gave widely disparate objective observations regarding the ranges of motion the Veteran was able to perform in connection with his lower back disability. See, e.g., December 2005 VA treatment record reflecting normal and full flexion; January 2006, March 2006, and April 2006 private records reflecting flexion limited to 10 degrees; May 2006 private record reflecting a normal range of motion; May 2006 VA treatment record reflecting a limited range of motion; January 2007 VA compensation and pension examination showing forward flexion to 90 degrees with pain; July 2007 private treatment record reflecting forward flexion of the thoracolumbar spine to 15 degrees. Indeed, these disparate medical observations caused the Board to remand this case to obtain a retrospective medical opinion regarding the nature and symptomatology of the Veteran's low back disability. The requested retrospective opinion was ostensibly given by the January 2014 VA examiner. The examiner opined that the Veteran's complaints have been consistent throughout the appeal, but it would be mere speculation to comment on where there was objective evidence of exactly when the condition worsened. In light of this opinion, and in light of the multiple records which demonstrate forward flexion of the thoracolumbar spine 30 degrees or less prior to May 23, 2011, the Board finds that a 40 degree disability rating is warranted throughout the entire period of appeal. For the entire rating period under appeal, the evidence does not indicate that the Veteran's low back disorder symptomatology more nearly approximated that required for the next higher 50 percent rating under any applicable Diagnostic Code. The Veteran has not claimed, and the record does not show, that the Veteran's thoracolumbar spine is ankylosed, as would be required for a higher rating. The Board has considered his self-report that his doctor told him to lay in bed "after injections" which he had received five times during the 2010 through 2011. Significantly, the Veteran could not recall how long he was told to lie in bed for. Further, the objective medical evidence does not reflect that the Veteran was prescribed bed rest due to incapacitating episodes of the spine at any time during the period of appeal; as such, the Veteran has not claimed, and the objective evidence does not show, that he was prescribed bed rest for incapacitating episodes due to intervertebral disc syndrome for a total duration of at least six weeks during any 12 month period pertinent to the current appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5242, 5243. When assigning a disability rating for an orthopedic disorder, the Board must consider functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca, 8 Vet. App. at 206-07. However, the record contains no evidence, either lay or medical, suggesting that the Veteran's low back disability more nearly approximated the symptomatology required for a next higher rating even upon repetitive testing or flare-up. Under Note (1) of the General Rating Formula, VA must consider whether combining ratings for orthopedic and neurological manifestations would result in a higher rating for the Veteran's service-connected lumbar spine disability. However, in a separate In a September 2007 rating decision, the RO granted service connection for radicular pain in the right and left lower extremities, each rated 10 percent disabling, effective November 14, 2005. The Veteran did not appeal the ratings for the extremities. As such, those issues are not before the Board. The Veteran has reported experiencing occasional fecal incontinence; however, the January 2014 VA examiner essentially explained that the Veteran's reports of occasional fecal incontinence were unrelated to his service-connected back disorder, as the nerve roots that are involved in urinary and fecal incontinence and sexual dysfunction are S2, S3, and S4, whereas the Veteran's affected nerve roots were L5-S1. Although the Veteran is competent to report observable symptomatology, this matter involves attribution of symptoms to specific, unobservable damaged nerves. As such, it involves a complex medical situation. Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, in this particular situation, the Veteran's statements are not considered to be competent nexus evidence and are outweighed by the January 2014 VA examiner's opinion. The evidence of record does not reflect the presence of other neurological manifestations attributable to the service connected lumbar spine disorder. Thus, no further consideration is necessary at this time under Note (1). In sum, extending every reasonable doubt in favor of the Veteran, the Veteran's low back disability symptomatology more nearly approximated that required for a 40 percent rating, but no greater, under Diagnostic Code 5237 for the entire period on appeal. See 38 U.S.C.A. § 5107(b); Gilbert, at 54-56. The above determination is based upon consideration of pertinent provisions of VA's rating schedule. The Veteran's service-connected lumbar strain has not been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extraschedular basis. See 38 C.F.R. § 3.321. In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, 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. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, 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. The Board finds that the first Thun element is not satisfied here. The Veteran's service-connected lumbar strain is manifested by signs and symptoms such as pain and tenderness, muscle spasm, limitation of motion, and impaired ability to sit, walk, and stand for prolonged periods of time. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The General Rating Formula for Diseases and Injuries of the Spine specifically contemplates symptoms such as pain (whether or not it radiates), stiffness, and aching, as well as neurologic abnormalities. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; instability of station; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's lumbar strain picture. For all the reasons discussed above, and extending every reasonable doubt to the Veteran, the Board has resolved reasonable doubt the Veteran's favor in determining that a 40 percent rating is warranted for the service-connected lumbar strain for the entire period of appeal. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 40 percent rating for lumbar strain with degenerative joint and degenerative disc disease is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs