Citation Nr: 1610985 Decision Date: 03/17/16 Archive Date: 03/23/16 DOCKET NO. 11-12 284 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a rating in excess of 20 percent for thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing. 2. Entitlement to service connection for dental condition/loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active service from June 1962 to June 1966. This matter is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, wherein the RO denied a claim of service connection for a dental disability and granted service connection thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing and assigned a 20 percent disability rating, effective from November 25, 2009. The Veteran appealed the denial of service connection for the dental disability and appealed the assigned rating for the back disability. This case was before the Board in August 2014, at which time the Board denied a rating greater than 20 percent for the Veteran's service-connected thoracic/lumbar spine disability (while remanding the dental disability claim and another matter). Thereafter, the Veteran filed an appeal to the United States Court of Appeals for Veterans Claims (Court). In March 2015, the Veteran's then-representative and VA's General Counsel filed with the Court a Joint Motion for Partial Remand (Joint Motion) to vacate the Board's August 2014 decision with respect to the Board's denial of an of increased rating for the Veteran's service-connected thoracic/lumbar spine disability, which motion was granted by the Court the same month. The basis for the Joint Motion included the Board's failure to provide an adequate statement of reasons or bases for concluding that the Veteran was not entitled to a rating in excess of 20 percent for his service-connected thoracic/lumbar spine disability on account of additional functional loss sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40, 4.45, 4.59. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). In May 2015, the Board remanded the back disability increased rating issue for additional development to ensure compliance with the directives of the March 2015 Joint Motion. At the time of the May 2015 remand, the development of the dental issue remanded by the Board in August 2014 had not yet been completed. Following the Board's May 2015 remand, the requested development concerning both the back and dental disability issues has been completed; both issues have now both been properly prepared for final appellate review at this time. The case has been reassigned to the undersigned Veterans Law Judge (VLJ). Prior action by the Board in this matter was by a VLJ other than the undersigned. The Board notes that the Veteran's appeal previously included the issue of entitlement to service connection for a right knee disability, which was remanded to the AOJ by the Board in its August 2014 decision. However, during the processing of that remand, service connection was granted for the claimed right knee disability in an August 2015 RO rating decision. The award of service connection is a full grant of the benefit at issue, and that issue shall not be discussed further in detail herein. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). A claim of service connection for a dental disability is also considered a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). In dental claims, the RO adjudicates the claim for service connection and the VA Medical Center adjudicates the claim for outpatient treatment. As the current issue of service connection for a dental disability stems from an adverse determination by the RO, the dental issue addressed herein must be limited to service connection for compensation purposes only. The claim for VA outpatient dental treatment is REFERRED to the Agency of Original Jurisdiction (AOJ) for further referral to the appropriate VA medical facility. See 38 C.F.R. §§ 17.161 and 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The Veteran's thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing is not shown to have manifested in limitation of forward flexion of the thoracolumbar spine 30 degrees or less, nor ankylosis of the entire thoracolumbar spine, nor incapacitating episodes having a total duration of at least 4 weeks during a 12 month period, nor any neurological manifestations aside from those acknowledged in the additional findings below. 2. The Veteran's thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing is not shown to have manifested in radiculopathy of the right lower extremity prior to July 31, 2015; incomplete paralysis of the sciatic nerve in the right lower extremity has not been shown to be moderately severe (or greater than moderate) for the period from July 31, 2015 onward. 3. Since August 4, 2015, the Veteran's right lower extremity radiculopathy is shown to involve moderate (but not severe) incomplete paralysis of the femoral nerve. 4. Since August 4, 2015, the Veteran's thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing is shown to involve left lower extremity radiculopathy featuring mild (but not moderate) incomplete paralysis of the sciatic nerve. 5. The Veteran is not shown to have, or during the pendency of the claim to have had, a dental disability for which compensation is payable. CONCLUSIONS OF LAW 1. A rating in excess of 20 percent for service-connected thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Codes 5237, 5243 (2015). 2. For the period from July 31, 2015, the criteria for a disability rating in excess of 20 percent for impairment of the sciatic nerve of the right lower extremity (as part of the right lower extremity radiculopathy) have not been met; the criteria for a separate compensable rating for right lower extremity radiculopathy prior to July 31, 2015 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 3. Effective August 4, 2015, the criteria for a separate disability rating of 20 percent, but no higher, for impairment of the femoral nerve of the right lower extremity (as part of right lower extremity radiculopathy) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2015). 4. Effective August 4, 2015, the criteria for a separate disability rating of 10 percent, but no higher, for radiculopathy of the left lower extremity (as impairment of the left leg sciatic nerve) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2015). 5. Service connection for a dental disability for compensation purposes is not warranted. 38 U.S.C.A. §§ 1110, 1131, 1712, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.381, 4.150, 17.161 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. By correspondence dated in December 2009, VA notified the Veteran of the evidence and information needed to substantiate and complete his claims, of what information he was responsible for providing, of the evidence that VA would attempt to obtain on his behalf, and how VA assigns disability ratings and effective dates of awards. The Veteran's service treatment records (STRs) are associated with the record, and pertinent VA and private treatment records have been secured. The AOJ arranged for VA examinations concerning the Veteran's back disability in March 2010, July 2015 (a fee-basis VA examination) and August 2015, which the Board find to be cumulatively adequate as they include both a review of the Veteran's history and physical examinations that included all necessary findings. The AOJ also arranged for VA examination concerning the dental disability at issue in this case in August 2015; the Board finds the August 2015 VA dental examination reports to be adequate as they included the pertinent clinical findings and diagnostic conclusions necessary to resolve this claim, informed by review of the Veteran's pertinent history. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). That is, these examinations, in the Board's judgment, show a thorough consideration of the disabilities on appeal and provide the necessary information to adjudicate the claims. The Board finds that the Board's prior remand directives (from the August 2014 and May 2015 Board remands) pertaining to the issues remaining on appeal have been completed with substantial compliance. The August 2015 VA examinations concerning the dental and back disability issues were conducted in accordance with the remand directives. The Veteran has not identified any pertinent evidence that remains outstanding. The Board finds that the record includes adequate competent evidence to allow the Board to decide the matter on the merits. Increased Ratings for Thoracic/Lumbar Levoscoliosis with Spondylosis and Degenerative Disc Space Narrowing Initially, the Board notes that it has reviewed all of the evidence in the Veteran's record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence.) Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations apply, 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 there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. With a claim for an increased initial rating, separate "staged" ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's statements describing his symptoms and condition are competent evidence to the extent that he can describe what he experiences. However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. Lay evidence is not competent evidence concerning complex medical questions requiring specialized training or expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans' Court.) When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to factors such as disability causing less movement than normal, more movement than normal, weakened movement, excess fatigability, and incoordination. The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); 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). Pain, in and of itself, that does not result in additional functional loss does not warrant a higher rating; the Court held that pain alone does not constitute function loss, but is just one fact to be considered when evaluating functional impairment. Id. The Veteran's service-connected thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing has been rated as 20 percent disabling by the RO under the provisions of Diagnostic Code 5237 for lumbosacral strain throughout the period on appeal. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made 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. Under the General Rating Formula for Diseases and Injuries of the Spine, the disability is evaluated 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 10 percent rating requires thoracolumbar spine forward flexion greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, 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 rating requires thoracolumbar spine forward flexion 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 rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the thoracolumbar spine warrants a 50 percent evaluation, and unfavorable ankylosis of the entire spine is rated 100 percent disabling. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note 1. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note 2. Further, all measured ranges of motion should be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note 4. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note 5. Intervertebral disc syndrome (preoperatively or postoperatively) may 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 when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months warrants a 10 percent rating. Incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months warrants a 20 percent rating. Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrants a 40 percent rating. A 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that required bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. During the pendency of this appeal, in an August 2015 rating decision, the RO has assigned a separate 20 percent disability rating for the Veteran's radiculopathy in the right lower extremity associated with the back disability, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, dealing with the sciatic nerve. Under Diagnostic Code 8520, pertaining to paralysis of the sciatic nerve, mild incomplete paralysis warrants a 10 percent disability rating, moderate incomplete paralysis warrants a 20 percent disability rating, moderately severe incomplete paralysis warrants a 40 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. An 80 percent disability rating is warranted for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. Also relevant to this case, Diagnostic Code 8526 pertains to mild incomplete paralysis of the anterior crural (femoral) nerve. Under Diagnostic Code 8526, disability evaluations of 10, 20, and 30 percent are assignable for incomplete paralysis of the anterior crural nerve which is mild, moderate, or severe, respectively. 38 C.F.R. § 4.124a, Code 8526. A schedular maximum evaluation of 40 percent disabling is warranted for complete paralysis of the anterior crural nerve, as manifested by paralysis of quadriceps extensor muscles. Id. The term "incomplete paralysis," with these and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. See "note" at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124a. In the July 2010 rating decision, the RO granted service connection and assigned an initial 20 percent rating for the Veteran's thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Veteran contends that his service-connected low back disability is more disabling than reflected by the assigned 20 percent rating. For the reasons that follow, the Board concludes that an increased disability rating for the spine disability itself is not warranted, but a new separate 10 percent rating for radiculopathy of the left lower extremity is warranted (after resolution of reasonable doubt in the Veteran's favor) and an additional separate rating for paralysis of the femoral nerve as part of the radiculopathy of the right lower extremity is warranted (in addition to the already established rating for paralysis of the sciatic nerve of the right lower extremity). Historically, the Veteran's service treatment records reflect that he presented at the military clinic in October 1964 with complaints of ongoing low back pain. He underwent a lumbar spine x-ray at this time, the findings of which revealed "a very slight levoscoliosis" as well as "minimal anterior wedging of the inferior margin of L-1," findings suggestive of a compression injury and partial herniation of the nucleus pulposus. Subsequent service treatment records show that the Veteran was involved in a motor vehicle accident (MVA) in October 1965, at which time he was taken to the hospital and treated for head injuries and memory loss. He also underwent a spinal puncture during this time which appears to have helped alleviate his condition and restore his memory. The Veteran was afforded a VA examination in connection to his claim in March 2010, at which time he provided his medical history and attributed his symptoms to his MVA in service. The Veteran reported experiencing a moderate level of pain in his lower back that occurs on a regular basis and which travels down his right leg and foot. The Veteran also described symptoms of stiffness, decreased motion and numbness associated with his spinal condition, but denied any symptoms of fatigue, spasms and paresthesia due to this disorder. According to the Veteran, the pain is exacerbated by physical activity and relieved through rest. The Veteran also reported to have functional impairment as a result of his flare-ups, noting that he cannot run or pick up heavy objects and has difficulty bending down easily during his flare-ups. The Veteran further reported experiencing functional limitations when standing and walking, adding that he cannot stand for long periods of time, and on average, he can only walk 1.5 miles as a result of his back condition. The Veteran also described symptoms of weakness in his leg and foot due to his spinal disorder, but denied any bowel problems in relation to his spine condition. The Veteran denied ever being hospitalized or undergoing surgery for his back condition, and noted that his condition had not resulted in any incapacitation in the past twelve months. On physical examination, the Veteran walked with a normal gait and was shown to have flexion to 58 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 30 degrees, and right and left rotation to 30 degrees. According to the examiner, the objective findings were absent any evidence of muscle spasms, guarding, tenderness or radiating pain on movement, and the examination was clear for any signs of weakness. The examiner further noted that the straight leg raising tests produced normal results, the Lasegue's sign was negative for abnormalities, and there were no indications or signs of atrophy present in the limbs. The Veteran also underwent an x-ray of the thoracic and lumbar spine, the impression of which showed mild lower thoracic levoscoliosis, minimal to moderate diffuse lumbar spondylosis, mild lower lumbar levoscoliosis, and minimal to moderate diffuse lumbar spondylosis in association with multilevel degenerative disc space narrowing. Based on his evaluation of the Veteran, the VA examiner diagnosed the Veteran with thoracic and lumbar levoscoliosis, thoracic and lumbar spondylosis and lumbar degenerative disc space narrowing. Subsequent VA treatment records reflect that the Veteran continued to present at the VAMC on a regular basis with complaints of chronic back pain. In the March 2015 Joint Motion, the parties pointed out the report of the March 2010 VA examination records the Veteran's assertions that "during flare-ups he could not 'run or pick up heavy objects' and could not 'bend down easily.'" The parties agreed that the Board's August 2014 decision erred in not addressing the Veteran's lay statement in this regard and directed that on remand, the Board should make a determination as to the competency and probative value of Veteran's lay statements regarding the additional functional losses he experiences during flare-ups and should consider whether the March 2010 VA examination was adequate in light of the Court's holding in Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes that for disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, which require the Board to consider additional functional loss a veteran may have sustained by virtue of such factors as more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. See DeLuca, supra. Consideration must also be given to functional loss on use or due to flare-ups. Id. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups, which determination are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. In Mitchell, the Court found an examination inadequate because the examiner failed to address, among other things, functional loss during flare-ups. Mitchell, 25 Vet. App. at 44. In its May 2015 remand, the Board found that compliance with terms of the parties' March 2015 Joint Motion required the Board to remand the issue of entitlement to a rating in excess of 20 percent for the Veteran's thoracic/lumbar spine disability for further development. The Board noted that the March 2010 VA examination report does not contain findings adequate for the Board to determine whether consideration of the DeLuca factors warrants a higher rating in this case. Notably, although the Veteran described the limitations he experiences during a flare-up, there is no discussion of the frequency or duration of the Veteran's flare-ups. While the Veteran is competent to describe the nature of his flare-ups, the lack of additional detail prevents the Board from determining whether the Veteran's decreased functional abilities due to flare-ups warrant a rating in excess of 20 percent. (An examination is also determined to be necessary given that more than five years had passed since the prior compensation examination was conducted.) Following the Board's May 2015 remand, the AOJ arranged VA examinations for the Veteran's back disability in July 2015 and August 2015. The July 2015 VA fee-basis examination shows that the Veteran was diagnosed with the thoracic/lumbar spine levoscoliosis with spondylosis and degenerative disc space narrowing with intervertebral disc syndrome and radiculopathy of the right lower extremity. This report specified finding "moderate" radiculopathy involving the "sciatic nerve." The report shows that the Veteran experienced flare-ups brought about "if walking a lot and when I get up in the morning or lifting or stooping low." Clinical testing revealed forward flexion to 50 degrees, with objective evidence of painful motion beginning at 45 degrees. Range of extension was to 25 degrees, with painful motion beginning at 15 degrees. Right lateral flexion was to 20 degrees, with painful motion evident at 20 degrees. Left lateral flexion was to 25 degrees, with painful motion evidence at 25 degrees. Right lateral rotation was to 15 degrees, with painful motion evident at 15 degrees. Left lateral rotation was to 20 degrees, with painful motion evident at 20 degrees. Ranges of motion testing after repetitive use testing revealed flexion to 40 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, right lateral rotation to 15 degrees, and left lateral rotation to 20 degrees. The July 2015 VA fee-basis VA examination report indicates findings of functional loss / impairment following repetitive use featuring reduced motion, pain on movement, and disturbance of locomotion. The Veteran had localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine, and he also had guarding or muscle spasm manifesting in abnormal gait. Muscle strength testing revealed normal strength in all respects for left lower extremity testing, and normal strength for the right lower extremity testing except for knee extension (rated "4/5 Active movement against some resistance"). There was no muscle atrophy. Reflex testing was "All normal" in all respects. Straight leg raising test was positive for the right leg and negative for the left leg. Right lower extremity sciatic radiculopathy was noted, without constant pain but with moderate intermittent pain, moderate paresthesias, and moderate numbness. No radiculopathy was found in the left lower extremity. The examiner indicated that there were no other neurologic abnormalities. The July 2015 VA fee-basis examiner found that the Veteran's intervertebral disc syndrome had not manifested in any incapacitating episodes over the prior 12 months. The report notes that the Veteran used a brace occasionally and a cane regularly for locomotion due to "back and knee pain." The examiner was "[u]nable to describe" the Veteran's further limitation during flare-ups "in terms of ROM loss because this will depend on the type of activity performed and severity of pain experienced by the claimant." Another VA examination evaluating the Veteran's back disability for rating purposes was performed in August 2015. The August 2015 VA examiner conducted direct examination of the Veteran and reviewed the Veteran's claims-file. This report describes that the Veteran reported "constant pain in lower back that radiates into right leg to ankle whenever he walks or drives too long." Additionally, "[h]e also has numbness and tingling wi[th] occasional weakness in the right leg that occurs if he sits too long, or walks too far. He is able to walk for about 1 block before having to sit and rest." The report notes that the Veteran "is receiving nerve root ablation procedures about twice per year ...." The report describes the Veteran's account of flare-ups: "occur every 6-8 months with increasing pain in back and more frequent radiation of the pain into his right leg with numbness and tingling in leg. Flare ups last for a few weeks during which time he is unable to walk as much or sit/drive for as long." Additionally, the report describes that the Veteran indicated being "[u]nable to walk for more than 1 block, or sit while driving for more than 2 hours." The August 2015 VA examination's range of motion testing revealed forward flexion limited to 70 degrees, extension limited to 10 degrees, right lateral flexion limited to 20 degrees, left lateral flexion limited to 20 degrees, right lateral rotation limited to 20 degrees, and left lateral rotation limited to 15 degrees. The VA examiner noted that "ROM in flexion was noted and observed as he was donning and doffing shoes and socks." The VA examiner found that the abnormal ranges of motion did not themselves contribute to a functional loss. Pain was observed in all tested ranges of motion, and on weight bearing. The VA examiner found: "pain noted on exam but does not result in/cause functional loss." The VA examiner's notes on observed repetitive use indicate that the Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. The August 2015 VA examiner noted that the examination did not take place immediately after repetitive use over time. The VA examiner opined that "[t]he examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time." The VA examiner found that pain significantly limited functional ability with repeated use over a period of time. The VA examiner explained that he could not describe the functional loss in terms of range of motion because he was "not present after a period of repetitive use in order to examine patient." The August 2015 VA examiner discussed the Veteran's flare-ups, noting that the examination was not conducted during a flare-up but opining that "[t]he examination is medically consistent with the Veteran's statements describing functional loss during flare-ups." The VA examiner opined that pain significantly limited functional ability during flare-ups, but was not able to describe in terms of specific range of motion because the examiner was "not present during a flare-up...." The August 2015 VA examiner found no guarding or muscle spasm of the thoracolumbar spine. The VA examiner found that the Veteran's disability from the back pathology involved disturbance of locomotion and interference with sitting. Muscle strength testing revealed "5/5 Normal strength" in all respects for both lower extremities. There was no muscle atrophy. Reflex testing revealed that right lower extremity reflexes were "0 absent" for the right lower extremity in both the knee and the ankle; for the left lower extremity, knee reflex was "1+ hypoactive" and ankle reflex was "0 absent." Sensory examination of the right lower extremity revealed "Normal" findings for the upper anterior thigh (L2) and thigh/knee (L3/4), but "Decreased" sensation for lower leg/ankle (L4/L5/S1) and for foot/toes (L5). Sensory examination of the left lower extremity revealed "Normal" findings for the upper anterior thigh (L2), thigh/knee (L3/4), and lower leg/ankle (L4/L5/S1), but "Decreased" sensation for foot/toes (L5). Straight leg testing was positive for the right and negative for the left. The VA examiner found that the Veteran had femoral and sciatic nerve radiculopathy of the right lower extremity but not of the left. The right lower extremity radiculopathy was noted to feature moderate intermittent pain (without constant pain), moderate paresthesias and/or dysesthesias, and moderate numbness. The severity of the right lower extremity radiculopathy was characterized by the VA examiner as of "moderate" severity. The VA examiner found that the Veteran had no other neurological abnormalities or findings related to a back condition. The August 2015 VA examiner found that the Veteran's intervertebral disc syndrome had not manifested in any episodes of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician in the prior 12 months. The VA examiner noted that the Veteran required constant use of a cane for locomotion assistance. The August 2015 VA examiner discusses that the Veteran "has pes cavus and hammer toes with feet and calves of the typical appearance of Hereditary sensorimotor neuropathy." The VA examiner states: "Some of the patient's sensory and DTR findings can most likely be attributed to this hereditary condition. It is not possible to state how much of the neurological deficits are related to this condition without resorting to speculation." The August 2015 VA examination report goes on to document that diagnostic imaging confirmed arthritis of the thoracolumbar spine, without any vertebral fracture with loss of 50 percent or more of height. Concerning functional impact, the VA examiner describes "Limited bending, stooping, crawling, heavy lifting or carrying." The VA examiner described that the involvement of nerve roots L3, L4, and L5 on the right caused "intermittent weakness ... described by the patient with a history of 'dragging' the right leg at times.... the equivalent of an 'incomplete paralysis of moderate severity'...." Significantly, the VA examiner opined that: [t]he nature, duration and frequency of the veteran's flare ups to include functional losses sustained as a result thereof does not more nearly approximate a disability tantamount in severity to that of forward flexion of the thoracolumbar spine limited to 30 degrees or less or to ankylosis. The VA examiner cited that the "Veteran describes a fairly active life despite the flare ups which are about twice per year and are fairly well managed with periodic nerve root ablations." In considering the evidence of record under the General Rating Formula for Diseases and Injuries of the Spine, the Board concludes that the Veteran is not entitled to an increased evaluation in excess of 20 percent for his service-connected back disability. The evidence of record does not indicate that the Veteran has had limitation of forward flexion of the thoracolumbar spine to 30 degrees or less, and it also does not show that he had favorable ankylosis of the entire thoracolumbar spine. As discussed above, the Veteran was shown to have flexion no worse than 40 degrees (shown in the July 2015 VA fee-basis VA examination report, accounting for pain and repetitive use testing). Although VA treatment records reflect treatment for his back pain, these records are absent any indication that the Veteran's range of motion during flexion was limited or reduced to 30 degrees. In addition, the VA examination reports and the VA treatment records present no suggestion of ankylosis of the lumbar spine. The Board notes that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). The evidence of record reflects that the Veteran is able to perform the range of motion exercises, and while his movement may be somewhat limited during these exercises, there is no indication that his spine is fixated in the neutral position or fixed in flexion or extension. The Board does not doubt that the Veteran has pain; however, in light of the ranges of motion documented at the examinations, the Board cannot find that his service-connected back disability equates to limitation of flexion of 30 degrees or less or favorable ankylosis of his entire thoracolumbar spine. As such, the Board finds that the Veteran has not met the criteria for an evaluation in excess of 20 percent under the applicable rating criteria (aside from the separate ratings for associated lower extremity radiculopathy, discussed below). The Board has also considered whether the Veteran would be entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, the medical evidence of record does not show that the Veteran has had incapacitating episodes with a total duration of at least four weeks during the past 12 months. There are no treatment records documenting the Veteran as having been prescribed bed rest by his physician due to his back disability. In fact, at the March 2010 VA examination, the Veteran reported that his thoracolumbar spine condition had not resulted in any incapacitating episodes during the past twelve months requiring bed rest or treatment by a physician, and the July and August 2015 VA examination report indicated no such incapacitation in the preceding year. The March 2010 VA examiner further noted no signs of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement. The July 2015 VA fee-basis examiner reported that the Veteran had experienced no incapacitating episodes of intervertebral disc syndrome in the preceding 12 months, and the August 2015 VA examiner further confirmed this fact. The evidence of record does not otherwise suggest that the Veteran has had incapacitating episodes requiring bed rest prescribed by a physician with a total duration of at least four weeks during a 12 month period. Thus, a higher rating is not warranted under the criteria for intervertebral disc syndrome. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's service-connected thoracolumbar spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions. The Board further observes that the Veteran has reported experiencing a number of functional limitations, to include difficulty standing and walking for long periods of time, as a result of his back disability. The March 2010 VA examiner did not observe evidence of additional limitation of motion or functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive movement. The March 2010 examiner noted no signs of muscle spasms, tenderness, guarding of movement or weakness when evaluating the Veteran's lumbar spine disability. As such, the Board finds that the effect of the pain in the Veteran's thoracolumbar spine is contemplated in the currently assigned 20 percent disability evaluation. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. Therefore, the Board concludes that an evaluation in excess of 20 percent for the Veteran's low back disability is not warranted. With attention to the concerns expressed in the March 2015 Joint Motion, the Board recognizes the Veteran's statements attesting to his chronic back pain and discomfort. Statements made by the Veteran at the March 2010 VA examination reflect that he has limitations and functional impairment when walking, standing and running and when trying to conduct certain day-to-day activities as a result of his back disability. The Veteran reported that "during flare-ups he could not 'run or pick up heavy objects' and could not 'bend down easily.'" Statements made by the Veteran at the August 2015 VA examination reflect that he has "constant pain in lower back that radiates into right leg to ankle whenever he walks or drives too long." Additionally, "[h]e also has numbness and tingling wi[th] occasional weakness in the right leg that occurs if he sits too long, or walks too far. He is able to walk for about 1 block before having to sit and rest." The August 2015 VA examination report describes the Veteran's account of flare-ups: "occur every 6-8 months with increasing pain in back and more frequent radiation of the pain into his right leg with numbness and tingling in leg. Flare ups last for a few weeks during which time he is unable to walk as much or sit/drive for as long." Additionally, the report describes that the Veteran indicated being "[u]nable to walk for more than 1 block, or sit while driving for more than 2 hours." Lay persons are competent to attest to observable symptomatology. In addition, the Veteran's statements describing his symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). Significantly, however, the August 2015 VA examiner discussed the details of the Veteran's described "[l]imited bending, stooping, crawling, heavy lifting or carrying" including during flare-ups. The August 2015 VA examiner presented a medical opinion considering "[t]he nature, duration and frequency of the veteran's flare ups to include functional losses sustained as a result thereof," and the August 2015 VA examiner concluded that the disability described "does not more nearly approximate a disability tantamount in severity to that of forward flexion of the thoracolumbar spine limited to 30 degrees or less or to ankylosis." The August 2015 VA examiner presented a rationale for this opinion, citing that the "Veteran describes a fairly active life despite the flare ups which are about twice per year and are fairly well managed with periodic nerve root ablations." The Board finds that the August 2015 VA examiner's medical opinion is adequate probative evidence presenting a characterization of the medical severity of the Veteran's described functional limitation, including during flare-ups, informed by medical expertise. The objective observed medical impairment (with clinically measured range of motion findings) fails to meet the criteria for a rating in excess of 20 percent for the back disability; with consideration of the August 2015 VA examiner's medical opinion together with the Veteran's description of functional limitation and the other evidence of record, the Board finds that the functional impairment associated with the service-connected back disability on appeal does not more nearly approximate the criteria for any rating in excess of 20 percent. The Veteran's statements describing his functional impairment must be viewed in conjunction with the objective medical evidence as required by the rating criteria. In this regard, the objective medical evidence, including the VA treatment records and the three VA examination reports, now includes the information necessary to rate the Veteran's disability in accordance with the rating criteria. The August 2015 VA examination report presents an expert medical opinion explaining that the Veteran's own description of the nature and frequency of his symptom exacerbations / flare-ups does not more nearly approximate the functional loss of limitation of flexion to 30 degrees or ankylosis. Thus, when considering the overall evidence of record, including the Veteran's statements, the Veteran's disability does not warrant a disability rating in excess of 20 percent (aside from the ratings for associated lower extremity radiculopathy, discussed below). Based on this evidentiary posture, the Board concludes that the evidence of record does not show that the Veteran's service-connected thoracic/lumbar levoscoliosis with spondylosis and degenerative disc space narrowing warrants a rating in excess of 20 percent at any time during the appeal period under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. With regard to the neurological complications of radiculopathy of the Veteran's lower extremities, the Board notes that a recent August 2015 RO rating decision awarded the Veteran a separate 20 percent rating for right lower extremity radiculopathy, effective July 31, 2015. This rating is effective from the date of the July 2015 VA examination report. This rating was assigned under Diagnostic Code 8520 contemplating paralysis of the sciatic nerve. The July 2015 and August 2015 VA examination reports served as the basis for the RO's award of a separate rating for right lower extremity radiculopathy. The Board notes that this evidence also presents significant evidence of left lower extremity neurological deficits. The August 2015 VA examination report shows that left lower extremity reflex testing revealed hypoactive reflex response at the knee and an absent reflex response at the ankle. There was also a finding of decreased sensation of the feet and toes corresponding to the L5 nerve root. Straight leg testing was positive for the left leg. The Board recognizes that the August 2015 VA examiner did not conclude that these left leg neurological deficits represented radiculopathy associated with the service-connected back disability. However, the August 2015 VA examiner's basis for distinguishing the left lower extremity neurological deficits from the service-connected spinal disability appears to have been that "[s]ome of the patient's sensory and DTR findings can most likely be attributed" to a congenital condition involving neuropathy. This implies that at least some portion of the left leg neurological deficits are not the result of the congenital condition. The August 2015 VA examiner stated that "It is not possible to state how much of the neurological deficits are related to [the congenital non-service-connected] condition without resorting to speculation." The Court has held that when it is not possible to separate the effects of a service-connected condition and a nonservice-connected condition, the provisions of 38 C.F.R. § 3.102 mandate that reasonable doubt on any issue is to be resolved in the Veteran's favor, and that all signs and symptoms be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Thus, the Board will, for the limited purpose of this decision, attribute all of the left lower extremity neurological deficits to radiculopathy from his service-connected spinal disability. The Board finds that a separate 10 percent rating is warranted for left lower extremity radiculopathy in this case. The findings indicative of left lower extremity radiculopathy in the August 2015 VA examination report reflects disability of lesser severity than is shown in the right lower extremity. The Board notes that the Veteran's description of lower extremity radiculopathy symptoms focus upon manifestations in the right leg rather than the left leg, and the August 2015 VA examination results show that some left leg reflexes were merely hypoactive whereas all right leg reflexes were absent, decreased sensation was noted for less of the left leg than was noted for the right leg, and straight leg testing was negative for the left leg. The August 2015 VA examination report identifies deficits associated with the L5 nerve root, which the report identifies as pertaining to the sciatic nerve and not the femoral nerve. Accordingly, the Board finds that a rating contemplating mild incomplete paralysis of the sciatic nerve in the left lower extremity is appropriate in this case; under the provisions of Diagnostic Code 8520, a 10 percent rating is warranted. The Board finds that the newly assigned separate rating for left lower extremity radiculopathy is warranted from an effective date of August 4, 2015; this is the date of the August 2015 VA examination report that first shows the left leg neurological deficits warranting the assignment of the rating. The Board notes that the July 2015 VA fee-basis examination report reveals no indication of left lower extremity neurological deficits. Turning attention to the right lower extremity radiculopathy, a 20 percent rating has been assigned for moderate incomplete paralysis of the sciatic nerve effective from July 31, 2015. For the period from July 31, 2015, a schedular rating in excess of 20 percent is not warranted for the impairment of the sciatic nerve because the evidence does not show greater than moderate incomplete paralysis of the sciatic nerve for the right lower extremity. The July 2015 VA examination report characterizes the radiculopathy as "moderate" in severity, with findings showing normal strength for the right lower extremity testing except for knee extension (rated "4/5"), no muscle atrophy, normal reflexes, "moderate" intermittent pain, "moderate" paresthesias, and "moderate" numbness. The August 2015 VA examination report describes the Veteran's complaints of occasional pain, numbness, and tingling with weakness in the right leg that occurs if he exceeds certain durations of sitting or walking, and noted normal strength in all respects, no muscle atrophy, absent reflexes, decreased sensation, "moderate" intermittent pain, "moderate" paresthesias and/or dysesthesias, "moderate" numbness, and an overall "moderate" degree of radiculopathy of the right leg. The August 2015 VA examiner further opined that the right lower extremity radiculopathy symptoms described by the Veteran represented "the equivalent of an 'incomplete paralysis of moderate severity." The Board finds that the July and August 2015 VA examination reports present findings indicative of right lower extremity radiculopathy featuring moderate incomplete paralysis of the sciatic nerve consistent with a 20 percent rating; the evidence does not show greater than moderate incomplete paralysis. There is otherwise no evidence of record indicating right leg sciatic nerve impairment greater than moderate incomplete paralysis. However, the Board notes that the August 2015 VA examination report found not only radiculopathy impairment of the sciatic nerve, but also additionally found radiculopathy impairment of the femoral nerve of the right lower extremity. As discussed above, Diagnostic Code 8526 provides disability ratings for paralysis of the femoral nerve. The August 2015 VA examination report does not specifically and clearly characterize the level of impairment of the right leg sciatic nerve and the right leg femoral nerve independently; the August 2015 VA examination report simply characterizes the right leg radicular neurological impairment as moderate incomplete paralysis. However, the August 2015 VA examination report clearly indicates that the femoral and sciatic nerves are involved in the moderately severe radiculopathy / incomplete paralysis in the right leg involve the sciatic and femoral nerve, and specifies that the "[n]erve roots affected primarily are L3, L4, L5 on the right," with the report elsewhere indicating that the L3 and L4 nerve roots involve the femoral nerve (with the L3 root indicated to be specific to the femoral nerve and not involved in the sciatic nerve). In light of the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's right lower extremity radiculopathy manifests in moderate incomplete paralysis of the femoral nerve (in addition to the already rated impairment of the sciatic nerve). Under Diagnostic Code 8526, an additional separate 20 percent rating is warranted for the moderate incomplete paralysis of the femoral nerve of the right lower extremity. The Board finds that such rating is warranted from August 4, 2015; this is the date of the August 2015 VA examination report that first identifies femoral nerve involvement in the right leg radiculopathy (the July 2015 VA examination report specifically identified "sciatic" nerve radiculopathy for the right side, and did not indicate the involvement of the femoral nerve). The Board has also considered whether a separate rating for right or left lower extremity radiculopathy as part of the Veteran's service-connected back disability is warranted during any portion of the period on appeal prior to July 31, 2015 (for the right leg sciatic nerve impairment) or August 4, 2015 (for the right leg femoral nerve impairment and for the left leg sciatic nerve impairment). The Board notes that findings from the March 2010 VA neurological examination reflect that the straight leg raising test produced negative results bilaterally, and the Veteran's motor strength in the upper and lower extremities was 5/5 bilaterally. In addition, the Veteran's sensation to various stimuli was characterized as normal and his knee and ankle reflexes were normal? and symmetric throughout. The March 2010 VA examiner specifically noted that examination of the lumbar spine revealed no sensory deficits from L1-L5, and the evaluation of the sacral spine revealed no sensory deficits at S1. The March 2010 VA examiner further noted no lumbosacral motor weakness and commented that the lower extremities were absent any signs of pathologic reflexes. The Veteran underwent another series of neurological tests at a pain management consultation visit in June 2011, the findings of which showed the Veteran's motor strength and sensory findings to be within normal limits and bilaterally symmetric in the lower extremities. Although results from the straight leg raising and Patrick tests produced positive results at the October 2011 VA treatment visit, VA treatment records following the examination (including those dated in November 2011, May 2012, October 2012, and May 2013) show that the straight leg raising tests were negative for both legs on examination. The Board finds that the evidence of record otherwise fails to show lower extremity radiculopathy warranting a separate compensable rating prior to the July 2015 VA fee-basis VA examination report (showing right lower extremity radiculopathy involving impairment of the sciatic nerve) and the August 2015 VA examination report (showing left lower extremity radiculopathy in addition to showing femoral nerve impairment associated with the right lower extremity radiculopathy). Additionally, the Board finds that the Veteran has not reported to have any bowel or bladder symptomatology associated with his low back disability, and the medical evidence of record does not reflect any such pathology. Thus, a separate compensable rating for such symptoms is not warranted. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (which stipulates that associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code). The Board notes that the Veteran's representative has argued (in the January 2016 written brief) that "[a] higher evaluation of 20 percent is warranted for degenerative arthritis where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations." The Veteran's representative argues that the evidence of record warrants application of the cited provisions. The Board notes that Diagnostic Code 5010 directs that the evaluation of arthritis be conducted under Code 5003, which provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint(s) involved. 38 C.F.R. § 4.71a, Code 5003. When there is no limitation of motion of the specific joint(s) that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of two or more major joints or two or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. In this case, however, the Veteran is already in receipt of a 20 percent rating that contemplates limitation of motion associated with the back disability at issue. In summary, then, the Board finds that no increase in the 20 percent rating assigned for the Veteran's spine disability is warranted under the rating criteria for spinal disabilities, but new separate ratings for neurological impairments resulting from the spinal disability are warranted. Resolving reasonable doubt in the Veteran's favor, a separate 20 percent rating for moderate incomplete paralysis of the femoral nerve of the right lower extremity (in addition to the established 20 percent rating for incomplete paralysis of the sciatic nerve) and a separate 10 percent rating for mild incomplete paralysis of the sciatic nerve of the left lower extremity are warranted in this case effective from August 4, 2015. Extraschedular and TDIU Considerations The above determinations are based upon application of the pertinent provisions of VA's rating schedule. The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis for the above disabilities. 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. 38 C.F.R. § 3.321(b)(1); 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 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, thus, 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 the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the Veteran's back disability manifests in limited motion with pain and lower extremity radiculopathy with neurological deficits representing incomplete paralysis. The Veteran has not alleged any symptoms or manifestations that suggest an exceptional or unusual disability picture in terms of the nature or severity of the disabilities. The Board finds that the associated symptomatology and severity of disabilities shown are entirely contemplated by the rating schedule. Therefore, referral for extraschedular consideration is not warranted. Finally, the Board has considered whether the Veteran's current increased rating claim has implicitly raised the matter of entitlement to a total disability rating based on individual unemployability (TDIU) as part and parcel of the present claim. See Rice v. Shinseki, 22 Vet. App. 447, 455 (2009). However, the preponderance of the evidence is against a finding that TDIU is raised in connection with the claim for higher ratings for the back disability. As the record now stands, the Veteran's combined schedular rating for his service-connected disabilities is 100 percent, effective November 8, 2011. Although no additional disability compensation may be paid when a total schedular rating is already in effect, the Court in Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008), recognized that a separate award of a TDIU predicated on a single disability may form the basis for an award of SMC. Thus, the claim for a TDIU should be considered not only for the period prior to the effective date of the combined 100 percent schedular rating but also from that date. In this case, SMC under 38 C.F.R. § 3.350(i) on account of a 100 percent rating for traumatic brain injury and additional service-connected disabilities independently ratable at 60 percent or more is in effect from November 8, 2011. Thus, the Board shall consider whether a TDIU claim has been raised in connection with the rating issue on appeal prior to November 8, 2011. The period under consideration in this appeal begins with the November 25, 2009 effective date for the award of service connection for the back disability. The March 2010 VA examiner noted that the Veteran had retired in November 2005, that he was unable to perform certain activities due to "headaches with pain." The evidence does not suggest that the Veteran was unable to maintain employment due solely to his back disability. Notably, the Veteran filed a claim expressly seeking a TDIU in November 2011, specifying that he believed his TBI and migraine headaches were the causes of his unemployability. Consequently, the Board finds that the matter of TDIU has not been raised in connection with the claim for higher ratings for the back disability. Entitlement to Service Connection for Dental Condition/Loss The Veteran seeks service connection for a dental disability for compensation purposes. The Veteran contends that his current dental condition, namely the loss of his teeth, was incurred in service. Specifically, he claims that a number of his teeth were extracted and/or removed during his period of service. Service connection may be granted for disability due to disease, or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection for a disability there must be evidence of (1) a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999). Disability compensation and VA outpatient dental treatment may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. VA compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. The types of dental conditions covered are: loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. See 38 C.F.R. §§ 4.150, Diagnostic Code 9913; 17.161(a). Otherwise, a veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal (i.e., gum) disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161. (As discussed in the introduction section, above, the issue of whether the Veteran may be entitled to VA outpatient dental services and treatment must be adjudicated separately, is not currently before the Board on appeal, and has been referred to the AOJ for appropriate action.) Service-connected compensation is also available for dental conditions including chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, temporomandibular articulation and limited jaw motion, loss of the ramus, loss of the condyloid process, loss of the hard palate, loss of the maxilla, and malunion or nonunion of the maxilla. See 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. 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 include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. Considering the evidence in light of the above, the Board finds that the Veteran does not have a compensable dental disability. Notably, he has not submitted any competent evidence showing that he has had any of the disabilities included under 38 C.F.R. § 4.150 during the pendency of this claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement of having a current disability is met "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim"). Review of the STRs indicates that the Veteran's dental condition was acceptable during his May 1962 enlistment examination, and there were no subjective or objective abnormalities noted of the mouth and teeth. Although the dental records associated with the Veteran's period of service reflect that he received ongoing dental care from July 1962 to February 1966, based on the medical notations written beneath the Diagnosis-Treatment category, the Board finds it somewhat difficult to determine what type of treatment the Veteran received for his teeth. However, based on a reading of these records, it does appear as though teeth numbers 1, 3, 5, 7, 12, 13, and 14 were surgically removed, and teeth numbers 1, 2, 4, 6, 8, 10, 11, 15, and 16 were extracted in June 1963. It also appears as though tooth number 17 was surgically removed, and teeth numbers 21, 23, 24, 25, and 26 were extracted in September 1963. At the May 1966 separation examination, it was noted that teeth numbers 1 through 17, as well as teeth numbers 19, 21, 23, 24, 25, 26 and 30, were missing. It was further noted that tooth number 20 was restorable. The post-service treatment records reflect that the Veteran was at the VA dental clinic in April 2013 at which time he reported that it had been forty years since he was lasted treated by a dentist. Upon reviewing the radiographic findings, the VA treatment provider noted signs of alveolar bone loss, and further noted "[c]omplete maxillary edentulism" and that the "[r]emaining dentition presents with rampant decay and end-stage periodontal [disease]." Upon conducting a dental evaluation of the Veteran, it was noted that teeth numbers one through seventeen, nineteen to twenty-one, twenty-three to twenty-six, and thirty were missing. It was further noted that teeth numbers "22(F), 27 (DL), 27(M), 28(L), 29, 31, 32(ML)" were carious, and that there had been a defective restoration at tooth number 18. Upon conducting an intraoral soft tissue examination, the treatment provider noted no signs of edema, purulence, lymphadenopathy, as well as generalized marginal gingival erythema consistent with plaque. The intraoral hard tissue evaluation based on clinical and radiographic findings showed that the remaining dentition for teeth numbers 18, 22, 27, 28, 29, 31, and 32 "presented with rampant caries, extent of cervical lesions consistent with non-restorability and end-stage periodontal involvement." It was further noted that teeth numbers 29 and 31 had carious root tips, and teeth numbers 18, 29, and 31 presented with periapical lucency (PARL). It was ultimately determined that the Veteran should return to the clinic to have teeth numbers 18, 22, 27, 28, 29, 31 and 32 extracted. The evidence reflects that the Veteran was seen at the dental clinic again in May 2013, at which time he underwent an alveoplasty of the left lower and lower right jaw, as well as the planned extraction of teeth numbers 18, 22, 27, 28, 29, 31 and 32. Subsequent VA treatment records dated in July and August 2013 reflect that the Veteran presented at the dental clinic in order to be fitted for complete dentures. More recent VA treatment records reflect that the Veteran continued to experience, and receive treatment for, dental problems. However, the evidentiary record does not indicate the presence of a diagnosed dental condition for which disability compensation may be provided. The Board's August 2014 remand of this issue directed that a VA dental examination be conducted to determine the nature of the Veteran's dental disability on appeal. As a result, the record now includes a number of VA fee-basis dental examination reports from July 2015 examination of the Veteran. These reports and medical opinions presented therein are informed by direct examination of the Veteran and review of the pertinent contents of the claims-file and medical history, specifically including the Veteran's STRs. These reports present a medical opinion, citing the STRs, stating that: "The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." Significantly, this opinion is presented with a statement of rationale explaining: "dental exam 1962 noted multiple decayed and missing teeth. His dental disorder was periodontal disease and tooth decay. Therefore was not a service injury." Another of the reports associated with this July 2015 VA fee-basis dental examination (from the same examiner) explains: "loss of teeth was not a result from loss of body of mandible." Another report from the same examination/examiner documents the medical determination that the Veteran does not have a disability of the temporomandibular joint and has never had such a disability. A further report from the same July 2015 examiner plainly states that the Veteran's only diagnosed dental conditions are "Periodontal disease" and "dental carries." This report states that the Veteran does not have any anatomical loss or bony injury of the mandible; does not have any anatomical loss or bony injury of the maxilla; does not have anatomical loss or bony injury of any teeth (other than that due to the loss of the alveolar process as a result of periodontal disease); does not have anatomical loss or injury of the mouth, lips, or tongue; does not have (and has never had) a diagnosis of osteomyelitis or osteoradionecrosis of the mandible; does not have a benign or malignant neoplasm or metastases related to any dental diagnosis; and does not have any scars related to any dental diagnosis. Diagnostic imaging was noted to show "edentulous teeth, mandible or maxilla." The VA fee-basis examiner remarked: "There is loss of teeth due to periodontal disease.... [T]here is no diagnosis because the condition has resolved. His dental condition was eliminated with removal of all teeth." The question the Board must consider is whether any of the Veteran's tooth loss has been of a nature that fits the regulatory criteria for consideration of compensation. The Board finds that the evidence of record does not indicate that the Veteran has had any identifiable dental disability of a nature that is eligible for compensation under the applicable regulatory provisions. The Veteran's STRs do not show trauma to his teeth or mouth. The reports from the July 2015 VA dental examination present competent and probative evidence, with expert opinion informed by review of the pertinent history and direct inspection of the Veteran, that the Veteran's loss of teeth has been the result of periodontal disease and carious tooth decay. Again, under 38 C.F.R. § 3.381, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal diseases are to be considered service-connected only for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. Regardless of whether the tooth decay existed during military service, the July 2015 VA examination reports present no suggestion that the Veteran's dental health profile includes any diagnosis that may be compensable as identified under the provisions of 38 C.F.R. § 4.150. The July 2015 reports do not suggest that the Veteran's lost teeth cannot be functionally replaced with a suitable prosthesis. The Board finds that the July 2015 VA examination reports are probative and adequate for the purposes of appellate review, as they present the conclusions of a competent medical professional informed by all of the pertinent medical history and current medical principles, explained with citation to the correct pertinent facts. 38 C.F.R. § 3.381(b) specifically states that "replaceable missing teeth" as well as "dental or alveolar abscesses, and periodontal disease are not compensable disabilities, but may nevertheless be service connected solely for the purpose of establishing eligibility for outpatient dental treatment...." Notably, VA dental records (including an August 2013 report) show that the Veteran was been issued "complete dentures" serving as replacement for his lost teeth. To the extent that the Veteran asserts a link between his tooth loss and his military service, this assertion may be further addressed in the adjudication of his (separate) claim of service connection for VA outpatient dental treatment purposes. The Board's analysis at this time with regard to the claim for service connected compensation for dental disability finds that the evidence does not show that the Veteran has had any dental disability for which compensation is payable. The evidence does not show that the Veteran's dental disability has been distinguished from the "dental or alveolar abscesses, and periodontal disease" that "are not compensable disabilities." 38 C.F.R. § 3.381(b). Missing teeth may be service-connected under 38 C.F.R. § 4.150, Code 9913 ("loss of teeth, due to loss of substance of body of maxilla or mandible without loss of continuity"). However, the Note immediately following states, "These ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling." The evidence of record does not show that the Veteran has a current dental disability which is due to loss of substance of body of maxilla or mandible through trauma or disease such as osteomyelitis. Rather, the evidence of record reflects that the Veteran's loss of teeth has been due to extraction in connection with dental treatment for periodontal disease and associated tooth decay, and not due to loss of substance of body of maxilla or mandible. [The Board notes that, because the Veteran never had any shown loss of substance of body of maxilla or mandible (i.e., the bone loss requisite for service connection for loss of teeth for compensation purposes), no analysis is necessary regarding whether such loss is due to trauma or disease such as osteomyelitis.] Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling for VA disability compensation purposes; such conditions will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 U.S.C.A. § 1712; 38 C.F.R. § 3.381. A claim for service connection for a dental condition for VA outpatient dental treatment purposes has been referred to the AOJ for appropriate action. The Veteran has not presented any competent evidence that he has a dental disability for which service connection for compensation purposes may be granted. He is a layperson and does not cite to supporting medical opinion or clinical or medical treatise evidence to demonstrate that his dental disability is of a nature eligible for service-connected compensation under the applicable regulations. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a dental disability for compensation purposes. Hence, the appeal in this matter must be denied. ORDER A rating in excess of 20 percent for thoracic/lumbar levoscoliosis, with spondylosis and degenerative disc space narrowing, is denied. A rating in excess of 20 percent for right lower extremity sciatic nerve impairment is denied. An effective date prior to July 31, 2015 for the rating for right lower extremity sciatic nerve impairment is denied. Effective August 4, 2015, a separate 20 percent rating for right lower extremity femoral nerve impairment is warranted. To this extent, the appeal is granted. A rating in excess of 20 percent for right lower extremity femoral nerve impairment is denied. Effective August 4, 2015, a separate 10 percent rating for left lower extremity radiculopathy (as sciatic nerve impairment) is warranted. To this extent, the appeal is granted. A rating in excess of 10 percent for left lower extremity radiculopathy is denied. Service connection for a dental disability (loss of teeth) for compensation purposes is denied. ____________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs