Citation Nr: 1803697 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 12-11 376A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to a rating in excess of 10 percent from April 1, 2012, for a left medial meniscus tear, status post partial medial meniscectomy/arthroscopy with degenerative arthritis. 2. Entitlement to a rating in excess of 20 percent from March 1, 2014, for left sacroiliac (SI) joint arthritis and instability, status post fusion surgeries. 3. Entitlement to special monthly compensation (SMC) based upon the need for aid and attendance (A&A) of another person. REPRESENTATION Appellant represented by: Minnesota Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD F. Yankey Counsel INTRODUCTION The Veteran served on active duty from July 2004 to September 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Veteran testified before the undersigned at a November 2015 videoconference hearing. The hearing transcript is of record. In February 2016, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. In a July 2016 rating decision, the RO restored the 20 percent rating for service-connected left SI joint arthritis and instability, status post fusion surgeries, effective March 1, 2014. The issue of an increased rating for left SI joint arthritis and instability, status post fusion surgeries, remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's left knee disability has not been manifested by flexion limited to 45 degrees and extension limited to 10 degrees; flexion limited to 30 degrees or less or extension limited to 15 degrees or more, even with consideration of pain and other functional impairment; there is no evidence of semilunar cartilage impairment, tibia or fibula impairment or ankylosis. 2. Throughout the appeal period, the Veteran's left sacroiliac joint arthritis and instability, status post fusion surgeries has been manifested by forward flexion of no less than 50 degrees, even with consideration of pain and functional impairment; there is no evidence of intervertebral disc syndrome, associated neurological deficit that has not already been accounted for or ankylosis. 3. The Veteran's service-connected disabilities do not make her permanently bedridden or unable to care for her daily needs without requiring the regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent from April 1, 2012, for left medial meniscus tear, status post partial medial meniscectomy/arthroscopy with degenerative arthritis, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2017). 2. The criteria for a rating in excess of 20 percent from March 1, 2014, for the left sacroiliac joint arthritis and instability, status post fusion surgeries, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R §§ 4.7, 4.71a, Diagnostic Codes 5236, 5243 (2017). 3. The criteria for SMC based on the need for A&A have not been met. 38 U.S.C. §§ 1114, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.350, 3.352 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has indicated no such records and all pertinent records have been obtained. General Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. 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, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations 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. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59 (2017). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In both initial rating claims and normal increased rating claims, the Board must discuss whether any "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. Left Medial Meniscus Tear, Status Post Partial Medial Meniscectomy/Arthroscopy with Degenerative Arthritis Traumatic arthritis (Diagnostic Code 5010) is rated as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Disabilities of the knee are rated under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Diagnostic Codes 5256 and 5262 are inapplicable to the Veteran's disability, as there is no evidence of ankylosis or tibia and fibula impairment during the appeal period. 38 C.F.R. § 4.71a. Diagnostic Code 5257 is also inapplicable to the Veteran's disability because there is no evidence during the appeal period of recurrent subluxation or lateral instability of the left knee. Diagnostic Code 5260 provides ratings based upon the limitation of flexion in the leg. A 10 percent rating is assigned when flexion is limited to 45 degrees. A 20 percent rating is assigned when flexion is limited to 30 degrees. A 30 percent rating is assigned when flexion is limited to 15 degrees. Id. Diagnostic Code 5261 provides ratings based upon the limitation of extension in the leg. A 10 percent rating is assigned when extension is limited to 10 degrees. A 20 percent rating is assigned when extension is limited to 15 degrees. A 30 percent rating is assigned when extension is limited to 20 degrees. A 40 percent rating is assigned when extension is limited to 30 degrees and 50 percent when limited to 45 degrees. Id. Normal range of motion of the knee is to 140 degrees flexion and to 0 degrees extension. Id. When evaluating joint disabilities rated on the basis of limitation of motion, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion) and Diagnostic Code 5261 (limitation of extension), may be assigned for disability of the same joint. VAOPGCPREC 9-2004. The VA General Counsel has also held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97; VAOPGCPREC 9-98. VA's General Counsel further explained that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Id. Analysis In a December 2004 rating decision, the RO granted service connection for post-operative left tibial tubercle shift, claimed as left knee pain. A 10 percent evaluation was assigned, effective September 17, 2004. In November 2011, the Veteran filed a claim for an increased rating for her left knee disability, and noted that she would be undergoing surgery on her knee. In January 2012, the Veteran underwent a left knee diagnostic arthroscopy, partial medial meniscectomy. In a January 2012 rating decision, the RO granted a temporary total rating (TTR) for the left knee disability, based on post-surgical convalescence, effective from January 3, 2012 to February 28, 2012. The 10 percent rating was continued from March 1, 2012. In an April 2012 rating decision, the TTR was extended to March 31, 2012. The 10 percent rating was continued from April 1, 2012. The claim for an increased rating for the left knee disability is exclusive to any periods where TTRs were assigned, as summarized above. VA outpatient treatment records from the VA Medical Center in Minneapolis, Minnesota, dated from August 2011 to January 2012, show complaints of locking in the knee where she is unable to completely straighten the knee or at times even bend the knee, accompanied with popping and constant swelling as well as anterior knee pain and medial joint line pain. On VA examination in December 2011, the Veteran complained of popping, constant swelling, tenderness in the left knee, limited extension and giving out of the knee when attempting to walk. On physical examination, she had marked pain with palpation along the medial joint line, which was reproducible and always located in the same location just posterior to the medial collateral ligament. She had no pain anteriorly to the medial collateral ligament along the joint line. She did have pain with palpation over the superior and inferior patellar pole, as well as some pain along the Hoffa fat pad. She had some mild discomfort to palpation along the lateral patella as well. Ligaments were all stable and the examiner was unable to elicit any pop or mechanical finding with the McMurray maneuver other than some medial joint line pain. During range of motion (ROM) testing, she was able to flex the left knee to 135 degrees, even with pain, and was able to extend the left knee to 5 degrees. ROM did not change following repetitive use testing, and there was no additional ROM loss following repetitive use testing. The only factor contributing to functional loss for the left knee was pain on movement. Muscle strength and stability tests were normal. It was noted that the Veteran had a meniscus tear (as noted above), with frequent episodes of joint locking and joint pain, but no meniscal dislocation. It was noted that the Veteran had a surgical scar on the left knee, but it was not painful and/or unstable or greater than 39 square inches. The diagnosis was post-operative left tibial tubercle shift. X-rays of the left knee were normal, but the examiner concluded that MRI scan showed a medial meniscus tear. It was recommended that she undergo left knee arthroscopy. VA treatment records from the VA Medical Center in Minneapolis dated from August 2011 to April 2012 show reports of continued left knee pain. Range of motion was measured at 10-90 degrees, the knee was stable in varus and valgus stresses, and the patella tracked normally. The doctors indicated the pain was unexplained, but released the Veteran to return to work on March 5, 2012. On VA examination in March 2012, the Veteran reported burning left knee pain that was "bad on the inside;" a painful scar, and swelling of the left knee down the leg, mostly at night or when she was on it a lot. She also reported that she was told she had "bad arthritis" and that her knee popped out 3 weeks prior. She denied any locking of the left knee and denied using any assistive devices. She reported flare-ups daily at the end of the day. On physical examination, there was tenderness and guarding of movement of the left knee. There was no effusion, edema, redness, inflammation, instability or deformity/malalignment. There were 3 arthroscopic scars 1 cm. long, healed, tender to palpation, not raised, not depressed, non adherent. ROM for the left knee showed 5 to 85 degrees of flexion, with pain at maximum flexion, and -5 degrees of extension. There was no additional limitation in ROM following repetitive use testing, but there was functional loss as a result of the left knee, due to pain on movement. Flexion and extension strength were normal, but the examiner noted that testing was limited due to pain. Gait was antalgic. There was pain to palpation of the left knee. Muscle strength testing was normal and stability testing was essentially normal. There was no evidence of patellar subluxation/dislocation. It was noted that the Veteran had a meniscus (semilunar cartilage) condition, with frequent episodes of joint locking and joint pain, but no meniscal dislocation. X-rays did not show evidence of arthritis of the left knee, and the examiner concluded that MRI was negative for evidence of meniscal tear. The diagnosis was post-operative left tibial tubercle shift. VA treatment records from the VA Medical Center in Minneapolis dated from January 2012 to August 2012 show continued reports of left knee pain. The Veteran had an MRI in June 2012, which revealed some early chondromalacia in the meniscus and no meniscus tears. During an orthopedic clinic followup from her MRI in June 2012, she continued to report left knee pain. ROM was from 10 to 100 degrees. She had some difficulty with full extension, which she said was secondary to pain. She drew out a dysesthetic burning pain pattern over the infrapatellar branch of the saphenous nerve root distribution. She was stable to Lachman, posterior drawer, anterior drawer, varus and valgus stress testing. No effusion was noted. The assessment was infrapatellar branch nerve neuroma and chondromalacia patella medial femoral condyle. On VA examination in July 2013, the Veteran reported flare-ups of left knee pain, in that her knee would swell and she would feel a burning sensation almost every time she went up and down stairs. On physical examination ROM testing showed 140 degrees of flexion of the left knee, even with pain and no limitation of extension. There was no additional limitation in ROM of the left knee following repetitive use testing. Functional loss was manifested by pain on movement, but the examiner noted that there were no additional functional limitations of the left knee during flare-ups, or secondary to repetitive use of the joint, weakness, excessive fatigability, lack of endurance or incoordination. There was pain on palpation of the knee, but muscle strength and stability testing were normal. X-rays showed evidence of degenerative arthritis of the left knee. The diagnosis was left meniscal tear, status post partial medial meniscectomy, and arthroscopy left knee. Social Security Administration (SSA), VA, and additional private treatment records document ongoing complaints of left knee pain. SSA records also show that the Veteran was determined disabled since December 2011, due to psychiatric disorders. These records do not contain any findings that meet the criteria for a higher rating under the applicable diagnostic codes. See SSA records, VA outpatient treatment records from the VA Medical Center in Minneapolis, Minnesota, dated from April 2012 through June 2014, private treatment records from TRIA Orthopedics dated from October 2012 to December 2012, and private treatment records from Park Nicollet dated from August 2012 to December 2012. In an August 2013 medical opinion, the VA examiner amended the Veteran's previous diagnosis of post-operative left tibial tubercle shift to her current diagnosis of left medial meniscal tear, status post partial medial meniscectomy/arthroscopy. He opined that the Veteran's in-service injury was actually a left medial meniscal tear and not a left tibial tubercle shift, as was previously diagnosed. On VA examination in November 2014, the Veteran denied any flare-ups for the left knee, or any functional loss or functional impairment of the knee. ROM testing showed flexion to 115 degrees and extension to 10 degrees. There was no evidence of pain with weight bearing, and no evidence of localized tenderness or pain on palpation of the joint. There was no additional loss of ROM after repetitive use testing, and functional ability with repeated use over time or with flare-ups was not significantly limited by pain, weakness, fatigability or incoordination. It was noted that the Veteran had a meniscus (semilunar cartilage) condition. Muscle strength was normal and there was no muscle atrophy. Joint stability testing was also normal. There was no unusual tenderness or swelling noted upon palpation of the left knee. The Veteran did report using a cane regularly for her left knee and back conditions. X-rays showed degenerative arthritis in the left knee. On VA examination in July 2016, the Veteran reported continued pain in the left knee, burning under the knee cap, popping when walking stairs, consistent swelling around the knee cap, instability when the knee pops, and hotness (not redness) in the knee. She reported flare-ups from 15 minutes to hours caused by activity, especially squatting. She also noted that she was supposed to use a cane when outside the house, but one of her children had broken it. She was able to walk 1/2 block with no issues on flat surfaces, but she had to use a cane for grocery shopping, she did not mow the lawn, she avoided stairs, and her husband did the laundry. Her reported functional impairment was when walking stairs her knee would pop and she had to grab the bars on stairs on both sides. ROM of the left knee was 0 to 115 degrees of flexion, and extension was 115 to 0 degrees. There was evidence of pain with weight bearing and evidence of localized tenderness or pain on palpation of the knee, and evidence of crepitus. There was no additional functional loss or loss of ROM after repetitive use testing. The examiner noted that pain significantly limited functional ability with flare-ups. Muscle strength testing was normal and there was no evidence of instability. The Veteran reported a history of intermittent swelling, but there was no evidence of such on examination. Again, X-rays showed evidence of degenerative arthritis of the left knee. In order for the Veteran to receive a higher rating for her right or left knee disabilities, there must be evidence of flexion limited to 45 degrees and extension limited to 10 degrees; flexion limited to 30 degrees or less or extension limited to 15 degrees or more; or more than slight instability in the knees. As noted above, the Veteran has not been shown to have flexion reduced to less than 80 degrees, even with consideration of pain or other functional impairment, or less than normal extension, during objective VA examination. See November 2008, June 2010 and July 2014 VA examination reports. Moreover, as there is no evidence of dislocated semilunar cartilage or removal of the semilunar cartilage, a separate rating under Diagnostic Codes, 5258 or 5259 is not warranted. In this regard, the Veteran has been noted on VA examination to have a meniscus tear, with frequent episodes of joint locking and joint pain, but there was no evidence on either examination or anywhere else in the record, of meniscal dislocation or symptomatic removal of semilunar cartilage. The Board also finds that a rating in excess of 10 percent is not warranted for the left knee at any time during the appeal under DeLuca. The Veteran has complained of pain, popping, swelling, tenderness, instability and giving out, and hotness of the left knee, as well as problems walking stairs and walking on flat surfaces for prolonged periods of time. She has also reported functional impairment due to pain in the knee, not being able to complete activities of daily living, such as bathing, grooming, cooking and other household chores, and not being able to play with her children, due to left knee pain. Furthermore, on VA examination in December 2011, March 2012 and July 2013, pain on movement contributed to functional loss, and on VA examination in July 2016, the examiner noted that pain significantly limited functional ability with flare-ups. Nevertheless, there was no additional loss of motion found following repetitive use testing in December 2011, March 2012, July 2013, November 2014 or July 2016. Furthermore, there were no additional functional limitations of the left knee during flare-ups, or secondary to repetitive use of the joint, weakness, excessive fatigability, lack of endurance or incoordination on examination in July 2013 or November 2014. Moreover, on all four examinations, the Veteran still demonstrated 85 or more degrees of flexion and 10 or more degrees of extension in the left knee, even with consideration of pain. Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). However, pain alone does not constitute a functional loss under VA regulations that evaluate disability based upon range-of-motion loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Furthermore, the Board notes that it is evident that the Veteran's functional impairment was already considered with the assignment of the current 10 percent rating, which was essentially assigned for painful and limited motion. Moreover, even with consideration of pain and other functional impairment, range of motion of the left knee has not been reduced nearly enough to warrant a rating in excess of 10 percent under any of the applicable diagnostic codes. Therefore, the Board finds that a rating in excess of 10 percent, based on functional impairment, is also not warranted. 38 C.F.R. §§ 4.40, 4.45, and 4.59. The Board notes further that although the Veteran has been noted on examination to have scars of the left knee, associated with her service-connected left knee disability, as the scars have not been shown during the period on appeal to be unstable or painful; deep and covering an area of at least 6 square inches; superficial and covering an area of 144 square inches or greater; or otherwise symptomatic, a separate rating under Diagnostic Codes 7800-7805 is also not warranted. The Veteran is competent to report the symptoms of her left knee disability. Her complaints are credible. The Veteran's complaints have been considered in the above noted evidence; however, evaluations for VA purposes have not shown the severity required for higher schedular ratings, as discussed above. After examining all the evidence, the Board concludes that the weight of the evidence is against a rating in excess of 10 percent for the left knee disability. 38 U.S.C § 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.21 (2017). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). Left Sacroiliac Joint Arthritis and Instability, Status Post Fusion Surgeries Legal Criteria Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling. Unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5237. The following notes accompany the General Rating Formula: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. Intervertebral disc syndrome is to be evaluated either under the general rating formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. Note (1) states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Analysis In a September 2012 rating decision, the RO granted service connection for left pyriformis syndrome (claimed as left SI joint), as secondary to the service-connected post-operative left tibial tubercle shift, claimed as left knee pain. A noncompensable evaluation, based on asymptomatic incomplete paralysis, under Diagnostic Code 8520 was assigned, effective April 17, 2012. In October 2012, the Veteran filed a claim for a TTR for left SI joint surgery she was having later that month. Subsequently, in October 2012, the Veteran underwent an anterior sacroiliac joint fusion, left side with iliosacral screw fixation. In a February 2013 rating decision, the RO granted an increased rating of 20 percent, effective April 17, 2012, under Diagnostic Code 5236, for left SI joint arthritis and instability status post fusion (previously evaluated as left pyriformis syndrome, claimed as left SI joint, under Diagnostic Code 8520). A TTR was assigned from October 17, 2012, based on surgical or other treatment necessitating convalescence. The 20 percent rating was continued from February 1, 2013. In August 2013, the Veteran underwent surgery again related to her left SI joint. In a September 2013 rating decision, the RO granted a TTR for the service-connected left SI joint arthritis and instability status post fusion from August 16, 2013 to October 31, 2013. The 20 percent rating was continued from November 1, 2013. In September 2013, the Veteran requested an extension of the TTR for her left SI joint arthritis and instability status post fusion. In October 2013, the Veteran filed a claim for individual unemployability, due in part to her service-connected left SI joint arthritis and instability. In a July 2014 rating decision, the RO extended the TTR for the left SI joint arthritis and instability from November 1, 2013 to February 28, 2014. The rating was decreased to 10 percent, effective March 1, 2014. The Veteran appealed the July 2014 rating decision, and in a July 2016 rating decision, the RO restored the 20 percent rating for the service-connected left SI joint arthritis and instability status post fusion surgeries to 20 percent, effective March 1, 2014. The claim for an increased rating for the left SI joint arthritis and instability disability is exclusive to any periods where TTRs were assigned, as summarized above. In order to warrant a rating in excess of 20 percent, the Veteran's lumbar spine disability must be manifested by forward flexion of the thoracolumbar spine 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or unfavorable ankylosis of the entire thoracolumbar spine. Private treatment records from Minnesota Sport & Spine dated from April 2011 to June 2012, show the Veteran reported that she was employed full time in a position that required her to be active in sitting and standing. She rated her overall health as good and noted that she exercised occasionally. She complained of low back pain, with aggravating factors of forward bending, returning from bent position, standing, walking, lifting/carrying, and turning over in her sleep. On active range of motion testing extension was 100%, flexion was 75%, left and right rotation were 75%, and left and right side bending were 100%. She had an abnormal gait, and was noted to have pain in the lumbar spine, as well as impaired ambulation, balance, functional activities, joint integrity/mobility, posture, ROM, muscle performance, soft tissue mobility, weakness and flexibility. Private treatment records from Midwest Spine Institute show that in July 2011, the Veteran complained of low back pain, equal bilateral buttock pain, equal bilateral posterior leg pain to the calves, and equal bilateral foot numbness. She reported that physical therapy was somewhat helpful, but chiropractic care was not. She was sent for an MRI earlier that month, which indicated disc etiology in the lumbar spine. On physical examination, straight leg raise and facet loading were both negative, bilaterally. There was pain on palpation of the left SI joint region. On neurological testing there were no sensory perception differences of the lower extremities. Stance was normal, shoulders and pelvis were level, and there was no evidence of spine deformity. There were no signs of lymphadenopathy. Lumbar ROM was 100% in all directions and hip ROM was full. Motor and sensory examinations were normal. It was noted that the MRI scan revealed no significant disc pathology, and normal disc height throughout. There was no stenosis centrally on the foramen at any segment and norma1appearing facets. There were no fractures or any other evidence of acute pathology. The diagnosis was suspected sacroiliitis, left greater than right and chronic low back pain. It was suggested that she obtain an SI joint steroid injection. August 2012 private treatment records from the Park Nicollet Methodist Hospital show the Veteran was tender over the left SI joint and moved cautiously. She had a minimally positive Patrick's test in the sitting position and a moderately positive test in the supine position. She complained of pain over the SI joint with the axial load of the SI joint with hip flexed 90 degrees. Her dependent reflexes were 2+ and symmetric at the knee and ankles. She had negative sciatic tension signs. Hip ROM was flexion beyond 90 degrees, internal rotation to 45 degrees, external rotation to 60 degrees, and abduction to 50 degrees. She did not have pain with rapid marked internal rotation with axial load in the seated or supine position. X-rays were negative for any obvious sign of SI joint degeneration and other imaging studies did not reveal any significant intervertebral disc disease. She did have a spondylolysis without listhesis. SI joints appeared normal on the MRI. On VA examination in June 2012, the Veteran complained of low back pain. She reported that she had tried chiropractic manipulation, physical therapy and steroid injection, without benefit. However, she denied any flare-ups of low back pain. During ROM exercises, she performed forward flexion to 90 degrees, with pain beginning at 55 degrees; extension to 30 degrees, with pain beginning at 25 degrees; right and left lateral flexion to 30 degrees, even with pain; right lateral rotation to 30 degrees without pain; and left lateral rotation to 30 degrees, even with pain. ROM was additionally limited following repetitive use testing, in that forward flexion was reduced to 50 degrees. The examiner also noted that there was functional impairment of the thoracolumbar spine in the form of less movement than normal and excess fatigability and pain on movement. There was marked tenderness over the left pyriformis and lesser tenderness over the left SI joint. There was no guarding or muscle spasm of the thoracolumbar spine and no muscle atrophy. Muscle strength testing was normal. Reflex and sensory examinations were normal, and straight leg raising test was negative. There was no radiculopathy, ankylosis or any other neurologic abnormalities noted, and there was no intervertebral disc syndrome. The Veteran denied using any assistive devices. A VA medical opinion was submitted in January 2013. The examiner concluded that the Veteran's diagnosis of left pyriformis syndrome was made in error, or with incomplete information. It was diagnosed due to lack of response to injection in the SI joint and pain over piriformis; however, further evaluation found SI joint instability and arthritis. This was stabilized surgically. This is the same condition for which she was diagnosed as having pyriformis syndrome. The examiner opined that it was at least as likely as not caused by or aggravated by the Veteran's post-operative left tibial tubercle shift. On VA examination in December 2013, the Veteran was able to flex the thoracolumbar spine to 65 degrees, extend to 20 degrees, left and right laterally bend to 30 and 20 degrees respectfully in each direction, and left and right rotate it to 25 and 20 degrees in each direction, with pain on motion and movement shown. The examiner also noted that there was less movement than normal and interference with sitting, standing, and/or weight bearing. There was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The examiner noted that pain, repetitive use, weakness, flare-ups, incoordination or fatigue would not cause any additional loss of range of motion in the thoracolumbar spine. It was noted that she was continuously using a cane and occasionally using crutches and motorized scooter due to her left SI joint surgery in August 2013. The Veteran was afforded her most recent VA examination for her lumbar spine disability in July 2016. Range of motion was shown as: flexion from 0 to 55 degrees when standing (90 degrees when sitting), extension from 0 to 20 degrees, right lateral flexion was normal from 0 to 30 degrees, left lateral flexion was from 0 to 25 degrees, and lateral rotation was from 0 to 25 degrees bilaterally, with pain on motion. There was no additional loss of function or ROM after repetitive use testing. The examiner noted that he was unable to determine without resorting to speculation, whether pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over a period of time. In this regard, the examiner noted that the Veteran ambulated with a limp after the examination whereas she had normal gait on arrival to the examination. She did not use a cane. She reported that she used a cane regularly, but did not have it with her at that time, as it was broken. It was noted that pain, and lack of endurance significantly limited functional ability with flare-ups. There was no guarding or muscle spasm of the thoracolumbar spine and no muscle atrophy. Reflex and sensory examinations were normal, and straight leg raising test was negative. There was no radiculopathy, ankylosis or any other neurologic abnormalities noted, and there was no intervertebral disc syndrome. The evidence of record also includes outpatient treatment records from the VA Medical Center in Minneapolis, Minnesota, and SSA records, which show the Veteran's complaints of chronic low back pain. However, they do not include information specific enough to rate the Veteran's lumbar spine disability relevant to the rating criteria. The evidence of record for this period reflects complaints of chronic back pain, but it also shows that the Veteran was able to flex forward well beyond 30 degrees and maintained significant movement in the spine, which means that there was no evidence of ankylosis. With regard to neurologic impairment, the Board notes that there is no evidence of record of any other neurologic abnormalities or findings related to the lumbar spine condition; thus, additional compensation for any other neurologic conditions is not warranted, and the evidence is therefore against a separate rating for neurologic impairment associated with the Veteran's lumbar spine disability. Consequently, the Board finds that a rating in excess of 20 percent is not warranted for this period under the general rating formula. Furthermore, in regards to DeLuca criteria, private treatment records show complaints of chronic left leg and back pain in 2011 and 2012, but range of motion for the lumbar spine and hip was essentially normal at that time. On VA examination in June 2012, the examiner noted that there was functional impairment of the thoracolumbar spine in the form of less movement than normal and excess fatigability and pain on movement, but ROM (flexion) was only additionally limited following repetitive use testing by 5 degrees. On VA examination in December 2013, the examiner noted that there was less movement than normal and interference with sitting, standing, and/or weight bearing, however, he also noted that pain, repetitive use, weakness, flare-ups, incoordination or fatigue would not cause an additional loss of range of motion in the thoracolumbar spine. On VA examination in July 2016, the examiner noted that the Veteran ambulated with a limp after the examination whereas she had normal gait on arrival to the examination. However, the examiner concluded that he could not definitively state that pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over a period of time. It was also noted that pain and lack of endurance significantly limited functional ability with flare-ups. However, there was no additional loss of function or ROM after repetitive use testing, and the Veteran did not have her cane, which she claimed to use regularly, as she claimed it was broken. Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). However, pain alone does not constitute a functional loss under VA regulations that evaluate disability based upon range-of-motion loss. Mitchell v. Shinseki, 24 Vet. App. 32 (2011). Moreover, the Board finds that the Veteran's painful motion is already contemplated in her 20 percent evaluation. A higher rating would, therefore, not be warranted on the basis of functional impairment. Cf. DeLuca, 38 C.F.R. §§ 4.40, 4.45. The Board also finds that a higher rating is not available under the formula for rating intervertebral disc syndrome based on incapacitating episodes. In this regard, the Veteran has denied any incapacitating episodes due to back pain on VA examination, and there is no documentary evidence of any incapacitating episodes or physician-prescribed bed rest for the Veteran's lumbar spine disability during the appeal period. Therefore, a rating in excess of 20 percent under Diagnostic Code 5243 based on incapacitating episodes is not warranted. The Board notes further that although the Veteran has been noted on examination to have scars of the low back area, associated with her service-connected lumbar spine disability, as the scars have not been shown during the period on appeal to be unstable or painful; deep and covering an area of at least 6 square inches; superficial and covering an area of 144 square inches or greater; or otherwise symptomatic, a separate rating under Diagnostic Codes 7800-7805 is also not warranted. The Veteran is competent to report the symptoms of her lumbar spine disability. Her complaints are credible. The Veteran's complaints have been considered in the above noted evidence; however, evaluations for VA purposes have not shown the severity required for a higher schedular rating, as discussed above. After examining all the evidence, the Board concludes that the weight of the evidence is against a rating in excess of 20 percent for the lumbar spine disability. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.21 (2017). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). Entitlement to SMC Based Upon the Need for A&A of Another Person SMC at the A&A rate is payable when a veteran, due to service-connected disability has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes or is permanently bedridden or so helpless as to be in need of regular aid and attendance. See 38 U.S.C. § 1114 (1) (2012); 38 C.F.R. § 3.350(b) (2017). Pursuant to 38 C.F.R. § 3.350(b)(3) and (4), the criteria for determining that a veteran is so helpless as to be in need of regular A&A, including a determination that he/she is permanently bedridden, are contained in 38 C.F.R. § 3.352(a) (2017). That regulation provides that the following will be accorded consideration in determining the need for regular A&A: inability of a claimant to dress or undress himself/herself or to keep himself/herself ordinarily clean and presentable, frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, inability to feed himself/herself through loss of coordination of upper extremities or through extreme weakness, inability to attend to the wants of nature, or incapacity, physical or mental, which requires care and assistance on a regular basis to protect him/her from the hazards or dangers incident to his/her daily environment. The Veteran contends that she is entitled to SMC based on the need for regular A&A of another person because she is unable to attend to the activities of daily living (ADL), due to her service-connected left knee and lumbar spine disabilities. Specifically, she alleges that she is unable to bathe herself or shave, to cook for herself or her family, to dress herself, because she cannot bend over enough to get her pants off, or to drive. She has not alleged that she is in need of A&A due to her service-connected psychiatric disability. The evidence of record shows that for several years, following her lumbar spine surgery in 2012, the Veteran received personal care aid (PCA), as she was unable to accomplish ADL, to include personal hygiene and care, food preparation and driving. This was paid for by her private insurance. An October 2012 PCA Assessment and Service Plan notes that the Veteran was able to get up from the bed and couch, but required standby assistance with transfers, due to her back surgery. She used a cane when outside of the home and was able to get up and down stairs on her own, but required standby assistance, due to her back surgery. She was noted to stay in one position during the night. She required physical assistance to and from the bathroom, due to her back surgery. She was able to put her shirt on, but otherwise needed physical assistance with dressing of her lower extremities because of pain and limited motion in her back. She needed assistance in and out of the bathtub and physical assistance washing her back and lower extremities due to pain and limited mobility of her back. She was able to perform all her grooming and hygiene and to eat independently, and did not need assistance with medication management. A July 2013 examination for housebound status or permanent need for regular aid and attendance, completed by the Veteran's PCA, noted that the Veteran had required PCA assistance since November 2012, and that she needed assistance with cooking (not able to prepare meals), bathing, shaving, dressing (as she was unable to bend over or twist), transfers, mobility and laundry. The PCA noted that the Veteran ambulated with an antalgic gait with a cane, but could sit in a chair comfortably. She was noted to have full active range of motion of the upper extremities and lower extremities, but decreased range of motion of the lumbar spine and left SI joint, and therefore, was unable to perform forward flexion of the spine or lateral rotation. She was weight bearing with a cane. She was noted to have limited daily activity, in that she was unable to grocery shop or run errands due to immobility; activities outside of the house were limited to doctors' appointments. She required the use of a cane for locomotion. It was noted that the Veteran was not legally blind, did not required medication management, and was not bedridden. In a September 2014 statement, the Veteran's caregiver through the MPLS VA Caregiver Support Program reported that the Veteran's service-connected left SI joint disability had worsened and that it was extremely hard for the Veteran to walk without support (without her cane), position herself, or get up from a sitting or lying position. He also noted that the Veteran needed assistance with her ADL, as well as prescription reminders and transportation to appointments. He also stated that the Veteran's pain, limited mobility and mood, due to her service-connected psychiatric disability, made it extremely difficult for her to do anything outside of the home except go to doctors' appointments. The Veteran's husband also submitted a September 2014 statement in support of her claim for SMC. He reported that the Veteran was suffering from chronic knee and back pain, which had taken a huge toll on their family. In an October 2014 statement, the Veteran's private PCA alleges that she had to help the Veteran with all of her ADL, help manage her medications, drive her to appointments, schedule her appointments, etc. In accordance with the Board's February 2016 remand, the Veteran was afforded an aid and attendance examination in July 2016. The report indicates that the Veteran needs assistance with ambulation, transferring, bathing and personal hygiene, dressing, preparing meals, housework (general housekeeping, laundry), shopping, transportation (totally dependent), managing medications, managing finances. She is independent in using the telephone. She is independent in feeding and toileting, and continent in bowel and bladder functions. She has handrails in the stairways, grab bars in the bathroom and a bath chair. It was noted that she had missed over 25 appointments at the VA, and that she no longer met the criteria for the Caregiver Support Program. The Veteran was not bedridden or hospitalized, and it was noted that she is able to travel beyond her current domicile. She reported that she occasionally went swimming with her kids, and that she was able to get down on the floor and play with them, but she needed help getting up. Other than spending time with her children, she did not go out and participate in social activities. She reported that her sleep was broken due to obstructive sleep apnea, and that she may wake up with pain in the night and has difficulty returning to sleep. Her husband helps shave her legs and helps wash her lower extremities during flare-ups, and helps her dress from the waist down. She is able to wipe with twisting and able to use the bathroom herself. She also has a tub/shower with a shower chair, and is able to get into the tub with grab bars. Her husband drives for her. She uses a cane when leaving the house. She denied dizziness or memory loss, but reported that imbalance constantly affects her ability to ambulate. It was noted that she is able to walk without the assistance of another person for up to a few hundred yards, but she needs her cane to ambulate. She was noted to have decreased range of motion of the lumbar spine and limitation of joint motion and muscle weakness in the lower extremities. Weight bearing was noted to be abnormal, in that she has an antalgic gait after exercise. The examiner noted the result of a January 2015 occupational therapy consultation. With regard to her home environment, it was noted that the Veteran entered her home through the garage into the lower level of her home, where her bedroom was located. Her home posed challenges with its split entry design and bathroom only on the upstairs level. There were 5 steps with handrail to enter the front door. She reported difficulty with bed mobility and a bed rail was ordered. There were six steps with handrail, landing and seven steps with partial handrail. HISA grant was reviewed for second handrail on lower steps, and a grab bar was to be installed on the second flight where there was only a partial handrail. The Veteran required the assistance of her husband to transfer on and off the couch she was seated on. She was also dependent on her husband for shower assistance and lower extremity dressing. The bathroom had an ADA toilet, tub/shower with hand held shower and broken shower chair. A safety pole was reviewed, but declined. Bathroom safety equipment, including a versa-frame, clamp on grab bar, 1-2 wall mount bars and replacement shower chair and lower extremity dressing equipment to promote safe transfers and maximum level of independence, were ordered. The Veteran spent the visit on the couch. She did transfer off and on, with support from her husband and ambulated a short distance. Her gait was abnormal and she appeared in pain. She had a SEC, which she used as needed. Her upper extremity range of motion was adequate to complete ADL. She reported falls associated with her left hip giving out and 2 falls outside, but they were related to icy conditions. She was not exercising. She had a license, but did not drive, due to pain and medications. She was assessed with the KATZ index of independence with ADL's with a score of 2/6. She used an electric cart if she went shopping and her husband helped with medication set up/reminders. It was determined that the goal of home accessibility, ADL's and equipment needs were met, and no future visits were scheduled. In rendering his opinion, the February 2016 examiner noted that although the Veteran reported inability to bathe her lower extremities, including shaving, and that she is unable to climb stairs to do laundry, and unable to drive due to pain and narcotics, she reports going to the water park with her children and playing in the pool. He also noted that she did not appear to have decreased mental function due to narcotics. She declined to undress during the examination so the examiner was unable to determine her ability to function getting into clothing. The examiner also noted that although the Veteran reported being able to get down to the floor to play with her children, but needing assistance to return to a standing position, it is expected that getting to a position of being seated on the floor would demand a greater range of motion than was demonstrated during the examination. He concluded that her limitation of motion of the lumbar spine as performed in the back examination and related to A&A is less than expected as due to her service-connected condition. The SI joint condition would not decrease range of motion to the degree noted on the examination. The Veteran may limit motion of the back due to pain, but not due to physiologic change in the anatomy. The SI joint normal has minimal motion and the fusion of such would not alter the range of motion of the lumbar spine. The examiner also noted that the Veteran reports that she needs assistance with ADL; however, there is no supportive evidence, including occupational therapy assessments or private medical evidence within the last year to review, as the Veteran has multiple failed appointments with the VA. He noted that on examination at that time, she was independent in sitting, standing and returning from lying to sitting. She reports needing assistance with dressing and bathing, but has declined a safety pole. Furthermore, with the ability to get to the floor to play with children, as she reports, it is expected that Veteran has more range of motion than demonstrated during the February 2016 examination. The examiner concluded that he was unable to confirm that the Veteran is in need of A&A, as defined by the VA, solely on the basis of her service-connected conditions. The evidence of record shows that the Veteran has limitation of motion of the lower extremities and lumbar spine, due to her service-connected disabilities, and that she is assisted by her husband when standing and washing her lower extremities, and with cooking and driving. However, the evidence also shows that she is able to ambulate, stand and walk independently with the use of her cane, and that she has a shower chair and grab bars installed in her bathroom to assist with bathing. On examination, as noted above, she was independent in sitting, standing and returning from lying to sitting. The Board notes that the Veteran's caregiver from the MPLS VA Caregiver Support Program reported in September 2014 that it was extremely difficult for the Veteran to walk and ambulate without assistance. However, on VA examination in July 2016 for her left SI joint disability, the examiner noted that the Veteran was there without her cane and ambulated independently, with a normal gait at the beginning of the examination, and with a limp after range of motion exercises. She reported at that time that her cane was broken. See July 2016 VA examination report. Therefore, the Board must assume that she was not using the cane or any other assistive device, but was able to walk and go up and down stairs unassisted. The Veteran has also reported that she is unable to dress herself from the waist down, but she refused to demonstrate for the examiner in 2016, and she has declined a safety pole to assist her with lower extremity dressing. She has never reporting being unable to feed herself or attend to the wants of nature, as she is independent in toileting. Furthermore, the Board notes that the Veteran has several types of safety equipment, including handrails, a bedrail, grab bars, a versa-frame, a clamp on grab bar and wall mount bars, as well as a shower chair in the bathroom, to help keep her safe at home when walking up stairs, showering/bathing, sleeping and dressing. Furthermore, the Board notes that the Veteran reports of going to the water park with her children and playing in the pool, as well as getting down on the floor to play with her children, make her reports of significantly decreased range of motion in the lumbar spine, inhibiting her ability to wash her lower extremities, shave and ambulate unassisted less credible. Therefore, the Board finds that the Veteran is not entitled to SMC based on the need for regular aid and attendance of another person as a result of her service-connected disabilities. The Board finds that the weight of the evidence of record does not show that the Veteran is permanently bedridden, that she is completely unable to dress or undress herself or keep herself ordinarily clean and presentable, that she requires assistance adjusting any special prosthetic or orthopedic appliances, that she is unable to feed herself, that she is unable to attend to the wants of nature, or that she requires care or assistance on a regular basis to protect her from hazards or dangers incident to her daily environment as a result of her service-connected disabilities. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to SMC based on the need for the regular aid and attendance of another person is not warranted. 38 U.S.C.A. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 10 percent for left medial meniscus tear, status post partial medial meniscectomy/arthroscopy with degenerative arthritis, is denied. A rating in excess of 20 percent for left SI joint arthritis and instability, status post fusion surgeries, is denied. Entitlement to SMC based on the need for the regular A&A of another person is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs