Citation Nr: 1804115 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 16-33 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to a disability rating in excess of 20 percent for degenerative disc disease of the lumbar spine (lumbar spine disability). REPRESENTATION Appellant represented by: Karl A. Kazmierczak, Attorney WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD J. Anderson, Counsel INTRODUCTION The Veteran served on active duty from October 1951 to September 1954 and December 1965 to January 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2017, the Veteran testified at a video conference hearing before the undersigned Veterans' Law Judge (VLJ). A transcript of that hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDING OF FACT Throughout the pendency of the appeal, the preponderance of the evidence indicates that the Veteran's lumbar spine disability was manifested by, at worst, thoracolumbar forward flexion to 40 degrees, pain, and stiffness; the evidence is against a finding of thoracolumbar forward flexion of 30 degrees or less, ankylosis of the entire thoracolumbar spine, incapacitating episodes, or neurologic abnormalities. CONCLUSION OF LAW The criteria for a lumbar spine disability rating in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic 5243 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has raised no issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2017). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2017); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2017); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2017); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2017). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2017); see also 38 C.F.R. §§ 4.45, 4.59 (2017). 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). Throughout the pendency of the appeal, the Veteran's lumbar spine disability has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2017). The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) provides a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2017). The General Rating Formula provides further guidance in rating diseases or injuries of the spine. In pertinent part, Note (1) provides that any associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Alternatively, intervertebral disc syndrome (IVDS) can be rated under Diagnostic Code 5243 and the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). Under this Formula, a 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a (2017). An "incapacitating episode" is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, IVDS Formula, Note (1). Treatment records from Dr. Lacy, dated in August 2013, indicate that the Veteran experienced increasing back pain over the last five years, that he was very sensitive regarding what mattress he used, and that his sleep number bed had been the most helpful treatment. It was noted that the Veteran maintained an active lifestyle and engaged in swimming and weight lifting. The Veteran reported that prior treatment included muscle relaxants and physical therapy. He described his pain as 2 or 3 out of 10 during the prior week, but a 6 of 7 out of 10 with flare-ups. Upon examination, the Veteran had limited thoracolumbar flexion secondary to pain, but there was no evidence of pain with extension. Straight leg raising was negative, there was no tenderness to palpation, reflex examination was normal at the bilateral patellae, but somewhat diminished at the bilateral ankles. There was no evidence of focal weakness in the bilateral lower extremities. Dr. Lacy noted that the chronicity of the Veteran's pain made it unlikely that it could be completely resolved. It was recommend that he engage in at home physical therapy and take Tylenol three times per day. No interventional procedures were recommended. A September 2013 disability questionnaire (DBQ) from Dr. Lacy indicates that the Veteran experienced chronic low back pain. The Veteran endorsed increased pain with activity as well as unpredictable increases in pain. He stated his pain was a 6 to 7 out of 10 at times. Upon examination, he had forward flexion to 70 degrees with pain at 15 degrees, extension to 15 degrees with pain at 10 degrees, bilateral lateral flexion to 15 degrees with pain at 10 degrees, and bilateral rotation to 20 degrees without any evidence of pain. There was no additional functional loss or reduction in range of motion with repetitive use testing. Muscle strength testing was 4/5 bilaterally for hip flexion and 5/5 bilaterally for knee extension, ankle plantar flexion, dorsiflexion, and toe extension. Bilateral reflex examination revealed normal knee reflexes, but somewhat diminished ankle reflexes. There was no evidence of muscle atrophy. The Veteran was noted to have guarding or muscle spasms, which did not result in an abnormal gait or spinal contour. Pain to palpation was evident in the bilateral lower lumbar paraspinal muscles. Straight leg raising testing was negative bilaterally and there was no evidence of radiculopathy or sensory disturbances. Dr. Lacy stated that the Veteran had IVDS of the thoraco-lumbar spine, but had not had any incapacitating episodes in more than two years. He opined that the Veteran's functional impairment included less movement than normal and pain on movement. He opined that the Veteran's thoracolumbar spine condition would impact the Veteran's ability to work if he were not retired. A September 2013 treatment record from Dr. Lacy indicates that the Veteran endorsed ongoing back pain, which he described as 5 out of 10 following physical activity. He also reported having muscle spasms approximately twice a year, which caused significant impairment. He noted that lifting heavy objects could contribute to the Veteran's pain, but the Veteran denied having pain that radiated into his lower extremities. Dr. Lacy indicated that the Veteran's pain was consistent with discogenic lumbar pain. On his October 2013 VA Form 21-526EZ, the Veteran stated that his lumbar spine disability warranted the maximum rating because his pain prevented him from doing many things, he had back spasms, and his wife had to do things for him. At his May 2014 QTC examination, the Veteran reported that there were many tasks that he was unable to perform and that he had difficulty with any task wherein he had to reach above his head. He stated that when his pain reached a 5 or 6 out of 10, he had to stop what he was doing to prevent a muscle spasm. He noted that activities, such as leaning over the table, increased his pain to a 5 or 6 out of 10. He reported that he was able to sleep on his "number bed" without much pain, but stated the pain was a 4 or 5 out of 10 after getting out of bed and that it took a while before his back was comfortable again. Upon examination, the Veteran had flexion to 40 degrees with pain at 40 degrees, extension to 10 degrees with pain at 10 degrees, and bilateral flexion and rotation to 15 degrees with pain at 15 degrees. There was no additional loss of function or reduction in range of motion with repetitive use testing. Bilateral muscle strength, reflex, and sensory examinations were within normal limits. There was no evidence of muscle atrophy, pain to palpation of the thoracolumbar spine, guarding, or muscle spasms. Straight leg raising testing was negative bilaterally and there were no signs or symptoms of radiculopathy or other neurologic abnormalities. The examiner opined that the Veteran did not have IVDS of the thoracolumbar spine. She observed that the Veteran did not require any assistive devices for locomotion, that his posture was within normal limits, and that his gait was within normal limits. The examiner opined that the Veteran's lumbar spine disability resulted in less movement than normal and pain on movement, and that it would limit his ability to work in an occupation that required heavy lifting or carrying. She opined that there were no contributing factors of weakness, fatigability, incoordination, or pain during flare-ups or with repeated use over time that would additionally limit the Veteran's functional ability. A May 2014 treatment record from Dr. Kim noted that the Veteran had no acute concerns and that musculoskeletal and neurologic examinations were negative. Treatment records from Dr. Howe, dated in May 2014, indicate that the Veteran's chronic back pain had recently begun to interfere more with his activities of daily living. The Veteran endorsed difficulty getting up in the morning secondary to his back pain and stated he was no longer able to bend over enough to play pool. He noted that almost any activity seemed to worsen his back symptoms. The Veteran's muscle strength was 5/5 bilaterally with hip flexion; quadriceps, dorsiflexion, and plantar flexion, weakness was noted bilaterally in the Veteran's extensor halluces longus. Straight leg raising was negative bilaterally. He underwent bilateral facet injections at the L4-5. A June 2014 treatment record from Dr. Howe indicates that the Veteran had undergone a bilateral L4-5 facet injection two weeks ago and he reported he was in less pain than he had been in years. Upon examination, no focal weakness in hip flexion, quadriceps, dorsiflexion, or plantar flexion was evident. Dr. Howe opined that the Veteran was doing exceptionally well and had a substantial decrease in his overall pain levels compared to prior to the injections. He was advised that he could have repeated injections up to three times per year. In an October 2014 statement, the Veteran stated that his "S1 was completely gone. . . [a] condition called ankylosis." He stated that his daily pain had increased to a 6 to 8 out of 10 and went as high as a 9 to 10 out of 10 when he performed tasks. He stated that he had to take breaks while performing tasks to prevent muscle spasms. He noted that if he experienced a muscle spasm he had to crawl to bed and lay down on a heating pad to reduce the pain. He reported that he had pain all the time, but later stated that his pain medication lasted for approximately 3.5 hours so he was "pain free" approximately 7 hours per day. He stated that the more he bent his back the more it hurt. He reported that his doctor had told him that tingling and weakness in the lower extremities could lead to permanent paralysis or even death. He stated that he had to eliminate many chores from his daily activities because they increased his pain. He noted that he had to pick things up by bending his legs rather than his back. Treatment records from Dr. Howe, dated in October 2014, indicate that the Veteran was returning for a reassessment of his chronic and activity limiting back pain. It was noted that there was no evidence of new symptomatology and that the facet injections administered in June 2014 resulted in significant long term improvement and until recently essentially eradicated his symptoms. Upon examination, the Veteran was not in acute distress, positional rotation was accomplished without any difficulties, and his gait was normal. Muscle strength testing was 5/5 bilaterally for hip flexion, quadriceps, dorsiflexion, and plantar flexion. Facet injections at the L4-5 level were administered. A June 2015 treatment record from Dr. Kim indicates that the Veteran was able to get up from a chair, walk 10 feet, turn around, walk back, and sit in the chair in less than 12 seconds. Neurological examination revealed no weakness. The records were silent for any reports or evidence of any lumbar spine symptomatology. An October 2015 treatment record from Dr. Howe noted that the Veteran experienced profound pain relief from his bilateral facet injections. Specifically, the Veteran reported that he had very little back pain, but did recently begin experiencing a burning sensation in the plantar aspect of his feet associated with sitting for prolonged periods. Upon examination, hip flexion, quadriceps, dorsiflexion, and plantar flexion muscle strength were 5/5. It was noted that the Veteran was requesting another facet injection. Dr. Howe opined that as the Veteran had done extremely well following his prior facet injection, it was reasonable for him to undergo another round of injections. In a February 2016 report of general information, the Veteran stated that his range of motion had nothing to do with his injury. He stated that his problem was pain and the need to be careful with everything. He reported that he experienced ongoing spasms since service, which were sometimes so severe he could not walk. At his June 2016 VA examination, the Veteran reported that if he drove for more than an hour the bottom of his feet had a burning sensation. He stated he had flare-ups of burning in his feet and an inability to walk to the bathroom during the night, specifically he reported that he had to crawl to the bathroom. The Veteran did not indicate when the above flare-up occurred. The Veteran was unable to perform range of motion testing because he stated that he was in "too much pain at this time." The examiner noted there was evidence of pain at rest and with non-movement, but not with weight bearing. Upon examination, there was evidence of moderate tenderness in the low back, but no evidence of guarding or muscle spasm. Muscle strength, reflex, and sensory testing were within normal limits. Straight leg testing was negative and the examiner opined that there was no evidence of any sign or symptom of radiculopathy. The examiner opined that there was no evidence of ankylosis of the spine, neurologic abnormalities related to the thoracolumbar spine, or IVDS. It was noted that the Veteran did not require any assistive devices for locomotion. The examiner opined that the Veteran's lumbar spine disability would limit his ability to walk and run. On the October 2016 VA Form 646, the representative asserted that the Veteran's lumbar spine disability severely impaired his functional abilities and that even if the Veteran did not meet the criteria for a disability rating in excess of 20 percent he was entitled to an extraschedular rating. In support of that assertion, the representative noted that the Veteran required pain injections, was unable to perform range of motion testing at his June 2016 VA examination, and that earlier medical records indicated the Veteran experienced incapacitating episodes and back spasms and noted the Veteran's reports that his symptoms had not improved significantly since then. An October 2016 treatment record from Dr. Howe noted that the Veteran had ongoing back pain that limited his activities. It was noted that the Veteran had previously undergone facet injections in October 2015, which had "essentially eradicated his symptoms until recently." Dr. Howe noted that numerous medical treatment options prior to the injections had not been helpful. Upon examination, the Veteran's muscle strength was 5/5 for hip flexion, quadriceps, dorsiflexion, and plantar flexion. Dr. Howe opined that the Veteran continued to struggle with severe low back pain, but had done extremely well with facet injections. In a November 2016 correspondence, the Veteran reported that he felt much better after his back injections. However, he noted that the relief only lasted 3 or 4 months before the effects of the injections decreased. He stated that even with the injections he still had to be careful about what he did, that he still had pain when he raised his arms, slept in the wrong position, or performed simple movements that others took for granted. He reported that he had burning sensations in his feet if he sat for more than one hour. He further noted that he was unable to lift anything heavy or ride a bike. At his December 2016 VA examination, the Veteran reported worsening back pain. He stated that he had constant pain that was a 2 or 3 out of 10. He stated that certain movements, such as driving, hanging drapes, raising a telescopic flag, lifting more than 10 pounds, or changing a light bulb, aggravated his pain. He reported that his injections and sitting with lumbar support helped, but did not alleviate his pain. He denied using a back brace or any other assistive device. With regard to flare-ups, the Veteran reported that his last flare-up was approximately 8 years ago. He stated that he had experienced limited movement during his last flare-up. Upon examination, the Veteran had forward flexion to 60 degrees, extension to 10 degrees, bilateral flexion to 20 degrees, and bilateral rotation to 20 degrees. Upon repetitive use testing, the Veteran had forward flexion to 50 degrees, extension to 10 degrees, bilateral flexion to 15 degrees, and bilateral rotation to 20 degrees. The examiner noted there was no evidence of pain with weight bearing or with palpation of the thoracolumbar spine. The examiner stated that there was evidence of pain throughout all spheres of range of motion testing, but opined that it did not result in or cause functional loss. The examiner indicated that there was no evidence of guarding or muscle spasms, and muscle strength, reflex, and sensory testing were within normal limits. Straight leg testing was negative and the examiner opined that there was no evidence of any sign or symptom of radiculopathy. The examiner opined that there was no evidence of ankylosis of the spine, neurologic abnormalities related to the thoracolumbar spine, or IVDS. The examiner noted that the Veteran was able to bend and untie his shoe while sitting. With regard to the functional impact of the Veteran's disability, the examiner noted that the Veteran would be limited in continuously walking more than a half a block, limited in lifting more than 10 pounds, and limited in sitting more than one hour. The examiner noted that the Veteran stated that he exercised by lifting 5 to 10 pounds, and that he walked approximately 5000-6000 steps per day. In a March 2017 correspondence, the Veteran reported that he experienced constant pain no matter what he was doing, whether sitting, standing, walking, or lying down. He noted that during range of motion testing at his December 2016 VA examination he had pain, but the pain was unchanged during that testing. In an April 2017 statement, the Veteran's representative asserted that the evidence of record demonstrated a history of marked interference with the Veteran's employment as well as incapacitating episodes; therefore, an extraschedular rating was warranted. At his September 2017 hearing, the Veteran rated his current pain as a zero but noted that he had difficulties performing different activities. He rated his pain as a 7 or 8 out of 10 if he aggravated it and noted that during such times he would have to sit and rest for a while. He stated that anytime he had to do work, reach above his head, walk more than two blocks, or lift something heavier than a car battery it bothered his back. He stated the pain also affected his sleep and that he could not sleep on a regular bed or on his back. He noted that his feet burned if he drove. He stated that his doctor gave him yearly steroid injections to help alleviate the pain. His wife noted that the alleviating effects of the injections began to wear off after 3 to 4 months and that the effects were noticeable. She also noted that the Veteran's back pain prevented them from flying when they traveled and that they had to stop frequently so the Veteran could walk around. She also noted that the Veteran had trouble bending over secondary to his back pain. An October 2017 treatment record from Dr. Howe indicates that the Veteran returned for his yearly appointment regarding his back pain. Dr. Howe noted that the Veteran had fairly exhaustive non-operative management of his back pain and that he described the yearly bilateral L4-5 facet injections as the most helpful of all the treatment. The Veteran endorsed occasional burning sensations in his feet, he denied focal weakness, but noted that these symptoms caused difficulties sleeping. Dr. Howe stated that the burning sensations in the Veteran's feet were attributable to peripheral neuropathy. Upon review of the evidence, the Board finds that the criteria for rating in excess of 20 percent have not been met. The preponderance of the evidence demonstrates that throughout the appeal period, the Veteran's lumbar spine disability symptoms included pain, stiffness, and limitation of motion, but did not include forward flexion of 30 degrees or less, ankylosis, or incapacitating episodes. To the contrary, the Veteran's forward flexion was, at worst, 40 degrees and in September 2013 Dr. Lacy stated that the Veteran had not experienced an incapacitating episode in the last two years. The subsequent medical evidence is also silent for any physician prescribed bedrest. The Board considered whether the Veteran's lumbar spine pain resulted in a level of functional loss greater than that already contemplated by the assigned rating. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45 (2017). While the September 2013 DBQ indicated that the Veteran had pain beginning at 15 degrees of flexion, notwithstanding the pain, the Veteran achieved 70 degrees of flexion during initial and repetitive use range of motion testing. Accordingly, the Board finds that the Veteran's painful flexion beginning at 15 degrees does not more nearly approximate flexion to 30 degrees or less. As such, a 40 percent rating is not warranted. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (finding that limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded). Additionally, while pain was noted during range of motion testing at the May 2014 and December 2016 VA examinations, both examiners indicated that pain did not additionally limit the Veteran's functional abilities. Thus, even considering functional loss, the Veteran's symptomatology does not meet the criteria for a rating in excess of 20 percent. 38 C.F.R. § 4.71a (2017). The Board has not overlooked the fact that the June 2016 VA examiner indicated the Veteran was unable to perform initial or repetitive range of motion testing because the Veteran stated that he was in "too much pain." However, the Veteran's reported inability to perform such testing is inconsistent with the other observations at that examination as well as the prior and subsequent VA examination reports and private treatment records. Specifically, while the Veteran reported that his pain was too severe to perform the requested testing, he was nevertheless able to perform muscle strength, reflex, and straight leg testing. Additionally, treatment records from Dr. Howe from October 2015 and October 2016 indicate that following his facet injections the Veteran had very little back pain and that the injections had "essentially eradicated his symptoms until recently." The Board finds it highly unlikely that the Veteran experienced a flare-up of such severity as to preclude range of motion testing several months prior but would not mention it to Dr. Howe and in fact state his symptoms had essentially been eradicated. AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Thus, the Board does not find the Veteran's reports regarding range of motion testing persuasive, in light of the other evidence of record. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Thus, the Board affords more weight to the other evidence of record than it does to the Veteran's isolated report that his pain was so severe that he was unable to perform range of motion testing. The Board also acknowledges the Veteran's assertion that he has ankylosis in his S1. Nevertheless, the Board finds that his assertion is inconsistent with the evidence of record. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). The May 2014, June 2016, and December 2016 VA examinations, private treatment records, and September 2013 DBQ from Dr. Lacy were silent for any evidence of ankylosis and consistently indicated that the Veteran had mobility of the thoracolumbar spine. Given that the Veteran retains mobility of his thoracolumbar spine, the Board finds that the Veteran's symptomatology does not more nearly approximate favorable or unfavorable ankylosis of the entire thoracolumbar spine. Thus, it does not warrant a rating in excess of 20 percent. Lastly, the Board has considered whether a separate rating was warranted for neurological manifestations. While the Veteran reports that his back disability causes burning sensations in his feet, that symptom has not been attributed to the Veteran's lumbar spine disability. To the contrary, Dr. Howe expressly stated that the burning sensation in the Veteran's feet was attributable to peripheral neuropathy. Additionally, the September 2013 DBQ as well as the May 2014, June 2016, and December 2016 VA examinations all indicated that the Veteran did not have any signs or symptoms of radiculopathy or other neurologic abnormalities or findings related to his thoracolumbar spine. Thus, for the entire period on appeal, a separate rating for neurological manifestations is not warranted. Extraschedular Consideration As the matter has been expressly raised by the Veteran's representative, the Board has also considered whether the Veteran's disability picture warrants an extraschedular rating. Such consideration requires a three-step inquiry. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Service to determine whether an extraschedular rating is warranted. The threshold factor for extraschedular consideration is a finding that the established schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability. See Thun v. Peake, 22 Vet. App. 111, 118 (2008). Here, the rating criteria and the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59 (2017) reasonably describe the Veteran's disability level and symptomatology, and the rating criteria provide for additional or more severe symptoms than currently shown by the evidence based on more severe limitation of motion, ankylosis, incapacitating episodes, and neurological impairment. The Board notes the Veteran reports that his pain disrupts his sleep, that he cannot sleep on his back, that he has trouble sitting and walking for extended periods, and that there are many tasks he cannot perform. Additionally, the Veteran's representative has asserted that an extra-schedular rating is warranted in light of the Veteran's history of incapacitating episodes. The General Rating Formula for the Veteran's lumbar spine disability contemplates symptoms such as pain and decreased range of motion that interfere with and cause difficulty with activities of daily living, such as sleeping, sitting, and walking. While the inability to accomplish a task, such as those described, is not a "symptom" set forth in any portion of the Rating Schedule, it is nevertheless a result of the same symptoms considered in the diagnostic codes and applicable regulations, specifically pain, painful motion, limitation of motion, fatigue, and incoordination. Mitchell v. Shinseki, 25 Vet. App. 32, 33-36 (2011) (pain alone does not constitute functional impairment under VA regulations, and the rating schedule contains several provisions, such as 38 C.F.R. §§ 4.40, 4.45, 4.59, that address functional loss in the musculoskeletal system as a result of pain and other orthopedic factors when applied to schedular rating criteria). Thus, it is a result contemplated by the rating criteria as it is based on the same symptomatology. With regard to incapacitating episodes, that symptom is expressly considered under General Rating Formula for the Veteran's lumbar spine disability. Moreover, as noted above, the evidence does not indicate that the Veteran has experienced incapacitating episodes during the pendency of the appeal. See 38 C.F.R. § 4.71a, IVDS Formula (2017). Accordingly, the Board finds that the rating criterion reasonably describes the Veteran's disability picture and symptomatology. Consequently, referral for extraschedular consideration is not warranted. For the sake of completeness the Board will also address the representative's assertion that the Veteran experienced incapacitating episodes and that his lumbar spine disability would cause marked interference with employment. As noted above, incapacitating episodes are expressly contemplated in the rating schedule and the presence of such would not establish an exceptional disability picture under the second prong under Thun. In any event, the inquiry is whether an exceptional disability picture exhibits "other related factors such as marked interference with employment or frequent periods of hospitalization." The evidence of record does not suggest and the Veteran has not asserted that his lumbar spine disability required frequent periods of hospitalization. With regard to marked interference with employment, the Veteran is retired so there is no evidence of actual interference with employment. Additionally, the weight of the evidence does not indicate that the Veteran's lumbar spine disability would result in marked interference with employment. Specifically, the May 2014 VA examiner indicated that the Veteran's lumbar spine disability would preclude heavy lifting or carrying; the June 2016 VA examiner indicated that it would limit his walking and running abilities; and the December 2016 VA examiner indicated that the Veteran was limited in his ability to walk continuously for more than half a block, lift more than 10 pounds, or sit for more than 1 hour. As noted above, such limitations are not exceptional and do not rise to the level of marked interference. Accordingly, the weight of probative evidence is against finding that there was marked interference with employment. As neither Thun prong is met, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to a rating in excess of 20 percent for a lumbar spine disability is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs