Citation Nr: 1804670 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 12-05 733 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for macular degeneration. 2. Entitlement to an evaluation in excess of 40 percent disabling for lumbosacral strain with degenerative disc disease at L4-L5. 3. Entitlement to an evaluation in excess of 40 percent disabling for radiculopathy of the left lower extremity. 4. Entitlement to an evaluation in excess of 10 percent disabling for radiculopathy of the right lower extremity. 5. Entitlement to an evaluation in excess of 10 percent disabling for a right ankle strain and sprain. 6. Entitlement an evaluation in excess of 10 percent disabling for a left ankle strain and sprain. 7. Entitlement to a total disability evaluation based upon individual unemployability. REPRESENTATION Appellant represented by: Robert V. Chisolm, Attorney at Law ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel INTRODUCTION The Veteran had honorable active duty service with the United States Army from January 1979 to December 1982. This matter comes before the Board of Veterans' Appeals (Board) from September 2008, September 2012, and May 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. This matter was previously remanded in a May 2017 decision for additional development, to include re-adjudication of the Veteran's claim for service connection for macular degeneration and issuance of a supplemental statement of the case. The remand directives also instructed the RO to issue a statement of the case with respect to the Veteran's claims for an increased evaluation for lumbosacral strain with degenerative disc disease at L4-L5, radiculopathy of the right and left lower extremities, right and left ankle strain and sprain, and entitlement to TDIU. As the above referenced development has been completed, this matter has now returned to the Board for appellate consideration. FINDINGS OF FACT 1. Macular degeneration was not caused or aggravated by a disease or injury sustained during active duty. 2. Throughout the period on appeal, the Veteran's lumbosacral strain with degenerative disc disease has been manifested by forward flexion of the thoracolumbar spine of 30 degrees or less; there is no evidence of ankylosis of thoracolumbar spine. 3. The Veteran's service-connected radiculopathy of the left lower extremity has not been manifested by severe incomplete paralysis with marked muscular atrophy. 4. Throughout the period on appeal, the Veteran's left and right ankle strain and sprain have not been manifested by marked limited motion of the ankle. 5. The Veteran's service-connected disabilities have rendered him unable to obtain or maintain a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for macular degeneration are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2017). 2. The criteria for establishing entitlement to an evaluation in excess of 40 percent disabling for lumbosacral strain with degenerative disc disease are not met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2017. 3. The criteria for establishing entitlement to an evaluation in excess of 40 percent disabling for radiculopathy of the left lower extremity are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 3.321, 4.1, 4.3, 4.7, 4.71a, 4.124a, Diagnostic Code (DC) 8520. 4. The criteria for establishing entitlement to an evaluation in excess of 10 percent disabling for a left and right ankle strain and sprain are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 5. The criteria for establishing entitlement to TDIU benefits have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2017). Copies of compliant VCAA notices were located in the claim's file. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. VA examinations have been conducted and any necessary opinions obtained. Neither the Veteran nor his representative has raised any 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 duty to assist argument). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. § 1110, 1131 (West 2015); 38 C.F.R. §§ 3.303 (a), 3.304 (2017). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2017). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2016). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Roper v. Nicholson, 20 Vet. App. 173, See also 38 C.F.R. §3.310 (a) (2017). In determining whether service connection is warranted for a disorder, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2015); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Macular Degeneration The Veteran contends that his macular degeneration was caused or aggravated by his active service. However, as outlined below, the preponderance of the evidence is against his claim. Service treatment records are negative for complaints, treatment or a confirmed diagnosis of an eye condition in service. At enlistment in November 1978, a report of medical history reported the Veteran's vision as 20/20 in the right eye and 20/25 in the left eye. It also noted refractive error and impaired color vision. Despite the aforementioned, the Veteran was deemed qualified for service. A report of medical history, dated November 1982, listed the Veteran's vision as 20/20 in the right eye and 20/25 in the left eye. No visual limitations or related complaints were reported at separation. Post-service treatment records indicate that the Veteran was diagnosed with macular degeneration and mild cataracts in November 2004. A private physician's opinion, dated November 2004, reported the Veteran's complaints of a history of progressive difficulty reading during recent years, color-blindness, and blurry vision. On examination, the Veteran's vision was noted as 20/30 in the right eye and 20/40 in the left eye. The opinion also notes that "it is unusual to see age-related causes of macular degeneration," and suggests an inherited retinal disease (Stargardt's) as a possible cause. There is no record of a specific injury to the Veteran's eyes. The Board notes that in March 2004, a non-diabetic eye examination was conducted and normal results were noted. A clinical note references "no complaints." In May 2008, a treatment note from a VA medical center referenced the Veteran's "low vision," and inability to drive due to his visual limitations. In January of the same year, a separate note referenced the Veteran's report of throbbing eye pain. A physician opinion, dated August 2009, described the Veteran's visual limitations as "legally blind;" however, no visual acuity data was reported. In April 2012, a visual acuity test showed that the Veteran's uncorrected vision was 20/100 in the right eye and 20/200 in the left eye. With correction, visual acuity in the Veteran's right eye was 20/50 and 20/200 in the left eye. The physician noted that the Veteran was able to move about the examination facility without assistance. In February 2017, the Veteran submitted an eye optometry resident note which indicated that the Veteran is legally blind with pigment affected pigmentary retinopathy and the condition is not expected to improve. Visual acuity lost was deemed unrecoverable. In response to a Board request, an independent medical opinion was submitted in February 2017. The opinion noted a thorough review of the Veteran's medical history and opined that it is less likely as not that the Veteran's macular degeneration was caused by or otherwise related to the Veteran's active military service. In reaching the stated conclusion, the physician noted that prior findings of macular pigmentary changes and drusen are common as to age related macular degeneration. Further, as the diagnosis did not occur until 18 years after separation, it is unlikely that a causal relationship exists between the Veteran's eye condition and his active service. The opinion disputed other medical evidence which suggested that the Veteran is legally blind. In making all determinations, the Board must fully consider all evidence submitted, including lay statements and medical opinions. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Evaluation of the evidence generally involves an assessment of whether the evidence came from a competent source, is credible or worthy of belief, and has probative value in light of the entirety of the record. See Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007); See also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997). In this case, the Board finds that the independent medical opinion is most probative. The opinion noted a thorough review of the Veteran's medical history and specifically addressed all the medical evidence of record, to include contentions that the Veteran is legally blind. A detailed rationale was provided for the examiner's opinion, including as to inconsistent medical evidence. While the Board is sympathetic to the Veteran's lay statements regarding his current eye condition and its impact on his daily life, the evidence of record does not demonstrate that the Veteran has the requisite training and expertise to offer a medical opinion as complex as linking a current eye disability to military service. Thus, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990). The Veteran's claim for service connection must be denied. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2017). The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 2015); 38 C.F.R. §§ 4.1, 4.10 (2016). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App 505 (2007). When evaluating disabilities based on limited motion, it is necessary to consider both the schedular criteria and any functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to section 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). Entitlement to an evaluation in excess of 40 percent for service-connected lumbosacral strain with degenerative disc disease at L4-L5 The Veteran contends that throughout the rating period, his service-connected lumbosacral strain with degenerative disc disease has been worse than reflected in the assigned rating evaluations. The preponderance of the evidence is against his assertions. The Veteran's lumbosacral strain with degenerative disc disease is currently rated under DC 5237, which pertains to lumbosacral or cervical strain. 38 C.F.R. § 4.71a (2017). Under the General Formula, a 20 percent rating is warranted for limited forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for limited forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a (2017). The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate DC. Note (2) provides that, 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. 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. 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. See also Plate V, 38 C.F.R. § 4.71a (2016). Note (3) provides that, 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) provides that the rater is to round each range of motion measurement to the nearest five degrees. Note (5) provides that, 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) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a (2017). For VA purposes, normal range of motion for the thoracolumbar spine is flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and rotation from 0 to 30 degrees. The combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Plate V (2016). As a preliminary matter, the Board notes that service connection for radiculopathy of the left and right lower extremity has been granted, and as no additional neurological abnormalities have been identified, an additional separate rating for neurological manifestations is not warranted. See 38 C.F.R. § 4.71a, DC 5242, Note (1) (2017). Further, there is no evidence that the Veteran has experienced incapacitating episodes of any duration throughout the period on appeal. Id., Note (6); 38 C.F.R. § 4.71a, DC 5243 (2017). In this case, the Board has thoroughly reviewed the evidence of record and finds no basis for an assignment of the next higher evaluation of 50 percent disabling for the Veteran's lumbosacral spine condition. Review of the record indicates that the Veteran was afforded multiple VA examinations to assess the nature and severity of his lumbosacral spine condition. In April 2012, the Veteran was afforded a VA examination. During the clinical evaluation, he indicated that in 1980 or 1981 heavy equipment fell on him in-service and he was diagnosed with a back strain. Surgery was performed in 1993 to remove herniated disks at L4-L5. On examination, range of motion testing revealed forward flexion limited to 40 degrees (normal 0 to 90 degrees) and extension limited to 10 degrees (normal 0 to 30 degrees). Right flexion was limited to 10 degrees (normal 0 to 30 degrees) and left lateral flexion was limited to 5 degrees (normal 0 to 30 degrees). Right lateral rotation was limited to 10 degrees (normal 0 to 30 degrees) and left lateral rotation was limited to 15 degrees (normal 0 to 30 degrees). The combined range of motion of the thoracolumbar spine is 190 degrees. The examiner noted objective evidence of pain. Repetitive use testing shows decreased range of motion (flexion from 0 to 35 degrees, and extension from 0 to 5 degrees). The Veteran reported flare-ups due to prolonged walking and standing. Additional functional loss and range of motion following repetitive use was listed as less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. Localized tenderness on palpation of the joints, muscle spasms, and abnormal gait was noted. Muscle strength registered at a 4 on a 5 point scale. There was no evidence of muscle atrophy, and the Veteran's reflexes were deemed normal. A sensory examination revealed decreased sensation in the lower leg/ankle and absent sensory in the foot/toes. Straight-leg testing was positive. Mild lower extremity radiculopathy was noted on the right side and severe lower extremity radiculopathy on the left side. Evidence of intervertebral disc syndrome with incapacitating episodes at 6 weeks was noted. The Veteran reported constant use of a cane. Following a review of the evidence, the examiner noted that the Veteran was unable to perform physical duties of employment due to severely impaired spinal range of motion and bilateral lower extremity weakness, which is worse on the left than the right. The Veteran opined that the Veteran is only able to perform sedentary duties with frequent breaks. Subsequently, in June 2017, the Veteran under a new examination. During the clinical evaluation, he reported current symptoms including a burning sensation in his lower back and hip that radiates down his legs and into his ankles. The Veteran described pain when bending over and impaired balance/mobility. Regular use of a cane and occasional use of a walker was reported. Range of motion testing revealed forward flexion limited to 60 degrees (normal 0 to 90 degrees) and extension limited to 10 degrees. Right and left lateral flexion and right and left lateral rotation were within normal ranges. The combined range of motion of the thoracolumbar spine is 190 degrees. On examination, the examiner noted objective evidence of pain on terminal flexion and extension and pain on weight-bearing. Pain, weakness, fatigability or incoordination did not significantly limit the Veteran's functional ability after repetitive use. There was no evidence of flare-ups, muscle spasms, atrophy, intervertebral disc syndrome, or additional function loss after repetitive use. The Veteran's muscle strength, reflexes, and sensory responses were within normal ranges. Straight leg testing was negative. Mild radiculopathy was noted to the left and right lower extremities. The evidence reveals mild improvement between the April 2012 and June 2017 examinations. The above evidence fails to demonstrate that the Veteran has met the schedular criteria for an evaluation in excess of 40 percent for a lumbar strain at any time during the pendency of this appeal. As the Veteran has maintained motion of the thoracolumbar spine, albeit limited, he does not suffer from ankylosis. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (defining ankylosis as immobility and consolidation of a joint due to disease, injury or surgical procedure). As such, the criteria for a higher evaluation are not satisfied. See 38 C.F.R. § 4.71a. In making all determinations, the Board must also fully consider the lay assertions of record. When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has fully considered the lay assertions of record, to include multiple lay statements from the Veteran regarding his limitation of motion, pain, and need for 3rd party assistance due to his limited mobility. It also acknowledges the lay statement of the Veteran's care-giver regarding his observed limitation. However, the probative value of the stated contentions are outweighed by the competent and credible medical evidence of record which includes evaluations of the true extent of the Veteran's impairment based on objective data coupled with the lay complaints. Jandreau v. Nicholson, 429 F.3d 1372 (Fed. Cir. 2007). Where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460 (1999); Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. While the Board is sympathetic to the Veteran's report of increasing severity of symptoms, the medical evidence does not support a higher evaluation for either period noted in this appeal. Accordingly, as the preponderance of the evidence is against the assignment of a disability rating in excess of 40 disabling for the Veteran's lumbosacral strain disability, the benefit-of-the-doubt doctrine does not apply. Therefore, the Veteran's increased rating claim is denied. 38 U.S.C.A. § 5107 (2016); 38 C.F.R. § 3.102 (2016); See Gilbert v. Derwinski, 1 Vet. App. 49, 553 (1990). Entitlement to an evaluation in excess of 40 percent for radiculopathy of the left lower extremity The Veteran contends that the severity of his radiculopathy of the lower left extremity warrants a higher evaluation throughout the rating period. The preponderance of the evidence is against his claim. Pursuant to 38 C.F.R. § 4.71a, neurological abnormalities resulting from spinal disabilities are to be separately evaluated. The Veteran currently has been found to suffer from radiculopathy of the left lower extremity as secondary to his service-connected lumbar spine disability. A separate evaluation of 40 percent under Diagnostic Code 8520 has been assigned since December 29, 2011. Pursuant to the aforementioned, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; and, a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis of the sciatic nerve, where the foot dangles and drops, with no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. See 38 C.F.R. § 4.124a. Review of the record indicates that the Veteran has been afforded multiple VA examinations to assess the nature and current severity of his radiculopathy of the left lower extremity. In April 2012, a neurological examination noted the Veteran's decreased lower leg and ankle sensation. Straight leg testing was positive of the left and the right side, with evidence of severe radiculopathy on the left side and mild radiculopathy on the right side. Constant use of a cane was reported. The Veteran's functional impact was described as unable to perform physical duties of employment due to severely impaired spinal range of motion and bilateral lower extremity weakness, which is greater on the left than on the right side. Sedentary duties were possible with frequent breaks. Lay statements from the Veteran and his home attendant, dated August 2012, noted increasing back and lower leg pain and weakness that caused loss of balance. Frequent swelling and difficulty managing personal hygiene due to the Veteran's leg and back condition were noted. A subsequent statement in October 2015, noted that the Veteran's service-connected back pain, bilateral leg radiculopathy and bilateral ankle strain prevented him from working full-time. His notable limitations include difficulty walking, standing, bending, difficulty with balance or lifting heavy objects. Frequent muscle spasms were also reported. In June 2017, the Veteran underwent a subsequent VA examination. Objective findings showed normal examination results as to strength, reflex, and sensory of the lower extremities. The VA examiner notes mild radiculopathy of the left lower extremity affecting the sciatic nerve. Straight leg testing was native on the left and right side. Although some improvement was noted on examination, the likelihood of sustained improvement was not definitively established. Following a thorough review of the evidence of record, to include lay statements and medical records, the Board finds that an evaluation in excess of 40 percent for radiculopathy of the left lower extremity is not warranted at any time during the pendency of this claim. To establish entitlement to a higher evaluation of 60 percent, the evidence must show marked muscular atrophy characteristic of severe incomplete paralysis. See 38 C.F.R. § 4.124a. There is no evidence of such a degree of impairment in this case. In fact, the June 2017 VA examination revealed evidence of some improvement in symptomology. As such, the preponderance of the evidence of record demonstrates that a higher schedular evaluation of 60 percent is not warranted at any time during the pendency of this claim. While the Board acknowledges the Veteran's competence to describe his current symptoms and is sympathetic to the complaints of an increasing severity of symptoms, the medical evidence does not support a higher evaluation for either period noted in this appeal. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994); and 38 C.F.R. § 3.159 (a)(2) (2017). Accordingly, as the preponderance of the evidence is against the assignment of a higher rating at any point during the rating period, the benefit-of-the-doubt doctrine does not apply. Therefore, the Veteran's increased rating claim is denied. 38 U.S.C.A. § 5107 (2016); 38 C.F.R. § 3.102 (2016); See Gilbert v. Derwinski, 1 Vet. App. 49, 553 (1990). Entitlement to an evaluation in excess of 10 percent for service-connected radiculopathy of the right lower extremity The Veteran contends that severity of his radiculopathy of the right left extremity warrants a higher evaluation throughout the rating period. The preponderance of the evidence is against his claim. The Board notes that the Veteran's right lower extremity radiculopathy has been rated as 10 percent disabling under DC 8522 for impairment of the musculocutaneous nerve. 38 C.F.R. § 4.124a (2017). Under this code, a 0 percent rating is warranted for mild incomplete paralysis of this nerve; a 10 percent rating is warranted for moderate incomplete paralysis of this nerve; a 20 percent rating is warranted for severe incomplete paralysis of this nerve; and a 30 percent rating is warranted for complete paralysis of this nerve with eversion of foot weakened. Id. Review of the evidence, as outlined in the previous section, reveals that the current severity of the Veteran's condition has been evaluated in numerous VA examinations. Throughout the rating period, the current severity of the Veteran's right lower extremity radiculopathy has been evaluated as mild in severity. To establish entitlement to 20 percent evaluation, evidence of moderate incomplete paralysis was required. See id. There is no evidence that the Veteran's symptomology met the required showing at any point throughout the rating period. In fact, the Board notes the Veteran's own lay statements report worsening symptomology on the left rather than the right side. While the Board is sympathetic to the Veteran's report of increasing severity of symptoms, the medical evidence does not support a higher evaluation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994); and 38 C.F.R. § 3.159 (a)(2) (2017). Accordingly, as the preponderance of the evidence is against the assignment of a higher rating at any point during the rating period, the benefit-of-the-doubt doctrine does not apply. Therefore, the Veteran's increased rating claim is denied. 38 U.S.C.A. § 5107 (2016); 38 C.F.R. § 3.102 (2016); See Gilbert v. Derwinski, 1 Vet. App. 49, 553 (1990). Entitlement to an initial evaluation in excess of 10 percent for a service-connected left ankle strain and sprain and a service-connected right ankle strain and sprain. The Veteran also contends that the current severity of his service-connected left and right ankle strain and sprain warrant a higher evaluation. However, as outlined below, the preponderance of the evidence is against his claims. Musculoskeletal disabilities of the ankle are rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5270-5274 (2017). Diagnostic Code 5270 (ankylosis of the ankle); Diagnostic Code 5271 (limited motion of the ankle); Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint); Diagnostic Code 5273 (malunion of the os calcis or astragalus). Also for consideration is Diagnostic Code 5262 (impairment of the tibia and fibula with ankle disability). In this case, the Veteran's service-connected right and left ankle disabilities have been rated pursuant to Diagnostics Code 5271, for limited motion of ankle. See 38 C.F.R. § 4.71a. Under this code, moderate limited motion of the ankle warrants a 10 percent rating and marked limited motion of the ankle warrants a 20 percent rating. Id. Normal range of motion for the ankle is from 0 to 20 degrees dorsiflexion and from 0 to 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II. The words "moderate" and "marked" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). Review of the evidence reveals that the Veteran underwent a VA examination in April 2013. During the clinical evaluation, the Veteran complained that he broke his ankle several times in service and that his condition has worsened ever since. On examination, the Veteran's right ankle plantar flexion was limited to 25 degrees (normal is from 0 to 45 degrees) and dorsiflexion was limited to 15 degrees (normal is from 0 to 20 degrees). The Veteran's left ankle plantar flexion was limited to 20 degrees (normal is from 0 to 45 degrees) and dorsiflexion was limited to 15 degrees (normal is from 0 to 20 degrees). The examiner noted objective evidence of pain. There was no evidence of additional loss of function or loss of range of motion after three repetitions, repeated use over time, or flare-ups. The examiner diagnosed bilateral ankle strain and sprain. Additional factors contributing to the Veteran's disability were noted as less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Muscle strength and stability testing was normal, with no evidence of ankylosis. The Veteran underwent a follow-up VA examination in June 2017. During the clinical evaluation, the Veteran reported weakness of the joints and pain at the medial and lateral aspects of both ankles. Difficulty walking on irregular surfaces and balance problems were noted. Objective findings revealed normal range of motion of the ankles. There was no evidence of additional loss of function or loss of range of motion after three repetitions, repeated use over time, or flare-ups. The examiner diagnosed bilateral lateral collateral ligament sprain. Muscle strength and stability testing was normal, with no evidence of ankylosis. On review of the evidence, the Board finds that the a higher evaluation of 20 percent is not warranted for limitation of motion of either ankle as the evidence of record dos not reveal marked limitation of motion. While the Board acknowledges the Veteran's competence to report of observable symptoms, the medical evidence does not reveal an increase in symptomology so as to warrant a higher rating. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994); and 38 C.F.R. § 3.159 (a)(2) (2017). In reaching the above determination, the Board has considered whether any additional diagnostic codes may be applicable in this case, as higher ratings are available when there is evidence of ankylosis of an affected joint. See 38 C.F.R. § 4.71a, Diagnostic Code 5270. However, the preponderance of the evidence of record in this case demonstrates that the Veteran has not suffered from ankylosis of either ankle at any time during the pendency of this claim. See Lewis, 3 Vet. App. at 259 (defining ankylosis as immobility and consolidation of a joint due to disease, injury or surgical procedure). Accordingly, as the preponderance of the evidence is against the assignment of a higher rating at any point during the rating period, the benefit-of-the-doubt doctrine does not apply. Therefore, the Veteran's increased rating claim is denied. 38 U.S.C.A. § 5107 (2016); 38 C.F.R. § 3.102 (2016); See Gilbert v. Derwinski, 1 Vet. App. 49, 553 (1990). Entitlement to a total disability rating based upon individual unemployability Finally, the Veteran contends that his service connected disabilities prevent him from securing or following any substantially gainful occupation. As outlined below, the Board finds that the evidence is at least in equipoise and suggests that the Veteran's service-connected disabilities render him unable to secure or maintain a substantially gainful occupation. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of substantial gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). The Veteran must meet specific requirements before consideration of whether the evidence demonstrates unemployability. If the Veteran has only one service-connected disability, it must be rated at 60 percent or more; if he has two or more service-connected disabilities, at least one must be rated at 40 percent or more, and there must be sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In the present case, the Veteran is service-connected for a lumbosacral strain (rated at 40 percent disabling), radiculopathy of the left lower extremity (rated as 40 percent disabling), radiculopathy of the right lower extremity (rated as 10 percent disabling), a left ankle strain (rated as 10 percent disabling) and a right ankle strain (rated as 10 percent disabling), for a combined disability evaluation of 80 percent. As such, the Veteran meets the criteria for establishing entitlement to TDIU benefits on a schedular basis. See id. The Board must now consider the central inquiry of "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). However, education, training, and past work experience are relevant to the questions. In this case, the Veteran's prior employment history included work as an electrician and maintenance worker. The Veteran discontinued all forms of employment following since undergoing back surgery, a laminectomy and disc removal at the L 4-5, in 1993. "Substantially gainful employment," denotes consideration of "whether a particular job is realistically within the physical and mental capabilities of the claimant." Moore v. Derwinski, 1 Vet. App. 356, 359 (1991), citing Timmerman v. Weinberger, 510 F.2d 439, 442 (8th Cir. 1975). Accordingly, a Veteran need not establish "100 percent unemployability" to prove an inability to maintain a "substantially gainful occupation;" the use of the word "substantially" suggests an intent to impart flexibility into a determination of the Veteran's overall employability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). In June 2017, the Veteran underwent a VA examination to assess the combined impact of his service- connected disabilities. The examiner addressed the question of impact on employability for each of the Veteran's service-connected disabilities individually prior to reaching an assessment of the combined impact on employability. Following an in-person interview, the examiner opined that it is more likely than not that the Veteran is able to perform sedentary employment. In reaching this conclusion, the examiner noted that the Veteran's back and ankle condition render him unemployable for active work that requires him to be on his feet or lift more than 10 lbs. However, it was nevertheless concluded that the Veteran is not prevented from performing sedentary activities from his home. The Board notes that the Veteran's Substantive Appeal, dated August 2017, rejects the VA examiners conclusions as to the Veteran's ability to perform sedentary employment from home. Specifically, the Veteran argues that the type of work and limitations listed in the examiner's conclusion cannot be considered substantially gainful under 38 C.F.R § 4.16 (2017). Review of the record reveals that the Veteran is incapable of lifting objects heavier than ten pounds and has been unable to perform work in his prior profession as a trained electrician since 1993. Although the VA examiner's opinion acknowledges that the Veteran's former skill-set would be a possible barrier in locating suitable work from home, it appeared to ignore a competent independent medical opinion which indicated that the Veteran lacks training, education, or previous work experience that would permit him to perform any type of sedentary work. Further, sedentary work would require the Veteran to meet the sitting, standing and walking requirements which are beyond his physical capabilities due to his service-connected disabilities. By the examiner's own admission, the Veteran's current back and ankle condition render him unemployable for active work, which is the only form of work that he has performed since active service. The Board has fully considered the evidence of record, to include the June 2017 VA examiner's opinion. While the Veteran's disabilities might permit sedentary employment, the record shows that the Veteran has no experience in such employment. Therefore, the Board finds the favorable medical evidence and the Veteran's appellate arguments most probative. It also notes that the Veteran is competent to describe the impact of his disabilities on his ability to be gainfully employed and the evidence supports his assertions as to the gravity of his symptoms and limitations. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for TDIU are met. (CONTINUED ON NEXT PAGE) ORDER Service connection for macular degeneration is denied. Entitlement to an evaluation in excess of 40 percent disabling for lumbosacral strain with degenerative disc disease at L4-L5 is denied. Entitlement to an evaluation in excess of 10 percent disabling for radiculopathy of the left lower extremity prior to December 29, 2011, and in excess of 40 percent disabling, thereafter, is denied. Entitlement to an evaluation in excess of 10 percent disabling for radiculopathy of the right lower extremity is denied. Entitlement to an evaluation in excess of 10 percent disabling for a left and right ankle strain and sprain is denied. Entitlement to a total disability rating for individual unemployability is granted. ____________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs