Citation Nr: 1805870 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 09-06 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals, left knee fracture, with degenerative joint disease, on and after June 15, 2012. 2. Entitlement to a disability rating in excess of 10 percent for chronic left quadriceps muscle strain from June 15, 2012 to December 29, 2015, and in excess of 40 percent thereafter. 3. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the thoracolumbar spine, on and after June 15, 2012. REPRESENTATION The Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Galante, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1987 to August 2007. These matters comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the United States Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In March 2011, the Veteran appeared and testified before a Veterans Law Judge. A transcript of that hearing is of record. The law provides that a Veterans Law Judge who conducts a hearing must participate in any decision made on that appeal. 38 U.S.C. § 7107(c) (2012); 38 C.F.R. § 20.707 (2017). In June 2015, the Board sent a letter to the Veteran explaining that the Veterans Law Judge who conducted his hearing was no longer available to participate in the appeal, and offered the Veteran the opportunity to request a hearing before a different Veterans Law Judge. The Veteran did not respond within the allotted time. As such, the Board will proceed with the matters on appeal. The undersigned Veterans Law Judge has been assigned to this case pursuant to 38 C.F.R. § 19.3(b). The testimony from his hearing has been considered. These matters were previously before the Board in August 2015, at which time they were remanded for further evidentiary development. The RO was instructed to contact the Veteran and request information regarding outstanding medical evidence. The RO did so in a November 2015 letter, however the Veteran did not respond. The RO was also requested to order updated VA examinations, which were conducted in December 2015. Neither the Veteran nor his representative has raised any contentions that these examinations are incomplete. As such, the Board finds that the RO substantially complied with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Appellate consideration may proceed. By a rating decision in February 2016, the RO increased the Veteran's rating for chronic left quadriceps muscle strain to 40 percent effective December 29, 2015. This is the highest schedular rating available for this disability; however, as the Veteran has not indicated that he is content with this rating, the appeal continues. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The record shows that the Veteran's left knee, left quadriceps, and low back disabilities impact his ability to work. However, there is no evidence to suggest, nor does he contend, that such limitations prevent him from working or that he is currently unemployed due to these disabilities. Significantly, at the June 2012 VA examination, the VA examiner noted that the Veteran was employed as a contractor for a missile defense agency and missed only 1.5 days due to his low back. Otherwise, he did not miss any work in the preceding year due to his service-connected disabilities. The December 2015 VA examiner indicated that the disabilities on appeal would impact physical employment, but would not affect sedentary employment. Further, the Veteran remains employed on a full-time basis. There is no allegation his earnings are marginal in nature. Therefore, the matter of entitlement to a total rating based on individual unemployability (TDIU) is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). FINDINGS OF FACT 1. Since June 15, 2012, the Veteran's service-connected left knee disability has been manifested by x-ray evidence of degenerative joint diseases, pain, and tenderness without limitation of motion. 2. From June 15, 2012 to December 29, 2015, the Veteran's service-connected chronic left quadriceps disability was manifested by a moderate muscle injury. The Diagnostic Code for this time period has been changed from 5313 to 5314 to more accurately reflect the evidence of record. 3. Since December 29, 2015, the Veteran's service-connected chronic left quadriceps disability has been manifested by a severe muscle injury. 4. Since June 15, 2012, the Veteran's service-connected degenerative arthritis of the thoracolumbar spine has been manifested by limitation of motion no worse than 60 degrees of forward flexion. Diagnoses of ankylosis or associated neurologic abnormalities have not been shown. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for service-connected residuals, left knee fracture, with degenerative joint disease, on and after June 15, 2012, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2017). 2. The criteria for a disability rating in excess of 10 percent for service-connected chronic left quadriceps disability, from June 15, 2012 to December 29, 2015, and in excess of 40 percent thereafter, have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.55, 4.56, 4.73, Diagnostic Code 5314. 3. The criteria for a disability rating in excess of 20 percent for service-connected degenerative arthritis of the thoracolumbar spine have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable the Veteran to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1) (2012); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist in gathering documentary evidence. 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). Thus, the Board need not discuss any potential issues in this regard. Regarding the VA examinations of record, neither the Veteran nor his representative have argued that these examinations are inadequate for adjudication purposes. However, in a November 2017 Informal Hearing Presentation, the Veteran's representative stated: The records reflect the appellant's last VAE for the issues on this appeal was approximately two years ago. Where the veteran claims a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the state of the condition, the VA must provide a new examination. [Internal citations omitted] While the representative cited the law regarding worsening of a condition in increased rating appeals, the representative never distinctly alleged that the Veteran's orthopedic disabilities had worsened since the December 2015 VA examinations, and such a contention is not supported elsewhere in the record. The age of an examination, by itself, is not enough to warrant a new one, and the Board finds that VA's duty to assist does not require affording the Veteran a new VA examination in this case. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board has reviewed the December 2015 VA examinations and finds them adequate for adjudication purposes. The VA examiner reviewed the Veteran's relevant medical records, recorded an exhaustive medical history, and performed the necessary medical tests needed to review the claims under the applicable diagnostic codes. Furthermore, there is nothing in the Veteran's medical records that suggests to the Board that the Veteran's orthopedic conditions have worsened since the December 2015 VA examinations. Absent this evidence, the Board declines to remand for updated VA examinations and will proceed with adjudicating this appeal on the merits. For the sake of completeness, the Board further acknowledges that neither the Veteran nor his representative has raised any arguments regarding the adequacy of the Veteran's June 2012 VA examination. Accordingly, this examination is subject to the presumption of regularity, which has not been rebutted. Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2008) (applying the presumption of regularity to a VA examination); see also Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011). In light of the above, VA's duty to assist in providing medical examinations has been satisfied in this matter. Further, the Veteran has not alleged any deficiency with the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens, 814 F.3d at 1361, that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott, 789 F.3d at 1381. Thus, the Board need not discuss any potential Bryant problem because neither the Veteran nor his representative have raised that issue before the Board. The regulations pertinent to this decision were previously provided to the Veteran in the January 2009 and November 2012 Statements of the Case, the February 2016 Supplemental Statement of the Case, and the Board's August 2015 decision. Since the Veteran has had adequate notice of the pertinent laws governing this appeal, they will only be discussed herein where the Board deems appropriate to do so. With these procedural matters established, the Board now turns to adjudicating this appeal. I. Increased rating for left knee disability, since June 15, 2012 The Veteran seeks a disability rating in excess of 10 percent since June 15, 2012 for his service-connected left knee disability. His left knee is currently rated under Diagnostic Code 5003. A. Summary of relevant evidence The Veteran was provided a VA examination in June 2012 to assess the severity of his service-connected left knee disability. The VA examiner charted that the Veteran's left knee pain ranged from 1 to 7-8 on a scale of 1 to 10. His pain averaged 2-5 out of 10, with pain in the 7-8 range staying at that level for 2 to 3 hours, even with the aid of Tylenol, sitting, and gentle range of motion. The Veteran reported increased left knee pain after ascending and descending stairs. He also reported one flare-up lasting a few days, with pain in the 7-8 range, during the prior year. The Veteran exhibited no catching or locking, no stiffness, and no swelling or instability. Claims of weakness were attributed to his left quadriceps injury. Upon objective examination, the Veteran displayed significant tenderness at the medial and lateral joint lines. McMurray's, varus and valgus stress, Lachman's, and anterior drawer tests were all negative. Left knee flexion was recorded at 110 degrees, with pain at 100 degrees. Left knee extension was recorded at +3 degrees with no pain. The examiner noted no significant change in active range of motion following repeat testing against resistance, but recommended an additional loss of range of motion of 20 degrees for left knee flexion due to the factors considered in DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran was afforded another VA examination in December 2015 to assess the nature and severity of his service connected left knee disability. Although left knee range of motion was listed as outside the normal range, with flexion to 120 degrees and extension at 0 degrees, the VA examiner explained that the range of motion was normal for the Veteran due to his body habitus, including weight, height, and the musculature of his legs. Pain was noted on flexion and was recorded as causing additional functional loss. Localized tenderness and pain on palpation were observed in the medial and lateral joint lines. The Veteran had no ankylosis, recurrent subluxation, or lateral instability in the left knee. Joint stability testing was performed and found to be normal. The examiner noted no present meniscal conditions. The Veteran's gait was antalgic due to the left knee. The examiner remarked that the Veteran's patella was deformed and the crepitance with flexion was marked and accompanied by popping. B. Legal analysis In assigning disability ratings, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2017). However, the assignment of separate evaluations for separate and distinct symptomatology is not precluded 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). With this principle in mind, the Board's analysis will take into consideration all applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In reviewing the record, there is no evidence of ankylosis, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5262, 5263 do not apply in this case. With respect to Diagnostic Codes 5258 and 5259, there is no medical evidence of record that the Veteran exhibits dislocated semilunar cartilage or symptomatic semilunar cartilage removal in the left knee; thus, these codes do not apply. Similarly, Diagnostic Code 5055 does not apply as the Veteran has not had a prosthetic knee replacement, and the December 2015 VA examiner concluded that the Veteran's left knee disability was not of such a severity that it would have been equally well served by an amputation with prosthesis. The Board has also considered whether the Veteran is entitled to a separate rating for lateral instability or recurrent subluxation of the left knee joint under Diagnostic Code 5257. At the June 2012 VA examination, the examiner noted the Veteran had "mild pseudolaxity" in the left knee joint, but found no medial or lateral instability, as supported by negative varus and valgus stress tests. Curiously, when examining additional functional loss due to pain, as considered by DeLuca, the examiner recommended an additional 20 degree loss of range of motion in left knee flexion due to factors including instability. However, in issuing a medical opinion, the examiner specifically stated that any present instability was not ligamentous in nature, but rather due to left quadriceps weakness. The examiner explained: This weakness does not have a neurological origin but is valid and due to chronic pain and altered patellofemoral biomechanics from patellar fracture and subsequent reconstruction and realignment surgeries. Left distal quadriceps is atrophied compared to the right and is sufficiently weak that it would cause significant knee instability if the [V]eteran were not so good about maintaining whatever level of fitness he can tolerate, and if he were not so cautious with ambulation on stairs and uneven terrains. Thus, the examiner explained that his left knee surgeries have biomechanically altered the Veteran causing weakness in the left quadriceps and corresponding instability. In light of the above explanation, the Board is inclined to afford greater evidentiary weight to objective varus and valgus stress tests over the VA examiners isolated finding of mild pseudolaxity and a passing reference to instability during DeLuca considerations, which are clearly attributed to the Veteran's left quadriceps disability, and not his left knee physiology. Moreover, the Board observes that no other objective medical evidence within the appeals period has identified laxity, recurrent subluxation, or lateral joint instability in the left knee. Indeed, at the December 2015 VA examination, the examiner found no objective evidence of instability or "pseudolaxity." Further, the record is devoid of any subjective evidence from the Veteran (during the appeals period) describing instability attributed directly to his left knee disability. To the extent that the Veteran reported weakness-which can be loosely interpreted as instability-it was in regards to his left quadriceps disability, not his left knee. Consequently, the Board finds no probative orthopedic evidence of recurrent subluxation or lateral instability in the left knee during the appeals period. As such, Diagnostic Code 5257 is not for application in the present matter. As the above Diagnostic Codes are not for application, the following analysis will be limited to focusing on whether the Veteran is eligible for higher disability ratings under Diagnostic Codes 5003, 5260, and 5261. The Board notes that assigning a separate rating under Diagnostic Code 5003 and Diagnostic Codes 5260 or 5261 would constitute pyramiding, as these diagnostic codes rate based on limitation of motion, including limitation of motion caused by pain. 38 C.F.R. § 4.14 (2017); Esteban, 6 Vet. App. at 261-62. In order to warrant higher rating for the Veteran's left knee under these diagnostic codes, the medical evidence must include x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations (20 percent rating under Diagnostic Code 5003 in the absence of limitation of motion); flexion limited to 30 degrees (20 percent rating under Diagnostic Code 5260); or extension limited to 15 degrees (20 percent rating under Diagnostic 5261), respectively. Under Diagnostic Code 5003, arthritis is rated based upon limitation of motion of the knee, with a 10 percent rating to be assigned if there is x-ray evidence of arthritis and limitation of motion is noncompensable under Diagnostic Codes 5260 and 5261. Here, the radiologic evidence from July 2009 has revealed evidence of degenerative changes in the patellofemoral compartment with marginal osteophytes. Current findings of degenerative joint disease, i.e., arthritis, were also noted by the December 2015 VA examiner. As discussed infra, the Veteran does not meet the requirements for a compensable rating under Diagnostic Codes 5260 or 5261. Based on this conclusion, the Veteran can maintain his current 10 percent evaluation under Diagnostic Code 5003. However, the Veteran is not eligible for a higher 20 percent rating under Diagnostic Code 5003 because the evidence does not show x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Moreover, while the Board acknowledges the Veteran's symptoms of pain and infrequent flare-ups, there is no evidence of incapacitating exacerbations of the arthritis in the left knee. The evidence does not support higher ratings for limitation of flexion or extension for the left knee under Diagnostic Codes 5260 or 5261, as the current findings do not even reach the compensable level contemplated under these codes. During the appeals period, the Veteran's left knee had limitation of flexion to no worse than 90 degrees and limitation of extension to no worse than 3 degrees, even when considering limitation of motion caused by pain. See DeLuca, 8 Vet. App. at 207. This limitation of flexion to 90 degrees comes from the June 2012 VA examination, in which the examiner noted the Veteran could reach 110 degrees of flexion, but recommended an additional 20 degrees of flexion loss due to DeLuca factors. In addition, the current ratings for both knees specifically account for painful motion under 38 C.F.R. § 4.59. Accordingly, the Veteran is not eligible for ratings under Diagnostic Codes 5260 or 5261. In sum, the evidence does not support a higher rating than the Veteran's current 10 percent evaluation under Diagnostic Code 5003, on and after June 15, 2012. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting a rating in excess of the 10 percent continued herein during the relevant time period, under any other applicable diagnostic code. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). II. Increased rating for left quadriceps muscle strain disability A. From June 15, 2012 to December 29, 2015 For this time period, the Veteran has been in receipt of a 10 percent disability rating for chronic left quadriceps muscle strain under Diagnostic Code 5313, consistent with moderate functionality due to injuries to Muscle Group XIII. See November 2012 rating decision. The Veteran seeks a higher rating than what is currently assessed. Initially, the Board notes that the December 2015 VA examiner indicated that the Veteran's muscle injury should be assessed under Diagnostic Code 5314 (Muscle Group XIV) instead of Diagnostic Code 5313 (Muscle Group XIII). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Here, the VA examiner explained that the prior assignment of Diagnostic Code 5313 (Muscle Group XIII) was simply an oversight made in error. The Board notes that the rating criteria for Diagnostic Codes 5313 and 5314 are identical, so there is no prejudice to the Veteran in changing the diagnostic code to match the correct muscle group per the VA examiner's findings. Accordingly, to maintain accuracy and consistency in adjudicating this appeal, the Board will analyze this increased rating claim under Diagnostic Code 5314 (Muscle Group XIV). At the June 2012 VA examination, the Veteran reported weakness in his left quadriceps, most notable when walking on flat surfaces and uphill, ascending and descending steps, swimming, and biking with any tension/resistance. Kneeling was described as impossible without a pillow, and he described several tasks, such as golfing, weight training, and traveling, which were made more difficult due to his quadriceps injury. Upon examination, the Veteran's thigh circumference measured 10 centimeters above the joint line was 50 centimeters on the left, and thigh circumference measured 20 centimeters above the joint line was 59 centimeters on the left. The VA examiner opined that: The quadriceps mechanism is sufficiently weak that it causes instability, fatigues quickly, and leads to an abnormal, compensatory gait...Severity of the left quadriceps disability...is moderate. This is based on the distal quadriceps atrophy and the degree of weakness in the quadriceps, balanced by the fact that the Veteran has not actually fallen or experienced negative sequelae of instability at this point. There is pain, weakness, and premature/excess fatigability. The Board finds this VA examination to be extremely probative in rating the Veteran's left quadriceps disability under the schedular rating criteria. The examiner explicitly found the degree of muscular atrophy to be consistent with a moderate muscle disability correlating to 10 percent evaluation, but no higher. Accordingly, the June 2012 VA examination-the only probative evidence between June 15, 2012 and December 29, 2015-does not support a disability rating higher than the currently assessed 10 percent evaluation for a moderate muscle injury. As the evidence preponderates against the claim, the reasonable doubt doctrine is not for application. Gilbert, 1 Vet. App. at 53-56; 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). B. Since December 29, 2015 The Veteran was awarded a 40 percent evaluation under Diagnostic Code 5314 (Muscle Group XIV) in a February 2016 rating decision, effective December 29, 2015. As an initial matter, the 40 percent rating is the maximum schedular rating under Diagnostic Code 5314 and represents a total grant of benefits sought on appeal for this issue. As such, the assignment of a rating in excess of 40 percent is impossible under the diagnostic criteria set forth in 38 C.F.R. §§ 4.56, 4.73 (2017). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in regards to this appeal. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, further appellate consideration is unwarranted and the appeal is denied. III. Increased rating for lumbar disability, since June 15, 2012 Since June 15, 2012, the Veteran's degenerative arthritis of the thoracolumbar spine has been rated at 20 percent disabling under Diagnostic Code 5003-5242. See November 2012 rating decision. The Veteran seeks a higher disability rating for this service-connected disability. As a preliminary matter, the Board notes that the Veteran is currently rated under a hyphenated diagnostic code. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.2 (2017). Diagnostic Code 5003 refers generally to degenerative arthritis, whereas Diagnostic Code 5242 refers specifically to degenerative arthritis of the spine. The Board finds that the rating criteria applied by the RO are appropriate and will proceed with evaluating the evidence in accordance with 38 C.F.R. § 4.71a; General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). A. Summary of Evidence The Veteran's thoracolumbar spine was examined and assessed during a June 2012 VA examination. The Veteran reported intermittent back pain located bilaterally in the spine, present for about 1/3 of the year. He did not experience pain, numbness, or tingling into the legs. His back pain was reported as fluctuating, and the Veteran was unable to identify what stimuli triggered increased back pain. He experienced one flare in the previous year, lasting 3 days and treated with medication, a heating pad, and rest. He did not have any incapacitating episodes requiring physician ordered bedrest within the previous year. The examiner found that the Veteran's range of motion was pain restricted as follows: flexion was 70 degrees (with pain at 45 degrees), extension was 20 degrees (with pain at 10 degrees), left and right lateral flexion was 25 degrees (with pain at 25 and 20 degrees, respectively), and left and right lateral rotation was restricted to 15 degrees (with pain at 10 degrees). In consideration of DeLuca, the examiner charted that lumbar pain developed rapidly with 3 repetitions resulting in an additional 10 degree loss of lumbar flexion (i.e., 60 degrees). Additionally, the Veteran's posture was affected by muscle spasms and guarding. The Veteran was afforded another VA examination of the thoracolumbar spine in December 2015. The Veteran reported 4 flare-ups of his lumbar spine condition, generally lasting 2 days and occurring after manual labor. Initial range of motion testing was normal, with forward flexion of 90 degrees and extension of 30 degrees. The Veteran reported pain on extension. No additional loss of function or range of motion was noted after 3 repetitions, and the examiner concluded pain, weakness, fatigability, and incoordination did not significantly limit functional ability with flare-ups. No radiculopathy was present. No ankylosis was observed. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. B. Legal analysis In order to warrant a higher rating for the Veteran's back disability under Diagnostic Code 5003-5242, evidence must show the following under the General Rating Formula: * unfavorable ankylosis of the entire spine (100 percent); or * unfavorable ankylosis of the entire thoracolumbar spine (50 percent); or * unfavorable ankylosis of the entire cervical spine; or forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine (40 percent); or * forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine (30 percent). In this case, the Board finds a higher rating for the Veteran's lumbar disability is not warranted under Diagnostic Code 5003-5242 for any time during the period on appeal for the following reasons. First, there is no medical evidence of record during the relevant timeframe demonstrating that the Veteran's service-connected lumbar spine disability has manifested with ankylosis of any kind, to specifically include favorable or unfavorable ankylosis of the entire spine or of the entire thoracolumbar spine. Second, a higher rating is not warranted under Diagnostic Code 5003-5242 because the Veteran's demonstrated range of motion results do not support the assignment of a higher rating. There is no evidence of record reflecting that the Veteran's service-connected lumbar spine disability manifests with forward flexion of the lumbar spine to 30 degrees or less. The Board gives great weight to the June 2012 and December 2015 VA examiners' range of motion findings. At the June 2012 VA examination, with functional loss due to pain considered, the Veteran's forward flexion of the thoracolumbar spine was not worse than 60 degrees. At the December 2015 VA examination, the Veteran's forward flexion of the thoracolumbar spine was recorded as 90 degrees, with no pain on flexion. Third, the Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-7. A rating in excess of 20 percent for the Veteran's service-connected lumbar spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptom of painful motion upon examination was explicitly contemplated by the 20 percent rating now assigned. Fourth, the Board has also considered whether an increased disability rating is warranted under the criteria for intervertebral disc syndrome (IVDS), used for evaluating incapacitating episodes. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Here, the June 2012 VA examiner found that the Veteran had not experienced incapacitating episodes requiring physician ordered bedrest in the last year. Likewise, after thoroughly considering the Veteran's claims file, reported medical history, an examination of the Veteran, and diagnostic imaging, the December 2015 VA examiner found no evidence of IVDS. The Board affords these VA examination results significant evidentiary weight. The Veteran is not eligible for a separate rating due to IVDS. Fifth, the Board has considered whether separate ratings are warranted for any additional neurological impairment attributed to the Veteran's lumbar spine disability, as the General Rating Formula provides for the assignment of separate disability evaluations under appropriate diagnostic codes for any objective neurologic abnormalities associated with a disease or injury of the spine. See General Rating Formula, Note (1). At the June 2012 VA examination, the Veteran denied pain, numbness, or tingling into the legs coming from the back. Following examination, the VA examiner found no evidence of lumbosacral radiculopathy. Similarly, at the December 2015 VA examination, the VA examiner found no evidence of radiculopathy or other neurologic abnormalities, such as bowel or bladder problems. As the only competent evidence on point, the Board affords the VA examinations significant evidentiary weight, and separate ratings for neurological abnormalities are not warranted. Lastly, the Board has considered whether any alternate diagnostic codes might serve as a basis for an increased rating. Diagnostic Codes 5235 (vertebral fracture or dislocation), 5236 (sacroiliac injury and weakness), 5238 (spinal stenosis), 5239 (spondylolisthesis or segmental instability), 5240 (ankylosing spondylitis), and 5241 (spinal fusion) are not applicable; even if they were, disabilities under these codes are evaluated under the General Rating Formula, and would not allow for an increased rating. There are no other applicable codes available for consideration. Moreover, regardless of which diagnostic code is used, all lumbar spine conditions are rated under either the General Rating Formula or incapacitating episodes criteria. In summary, the Board finds a higher rating for the Veteran's back disability is not warranted for any time during the appeal period, including after consideration of the DeLuca criteria and associated neurological abnormalities. As the evidence preponderates against the claim, the benefit of the doubt rule has no application. Gilbert, 1 Vet. App. at 53-56; 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). ORDER Entitlement to a disability rating in excess of 10 percent for service-connected residuals, left knee fracture, with degenerative joint disease on and after June 15, 2012, is denied. Entitlement to a disability rating in excess of 10 percent for chronic left quadriceps muscle strain from June 15, 2012 to December 29, 2015, and from 40 percent thereafter, is denied. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the thoracolumbar spine on and after June 15, 2012, is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs