Citation Nr: 18140810 Decision Date: 10/05/18 Archive Date: 10/05/18 DOCKET NO. 09-05 541 DATE: October 5, 2018 ORDER Entitlement to an initial rating in excess of 10 percent prior to April 22, 2015, for plantar fascia fibromatosis (hereinafter referred to as a “bilateral foot disability”) is denied. Entitlement to disability ratings of 30 percent, but no higher, from April 22, 2015, to November 7, 2017; and of 50 percent, but no higher, from November 8, 2017, for a bilateral foot disability is granted. Entitlement to an initial rating in excess of 20 percent for degenerative joint disease (DJD) of the left shoulder with impingement syndrome by magnetic resonance imaging (MRI) (hereinafter referred to as a “left shoulder disability”) is denied. Entitlement to a disability rating in excess of 20 percent for lumbar strain/myositis (hereinafter referred to as a “lumbar spine disability”) is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for chondromalacia patella with joint effusion of the right knee (hereinafter referred to as a “right knee disability”) is remanded. Entitlement to a disability rating in excess of 10 percent for mild left knee effusion and Baker cyst (hereinafter referred to as a “left knee disability”) is remanded. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to April 22, 2015, the Veteran’s bilateral foot disability was manifested by bilateral pain described as mild and constant with no callouses. 2. From April 22, 2015, to November 7, 2017, the Veteran’s bilateral foot disability was manifested with intermittent severe foot pain, pain accentuated on use and manipulation, swelling on use, characteristic callouses, extreme tenderness on the plantar surfaces that was improved by orthopedic shoes or appliances, marked deformity, and marked pronation. 3. From November 8, 2017, the Veteran’s bilateral foot disability has been manifested by pain that was accentuated with use and manipulation, swelling on use, characteristic callouses, extreme tenderness of the plantar surfaces that was not improved by orthopedic shoes or appliances, marked deformity, and marked pronation. 4. The Veteran’s left shoulder disability has been manifested by painful motion with forward flexion ranging from 80 to 175 degrees and abduction ranging from 85 to 175 degrees, even after considering pain, with limitations in his ability to lift anything or reach above his shoulder level during flare-ups. 5. The weight of the evidence reflects that the Veteran’s lumbar spine disability has been manifested by forward flexion ranging from approximately 40 to 60 degrees, and no ankylosis. CONCLUSIONS OF LAW 1. Prior to April 22, 2015, the criteria for an initial rating in excess of 10 percent, for a bilateral foot disability were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5299-5276. 2. From April 22, 2015, to November 7, 2017, the criteria for a disability rating of 30 percent, but no higher, for a bilateral foot disability were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5299-5276. 3. As of November 8, 2017, the criteria for a disability rating of 50 percent for a bilateral foot disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5299-5276. 4. For the entire appeal period, the criteria for an initial rating in excess of 20 percent for a left shoulder disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5201. 5. For the entirety of the appeal period, the criteria for a disability rating in excess of 20 percent for a lumbar spine disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had a period of active duty for training from May 1982 to September 1982, and a period of active duty from January 2006 to April 2007. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion (ROM) testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 49. 1. Entitlement to an initial rating in excess of 10 percent for a bilateral foot disability The Veteran contends that an initial rating of 30 percent is warranted as the November 2017 examination report reflects pain on use and manipulation, swelling, callouses, marked deformity, and marked pronation on both feet. Based on a careful review of all of the evidence, the Board finds that an initial rating in excess of 10 percent is not warranted prior to April 22, 2015, for a bilateral foot disability. However, the Board finds that an increase to 30 percent, but no higher, from April 22, 2015, to November 7, 2017; and to 50 percent from November 8, 2017, is warranted for his bilateral foot disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The Veteran has been in receipt of a 10 percent rating for his bilateral foot disability, specifically plantar fascia fibromatosis, previously under 38 C.F.R. § 4.71a, DC 5299-5276 and currently under DC 5276. Under DC 5276, a 10 percent rating is warranted for moderate acquired flat foot, with the weight-bearing line over or medial to the great toe, inward bowing of the tendon Achilles, and pain on manipulation and use of the feet, either bilateral or unilateral. Ratings of 20 percent (unilateral) and 30 percent (bilateral) are warranted for severe acquired flatfoot manifested by marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use of the feet, indications of swelling on use of the feet, and characteristic callosities. Ratings of 30 percent (unilateral) and 50 percent (bilateral) are warranted for pronounced acquired flatfoot manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, and marked inward displacement and severe spasm of the tendon Achilles on manipulation which is not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Descriptive words such as “slight,” “moderate,” and “severe” are not defined in the 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. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Turning to the relevant evidence, a March 2008 VA podiatry treatment record reflects no callouses and mild pain on the plantar fascia bilaterally upon pressure, and an assessment of plantar fasciitis. An April 2013 VA examination report reflects review of the Veteran’s claims file, and diagnosis of plantar fasciitis. The examiner found that the Veteran also had asymptomatic hallux valgus. An April 2014 VA examination report reflects review of the Veteran’s claims file and diagnosis of bilateral plantar fasciitis. The Veteran complained of constant bilateral plantar foot pain, which was worse during the first few steps of the day. An April 22, 2015, VA examination report reflects review of the Veteran’s claims file, diagnosis of bilateral plantar fasciitis, and the Veteran’s complaint of severe bilateral foot pain that was intermittent and limited ambulation with recurrent swelling. He reported that, during flare-ups, he was unable to walk. The Veteran had pain accentuated on use and manipulation, swelling on use, characteristic callouses, extreme tenderness on the plantar surfaces that was improved by orthopedic shoes or appliances, marked deformity, and marked pronation of both feet. He did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation. He had pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or with repeated use over a period of time, specifically limitations with walking. A November 8, 2017, VA examination report reflects review of the Veteran’s claims file and diagnosis of bilateral plantar fasciitis. The Veteran complained of sharp pain in the heels upon standing after inactivity, such as upon getting out of bed or standing from a chair after sitting for a long time. The pain radiated towards the medial arch of the feet with perceived stiffness of the plantar foot. He reported flare-ups with prolonged standing and walking that provoked heel and arch pain. The Veteran had pain accentuated on use and manipulation, swelling on use, characteristic callouses, extreme tenderness of the plantar surfaces that did not improve with orthopedic shoes or appliances, marked deformity, and marked pronation. The Veteran did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation. The examiner also found that the Veteran had tenderness to palpation at the medial heel and at the plantar aponeurosis as well as along the longitudinal arch bilaterally, which was moderate in severity bilaterally and chronically compromised weight-bearing. Prior to April 22, 2015, the Board finds the weight of the competent evidence demonstrates the Veteran does not meet the criteria for a rating in excess of 10 percent for his bilateral foot disability. There is no evidence of marked deformity, accentuated pain on manipulation and use, indication of swelling on use, or characteristic callouses. Rather, he had foot pain described as mild, yet constant with no callouses. As such, the Board finds that the severity of the Veteran’s bilateral foot disability more closely approximates a 10 percent rating prior to April 22, 2015. However, from April 22, 2015, to November 7, 2017, the Board finds that a 30 percent rating, but no higher, is warranted based on a severe bilateral foot disability. The April 2015 VA examiner found that the Veteran had accentuated pain on manipulation and use, swelling on use, characteristic callouses, and marked deformity, which are all indicative of a severe disability. See 38 C.F.R. § 4.71a, DC 5276. The Board notes that he also had extreme tenderness of the plantar surfaces, as well as marked pronation. However, his symptoms were improved by orthopedic shoes or appliances. As such, his bilateral foot disability more closely approximates the criteria for a 30 percent rating, but no higher, from April 22, 2015, to November 7, 2017. Additionally, from November 8, 2017, the Board finds that a 50 percent rating is warranted based on a pronounced bilateral foot disability. In addition to the previous symptoms, the November 2017 VA examiner found that the Veteran had marked pronation and extreme tenderness of the plantar surfaces that was not improved by orthopedic shoes or appliances, which the Board considers to be indicative of symptoms that more closely approximate a 50 percent rating. The Board considered the applicability of other DCs pertaining to foot disabilities, but finds that there are none which would provide higher ratings for which the appropriate symptomatology is shown. In other words, there is no evidence of record of pes planus (DC 5276), weak foot (5277), pes cavus (5278), hammer toe (5282), or other foot injury (5284). The Board notes that the April 2013 VA examiner found that the Veteran also had metatarsalgia of the left foot and bilateral hallux valgus. However, he stated that the bilateral hallux valgus was asymptomatic. Additionally, although he did not provide any other detail regarding the severity of the Veteran’s metatarsalgia, subsequent VA examiners did not find any indication of metatarsalgia. As such, this finding of metatarsalgia appears to be an anomaly that is outweighed by the subsequent evidence of record. The November 2017 VA examiner also stated that the Veteran had another foot injury that was not already described, specifically tenderness to palpation at the medial heel, the plantar aponeurosis, and the longitudinal arch bilaterally. However, the Veteran has continuously complained of plantar foot pain. As such, the symptoms described appear to be addressed in and considered as part of the service-connected bilateral foot disability. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). 2. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability The Veteran contends that a rating in excess of 20 percent, as well as extraschedular consideration, is warranted for his left shoulder disability. Specifically, in July 2014, the Veteran contended that extraschedular consideration was warranted as the November 2011 VA examiner found that the left shoulder disability had a “significant” effect on his ability to work as it prevented him from exercising and playing sports, and severely limited his ability to bathe himself. Based on a careful review of all of the evidence, the Board finds that an initial rating in excess of 20 percent is not warranted for his left shoulder disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The Veteran was initially assigned a 10 percent rating for his left shoulder disability, effective April 16, 2007. A December 2016 rating decision increased the rating to 20 percent, effective April 22, 2015. However, a November 2017 rating decision made the 20 percent rating effective April 16, 2007, under 38 C.F.R. § 4.71a, DC 5003-5201. As discussed above, hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. As such, the Veteran’s left shoulder disability, specifically DJD of the left shoulder under DC 5003, is rated under DC 5201 based on limitation of motion of the arm. As a foundational matter, ratings based on function impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major. 38 C.F.R. § 4.69. The medical evidence in this case reflects that the Veteran is right-hand dominant. See November 2017 VA examination report. Therefore, his left upper extremity will be considered as the minor extremity. DC 5201 provides for a 20 percent rating for limitation of minor arm motion at the shoulder level, a 20 percent rating for limitation of the minor arm to midway between the side and shoulder level, and a maximum 30 percent rating for limitation of the minor arm to 25 degrees from the side. 38 C.F.R. § 4.71a. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Turning to the evidence, VA treatment records include a May 2007 MRI revealing mild acromioclavicular joint hypertrophic degenerative changes with no evidence suggesting a rotator cuff tendon tear. In July 2007, the Veteran was assessed with osteoarthritis of the left shoulder with full ROM, although he had some limitation during lifting of weight due to pain. An August 2008 VA examination report reflects the Veteran’s report of pain and stiffness in the left shoulder with flare-ups lasting several hours at least two to four times per month. When he was repeatedly asked to flex the left shoulder without resistance, there was pain but no weakness or fatigue. There was no ankylosis. He had forward flexion and abduction to 160 degrees with pain “in last 30” and “functional loss of 20 due to pain,” external rotation to 80 degrees with pain “in last 30” with “functional loss of 10 due to pain,” and internal rotation to 90 degrees with pain “in last 30” with “functional loss of 0 due to pain.” A March 2011 VA examination report reflects the Veteran’s complaint of left shoulder pain. He had decreased speed of joint motion and no flare-ups. He had flexion and abduction to 175 degrees, and internal and external rotation to 90 degrees. An April 2014 VA examination report reflects review of the Veteran’s claims file, a diagnosis of left shoulder DJD with associated impingement syndrome, the Veteran’s complaint of constant left shoulder pain without any giving away sensation, and no flare-ups. He had flexion to 90 degrees with pain beginning at 80 degrees, and abduction to 100 degrees with pain beginning at 90 degrees. After repetitive use testing, he had flexion and abduction to 90 degrees with objective evidence of pain with active motion. He had no pain or tenderness and no ankylosis. An April 2015 VA examination report reflects review of the Veteran’s claims file and diagnoses of shoulder impingement syndrome and degenerative arthritis of the left shoulder. During flare-ups, he was unable to elevate his arm. The left shoulder had flexion and abduction to 160 degrees, and external and internal rotation to 90 degrees. He had pain with flexion and abduction, as well as with weight-bearing, but it did not result in or cause functional loss. He was unable to perform repetitive-use testing due to pain. There was no ankylosis; positive Hawkins’ impingement and empty-can tests; no shoulder instability, dislocation, or labral pathology suspected; no clavicle, scapula, acromioclavicular joint, or sternoclavicular joint condition suspected; and no impairment of the humerus. A November 2017 VA examination report reflects review of the Veteran’s claims file and diagnosis of DJD of the left shoulder with impingement syndrome. The Veteran complained of increased left shoulder pain with gradual decrease in movement of the shoulder and increased difficulty in doing things due to the left shoulder pain. He stated that sometimes he was unable to lift anything or reach above his shoulder level as it was too painful and difficult. He also stated that he had decreased endurance and was unable to sustain his left arm up when reaching shoulder height and was unable to reach above shoulder height. He had flexion to 110 degrees, abduction to 85 degrees, external rotation to 75 degrees, and internal rotation to 65 degrees. Although he had pain with all movements and with weight-bearing, it did not result in or cause functional loss. The Hawkins’ impingement and empty-can tests revealed a rotator cuff condition. He had no shoulder instability or dislocation; clavicle, scapula, acromioclavicular joint, and sternoclavicular joint conditions; or impairments of the humerus. The examiner noted that the Veteran had pain on passive ROM testing as he complained of pain and grimaced during passive ROM of the left shoulder. The Board finds the weight of the competent evidence demonstrates the Veteran does not meet the criteria for a rating in excess of 20 percent for his left shoulder disability. DC 5201 reflects that a rating in excess of 20 percent requires that motion be limited to 25 degrees from the side. However, although the Veteran has experienced limitation in motion of his left arm, there is no indication that it was ever limited to the point that a 30 percent rating is warranted, specifically limited to 25 degrees from his side. Rather, forward flexion and abduction, after pain is considered, has been limited, at the most severe, to 80 and 85 degrees, respectively. The Board acknowledges that the Veteran reported flare-ups at the August 2008, April 2015, and November 2017 VA examinations. At the August 2008 VA examination, the Veteran only discussed flare-ups of pain and stiffness. At the April 2015 VA examination, he stated that he was unable to elevate his arm during flare-ups, but he did not specifically discuss the effect on his ROM and at what degree he became unable to elevate his arm. At the November 2017 VA examination, he reported that the pain intensity fluctuated and that he was unable to lift or reach above his shoulder level as it was too painful and difficult. As such, the weight of the evidence, even considering any limitations in ROM due to flare-ups, does not indicate that the Veteran’s arm motion was limited to 25 degrees from his side. The Board also considered the remaining DCs relating to the shoulder; however, the Board finds that they are not applicable to the Veteran’s case. Upon review of the claims file, the record does not demonstrate evidence of ankylosis of the scapulohumeral articulation (DC 5200), other impairment of the humerus (DC 5202), or impairment of the clavicle or scapula (DC 5203). As such, the Board finds that a higher or separate rating for the left shoulder disability is not warranted under any of these DCs. Additionally, the Board has considered the Veteran’s contention that extraschedular consideration is warranted for the issue on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” 38 C.F.R. § 3.321(b)(1) (related factors include “marked interference with employment” and “frequent periods of hospitalization”). When the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step – a determination of whether, to accord justice, the claimant’s disability picture requires the assignment of an extraschedular rating. Thun, supra. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran’s service-connected disability, which are recited in detail above, are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The criteria under DC 5201 is based on limitation of motion, but other factors such as painful motion, flare-ups, repeated use, weakened movement, excess fatigability, and incoordination have been considered in evaluating the severity of the Veteran’s left shoulder disability. See 38 C.F.R. §§ 4.40, 4.45, 4.59. Thus, the Board finds that the rating schedule is adequate, and that referral for extraschedular consideration is not warranted under the circumstances of this case. 3. Entitlement to a disability rating in excess of 20 percent for a lumbar spine disability The Veteran contends that a rating in excess of 20 percent, as well as extraschedular consideration, is warranted for his lumbar spine disability. Specifically, in August 2016, the Veteran contended that extraschedular consideration was warranted given the marked interference with employment as the April 2015 VA examiner found that the lumbar spine disability caused functional impact due to limitations in bending, sitting, standing, and carrying more than 10 pounds. Additionally, in September 2018, the Veteran contended that, based on the ROM testing results, he had serious limitation of motion that caused functional loss with pain; and appears to indicate that the November 2017 VA examination report was inadequate. Based on a careful review of all of the evidence, the Board finds that a disability rating in excess of 20 percent is not warranted for his lumbar spine disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The Veteran’s lumbar spine disability is evaluated as 20 percent disabling under 38 C.F.R. § 4.71a, DC 5237. The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasms, and tenderness. See 38 C.F.R. § 4.71a, DCs 5235-5243. The General Rating Formula provides for a 20 percent rating where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined ROM of the thoracolumbar spine is not greater than 120 degrees; or there is 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 where there is forward flexion of the thoracolumbar spine is 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is available for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is available for unfavorable ankylosis of the entire spine. 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 ROM refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined ROM of the thoracolumbar spine is 240 degrees. The normal ROMs for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined ROM. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (2); see also Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (5). Intervertebral disc syndrome (IVDS) (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5243. A 20 percent rating requires incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating requires incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, and a 60 percent rating requires incapacitating episodes having a total duration of at least six weeks during the past 12 months. 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, DC 5243, Note (1). Turning now to the evidence, an August 2008 VA examination report reflects the Veteran’s report of non-radiating pain in the lumbosacral area. He had flare-ups with pain that increased in intensity and no other functional impairment. He had forward flexion to 40 degrees with pain at the last 20 with a functional loss of 50 due to pain. A March 2011 VA examination report reflects the Veteran’s report of stiffness, spasm, and lumbar spine pain that was moderate, constant, and daily with no radiation of pain. On active motion, he had flexion to 45 degrees with objective evidence of pain. He was diagnosed with lumbar strain with associated paravertebral myositis, lumbar disc paracentral protrusion at L5-S1 level, and lumbar spondylosis. An April 2013 VA examination report reflects diagnoses of lumbar spondylosis and lumbar degenerative disc disease; and the Veteran’s report of flare-ups after prolonged standing, stooping, heavy lifting, and ambulation. He had forward flexion to 40 degrees with pain beginning at 5 degrees. After repetitive-use testing, he had forward flexion to 35 degrees. There was no radiculopathy, other neurologic abnormalities, or IVDS. In a June 2013 letter a private physician stated that the Veteran presented continuous strong back pain that was worsening with recurrent episodes of “locking.” He was no longer able to tolerate prolonged sitting, walking, climbing stairs, and standing; was not able to lift heavy items, bend, squat, or crawl; and was limited in how far he could climb and reach. He complained of constant stiffness with continuous muscle spasms, numbness, and pinprick sensation in the lower extremities. An April 2014 VA examination report reflects review of the Veteran’s claims file and diagnosis of lumbar strain myositis. The Veteran complained of constant low back pain without irradiation. He reported flare-ups during which he was unable to stand from bed or stand in a straight position for a few hours. He had flexion to 25 degrees with pain beginning at 15 degrees. After repetitive-use testing, flexion was limited to 20 degrees. However, the examiner noted that the Veteran “was not doing full effort during lumbar active range of motion evaluation (overreacting).” He did not have radiculopathy, ankylosis, or other neurologic abnormalities. He had IVDS with incapacitating episodes of at least one week but less than two weeks during the past 12 months. Based on the examiner’s assessment of the Veteran’s effort, or lack thereof, the Board does not find the limitation of motion findings here valid and adequate to decide the claim. An April 2015 VA examination report reflects a diagnosis of lumbar strain myositis and the Veteran’s report of constant back pain with loss of balance. He stated that he had flare-ups during which he was unable to get out of bed. There was forward flexion to 40 degrees with pain that caused functional loss and with weight-bearing. There was objective evidence of localized tenderness. Repetitive-use testing could not be performed due to severe pain. There was no radiculopathy, ankylosis, neurologic abnormalities, or IVDS. VA treatment records reflect forward flexion to 48 degrees in May 2015, and to 60 degrees in July 2015. He also had moderate tenderness and mild spasm. In July and October 2016, he had full active and passive ROM with pain in rotation, extension, and lateral bending to the left. A November 2017 VA examination report reflects review of the Veteran’s claims file and diagnosis of lumbar strain myositis. The Veteran complained of constant low back pain without radiation. He reported flare-ups, which caused him to stay home all day, and limitation in standing and sitting. He had forward flexion to 50 degrees with pain noted but not causing functional loss. Repetitive use testing did not result in additional loss of function or ROM. The examiner could not say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups. The Veteran did not have any signs of radiculopathy, ankylosis of the spine, neurologic abnormalities, or IVDS. There was evidence of pain on passive ROM testing and with nonweight-bearing. The Board finds the weight of the competent evidence demonstrates the Veteran does not meet the criteria for a rating in excess of 20 percent for his lumbar spine disability. The General Rating Formula reflects that a rating in excess of 20 percent requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. The Board acknowledges that the Veteran had forward flexion to 40 degrees with pain beginning at five degrees, and to 35 degrees after repetitive-use testing, at the April 2013 VA examination; and flexion limited to 25 degrees with pain beginning at 15 degrees at the April 2014 VA examination. However, the April 2014 VA examiner noted that the Veteran was overreacting and not putting full effort during active ROM testing and, as reflected above, the Board finds these limitation of motion results inadequate to evaluate the claim. The remaining evidence reflects forward flexion ranging from 40 degrees, with indications of pain, to 60 degrees. The Board notes that the November 2017 VA examiner noted pain on passive ROM testing and with nonweight-bearing, but did not provide the specific degree at which pain began. Regardless, there is no indication that the Veteran’s forward flexion was so severe as to approximate 30 degrees or less. Additionally, there is no evidence indicating ankylosis of the entire thoracolumbar spine. As such, the Board finds that the weight of the evidence does not reflect forward flexion limited to 30 degrees or less, or ankylosis. The Board acknowledges that the Veteran appears to contend that the November 2017 examination report was inadequate as the examiner stated that he was unable to say without mere speculation if pain, weakness, fatigability, or incoordination significant limited his functional ability with flare-ups. However, the examiner explained why this was so. Additionally, the Veteran reported flare-ups at the August 2008, April 2013, April 2014, April 2015, and November 2017 VA examinations. At the August 2008 VA examination, the Veteran described the flare-ups as involving increased pain but no other functional impairment. Unfortunately, he did not describe the nature of his flare-ups at the April 2013 VA examination. At the April 2014 VA examination, he stated that he was unable to stand from bed or in a straight position during flare-ups. However, the VA examiner noted that the Veteran was overreacting during ROM testing. In April 2015, he stated that he was unable to get out of bed during flare-ups. At the November 2017 VA examination, the Veteran stated that flare-ups caused him to stay home all day, and limited standing and sitting. Unfortunately, the Veteran did not describe the changes, if any, in his ROM during flare-ups. However, the Veteran reported being unable to stand straight during flare-ups. As stated above, fixation in neutral position (zero degrees) always represents favorable ankylosis. Unfortunately, in this case, the Veteran reported being unable to stand straight, which would not be in neutral position and thus not indicative of favorable ankylosis. It also would not be considered unfavorable ankylosis as there is no indication of 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. See 38 C.F.R. § 4.71a, DCs 5235-5243, Note (5). As such, although the November 2017 VA examiner was unable to say without mere speculation whether the Veteran’s flare-ups limited his functional ability, the Board finds that the totality of the evidence does not reflect any limitation in functional ability that would warrant an increased rating. Additionally, the Board notes that the April 2014 VA examiner found that the Veteran had IVDS with incapacitating episodes of at least one week but less than two weeks during the past 12 months. However, subsequent VA examiners found that the Veteran did not have IVDS. Regardless, in order to have a rating in excess of 20 percent for IVDS based on incapacitating episodes, the Veteran must have incapacitating episodes of at least four weeks but less than six weeks during the past 12 months. There is no evidence of such. Furthermore, the Board acknowledges that the Veteran’s service-connected lumbar spine disability causes pain. The presence of pain, as described by the Veteran, is certainly a component of his disability and is contemplated in the rating criteria. The Board finds that the 20 percent rating assigned adequately portrays any functional impairment, pain, fatigue, weakness, and any flare-ups that the Veteran experiences as a consequence of his back disability. Accordingly, a 20 percent rating is appropriate as it already encompasses the provisions of 38 C.F.R. §§ 4.40, 4.45, and the DeLuca considerations. In addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). In this case, the competent evidence consistently reflects the absence of any such abnormalities. Moreover, the Board has considered the Veteran’s contention that extraschedular consideration is warranted for the issue on appeal. Turning to the first step of the extraschedular analysis discussed above, the Board finds that the symptomatology and impairments caused by the Veteran’s service-connected disability, which are recited in detail above, are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The General Rating Formula for diseases and Injuries of the Spine is based on limitation of motion, but other factors such as painful motion, flare-ups, repeated use, weakened movement, excess fatigability, and incoordination have been considered in evaluating the severity of the Veteran’s lumbar spine disability. See 38 C.F.R. §§ 4.40, 4.45, 4.59. Thus, the Board finds that the rating schedule is adequate, and that referral for extraschedular consideration is not warranted under the circumstances of this case. REASONS FOR REMAND Issues 1-2: Entitlement to disability ratings in excess of 10 percent for right and left knee disabilities is remanded. The claims for increased ratings for the Veteran’s right and left knee disabilities are remanded for a new VA examination. The November 2017 VA examination did not completely evaluate the Veteran’s flare-ups by ascertaining adequate information, such as frequency, duration, characteristics, severity, or functional loss. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). He merely noted the Veteran’s reports that his flare-ups limited his standing and ambulating, and caused him to stay home all day. As such, a remand is necessary in order to more fully address the Veteran’s flare-ups and any additional limitations that may result. 3. Entitlement to a TDIU is remanded. The Veteran’s claim for a TDIU is inextricably intertwined with the claims remanded herein, and the adjudication of this claim may depend on the outcome of the other remanded claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to evaluate his service-connected bilateral knee disabilities. All indicated tests and studies should be accomplished and the findings reported in detail. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. The examiner is asked to examine the Veteran, review his claims file, and then respond to the following: (a) Indicate all current symptoms associated with the Veteran’s service-connected bilateral knee disabilities and address their severity. (b) Test and report the ROM in active motion, passive motion, weight-bearing, and nonweight-bearing for each knee. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, s/he should clearly explain why that is so. If an opinion cannot be given without resorting to mere speculation, the VA examiner should state so and further provide a reason for such conclusion. (c) In reporting the ROM findings, comment on the extent of any painful motion, at which measurement the pain begins, functional loss due to pain, weakness, excess fatigability, and additional disability during flare-ups or upon repetitive use testing. (d) Ascertain adequate information regarding the Veteran’s flare-ups, such as the frequency, duration, characteristics, severity, and functional loss. Address whether such flare-ups constitute incapacitating exacerbations. (e) Provide information concerning any functional impairment resulting from the service-connected bilateral knee disabilities that may impact the Veteran’s ability to function and perform tasks in a work or work-like setting. The examiner should provide an explanation for any conclusions reached. 2. Thereafter, readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jane R. Lee