Citation Nr: 18153794 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-30 898 DATE: November 28, 2018 ORDER Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left foot condition (claimed as gout) is denied. Entitlement to service connection for acid reflux disease is denied. Entitlement to service connection for migraines is denied. Entitlement to service connection for hypertension is denied. A rating in excess of 40 percent for the service-connected back disability prior to January 29, 2018, is denied. A rating of 50 percent for the service-connected low back disability on and after January 29, 2018, is granted. A separate rating of 10 percent for radiculopathy of the left lower extremity secondary to the service-connected back disability as of January 29, 2018, is granted. A rating of 40 percent for the service-connected right foot drop, sciatic nerve involvement prior to January 29, 2018, is granted. A rating in excess of 60 percent for the service-connected right foot drop, sciatic nerve involvement on an after January 29, 2018, is denied. FINDINGS OF FACT 1. The record does not reflect a current diagnosis or persistent or recurrent symptoms for a neck disability. 2. The record does not reflect a current diagnosis or persistent or recurrent symptoms for a left hip disability. 3. The record does not reflect a current diagnosis or persistent or recurrent symptoms for a right hip disability. 4. The record does not reflect a current diagnosis or persistent or recurrent symptoms for a left knee disability. 5. The record does not reflect a current diagnosis or persistent or recurrent symptoms for a right knee disability. 6. The record does not reflect a current diagnosis or persistent or recurrent symptoms of a left foot condition (claimed as gout). 7. The record does not reflect a current diagnosis or persistent or recurrent symptoms for acid reflux disease. 8. The record does not reflect a current diagnosis or persistent or recurrent symptoms for migraines. 9. The record does not reflect a current diagnosis or persistent or recurrent symptoms for hypertension. 10. Prior to January 29, 2018, the Veteran’s thoracolumbar spine disability did not manifest in ankylosis of the thoracolumbar or entire spine; nor is there evidence of incapacitating episodes due to IVDS prescribed by a physician. 11. As of January 29, 2018, the Veteran’s thoracolumbar spine disability manifested in unfavorable ankylosis of the thoracolumbar spine; there is no evidence of incapacitating episodes due to IVDS prescribed by a physician. 12. As of January 29, 2018, the Veteran’s back disability has manifested in radiculopathy of the left lower extremity of mild severity. 13. Prior to January 29, 2018, the Veteran’s right foot drop with sciatic nerve involvement manifested in numbness, muscle atrophy and decreased senses. 14. As of January 29, 2018, the Veteran’s right foot drop with sciatic nerve involvement manifested in severe symptoms with marked muscle atrophy, constant pain, and decreased senses. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 2. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 3. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 4. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 5. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 6. [The criteria for service connection for a left foot condition (claimed as gout) disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 7. The criteria for service connection for acid reflux disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 8. The criteria for service connection for migraines have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 9. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.303(a) (2017). 10. Prior to January 29, 2018, the criteria for a rating in excess of 40 percent for the thoracolumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.71a, Diagnostic Code 5237 (2017). 11. From January 29, 2018, the criteria for a rating of 50 percent for the thoracolumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.71a, Diagnostic Code 5237 (2017). 12. As of January 29, 2018, the criteria for service connection for radiculopathy of the left lower extremity secondary to the service-connected back disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2012); 38 C.F.R. § 3.310(a) (2017). 13. Prior to January 29, 2018, the criteria for a rating of 40 percent for right foot drop with sciatic nerve involvement have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.13, 4.123, 4.124, Diagnostic Code 8520 (2017). 14. From January 29, 2018, the criteria for a rating in excess of 60 percent for right foot drop with sciatic nerve involvement have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.13, 4.123, 4.124, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from March 1973 to September 1994. As to the claim for service connection for insomnia, the Veteran was granted service connection for a psychiatric disorder, to include insomnia, during the appeal period in the February 2018 rating decision. As this grant represents a full grant of the benefits sought, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Entitlement to service connection requires: (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). As to the claims for service connection for a neck disability, left and right hip disabilities, left and right knee disabilities, left foot condition (claimed as gout), migraines, hypertension, and acid reflux disease, the record does not reflect a current diagnosis for these disabilities. Nor does the record reflect recurrent or persistent symptoms of these conditions. A current diagnosis is a cornerstone of a service connection claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Lacking a current diagnosis, service connection cannot be established. As such, the claims must be denied. Increased Rating The Veteran’s entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). At the time of an initial rating, consideration of the appropriateness of a staged rating is also required. Fenderson v. West, 12 Vet. App. 119 (1999). The Board will also consider entitlement to staged ratings to compensate for times since the claim was filed when the disability may have been more severe than at other times during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In such case, VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. In the instant case, the Veteran has been service connected for the thoracolumbar spine (back) disability since 1998, and he filed his claim for increase on March 19, 2014. Therefore, the claim for increase for the back disability is not an initial claim for increase, and the period under consideration begins on March 19, 2013. Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to a rating in excess of 40 percent for the service-connected low back disability The Veteran’s back disability has been evaluated under Diagnostic Code 5237 for lumbosacral strain, which is rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. The Veteran also has intervertebral disc syndrome (IVDS) associated with his lumbar spine disability. IVDS is also evaluated under the General Rating Formula for Diseases and Injuries of the Spine, which covers Diagnostic Codes 5235-5243. Id. Under the General Rating Formula for Diseases and Injuries of the Spine referring to the thoracolumbar spine, forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine is rated at 40 percent. With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, unfavorable ankylosis of the entire thoracolumbar spine is rated at 50 percent. A maximum 100 percent rating is reserved for unfavorable ankylosis of the entire spine. Note (1) to the General Rating Formula for Diseases and Injuries of the Spine indicates to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2) (See also Plate V.) provides that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Alternatively, disabilities of the spine may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Under this rating formula, incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months is rated 40 percent disabling. Incapacitating episodes having a total duration of at least six weeks during the past 12 months is rated 60 percent disabling. Note (1) to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes explains that an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome (IVDS) that require bed rest prescribed by a physician and treatment by a physician. Note (2) explains that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Additionally, the Court has held that an adequate VA examination for the joints must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Correia v. McDonald, 28 Vet. App. 158 (2016); 38 C.F.R. § 4.59. Painful motion is an important factor of disability, and actually painful, unstable, or maligned joints are entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). However, in the present case, the Veteran is in receipt of the highest rating available for limitation of motion of the thoracolumbar spine, and a higher rating is contingent on whether the Veteran has ankylosis. The provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Therefore, Correia and Deluca, and the provisions addressed therein, are not applicable here. As such, in discussing the medical evidence, the Board will not discuss rating criteria relevant to limitation of motion or additional functional impairment. Nor will the Board discuss criteria relating to a lower rating, such as muscle spasms and spinal contour. Given the evidence of record, the Board finds that staged ratings are warranted for the Veteran’s back disability as of January 29, 2018, the date of the VA examination in which the evidence indicates an increase in the severity of the condition. Therefore, the Board will discuss the rating periods separately. Prior to January 29, 2018 Turning to the medical evidence during this period of the appeal, the Veteran underwent a VA examination for his back disability in July 2014. The examiner provided a diagnosis for IVDS. The examination report indicates that muscle strength testing was all normal for the left lower extremity. Muscle strength testing for the right lower extremity was normal except there was active movement against gravity for the right ankle dorsiflexion and right great toe extension. The report indicates that the Veteran has muscle atrophy. The report specifies that there is muscle atrophy of the right calf with the normal side measuring 37cm and the atrophied side measuring 34 cm. Reflex exams were all normal for both lower extremities. Sensory exams were all normal for the left lower extremity. Sensory exams were normal for the right lower extremity except there were decreased senses for the right lower leg/ankle and foot/toes. Straight leg testing was negative for the right and left leg. The report indicates that there are signs of radiculopathy. The Veteran is already rated separately for this condition for the right lower extremity, and that rating is on appeal. As such, the Board will discuss the Veteran’s radiculopathy symptoms of the right lower extremity in the portion of the decision regarding that appeal. There were no symptoms of radiculopathy indicated for the left lower extremity. The report indicates that there is no ankylosis of the spine. The report also indicates there are no other neurologic abnormalities or findings related to the thoracolumbar spine (back) condition, such as bowel or bladder problems/pathologic reflexes. The report also indicates that there is no IVDS of the thoracolumbar spine. The Board notes that this finding is inconsistent with the diagnosis provided in the report for IVDS of the thoracolumbar spine. However, as will be discussed, the Veteran has not indicated that he had incapacitating episodes commensurate with a 60 percent rating (lasting six weeks in a 12-month time period) during this period of the appeal. As such, the Board finds the discrepancy trivial. The report notes use of assistive devices, specified as use of a brace constantly. The report indicates there is not functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis (noting that functions of the lower extremity include balance and propulsion, etc). The examiner noted that there are associated scars. The examiner indicated that the scars are not painful and/or unstable nor is the total area of all related scars greater than 39 square cm (6 square inches). There are no additional treatment reports or examinations of record during this period of the appeal addressing the rating criteria. Nor are there any lay statements from the Veteran or his attorney addressing criteria for a higher rating. Given the findings of the July 2014 VA examination, the Board finds that a higher rating is not warranted prior to January 29, 2018. The Veteran is in receipt of the highest rating for limitation of motion, and a higher rating for the thoracolumbar spine requires some form of ankylosis. The July 2014 examination report indicates that there is no ankylosis of the thoracolumbar or entire spine. Nor has the Veteran asserted that his spine was ankylosed during this period of the appeal. Absent competent evidence of ankylosis, a higher rating is not warranted. Nor is a higher rating warranted under the Formula for Rating IVDS Based on Incapacitating Episodes. As discussed, the July 2014 VA examination findings are inconsistent as to whether the Veteran has IVDS. However, the Veteran has not suggested that he had any incapacitating episodes due to IVDS during this period of the appeal. As such, there is no basis for granting a 60 percent rating for IVDS, which requires at least six weeks of incapacitating episodes prescribed by a physician. Nor is a separate rating warranted. The medical evidence indicates that the Veteran did not have any other associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment. Nor does the Veteran suggest that he has bowel or bladder problems. A separate rating for associated scars is also not warranted. While the medical evidence indicates the Veteran has scars associated with his back disability, the clinical evidence indicates that the scar is not painful or unstable nor covers an area commensurate with a compensable rating. Given the evidence, the Board finds that a 40 percent rating, but no higher, is warranted for the Veteran’s back disability prior to January 29, 2018. From January 29, 2018 During this period of the appeal, the Veteran was afforded another VA examination in January 2018. The examiner indicated diagnoses for degenerative arthritis of the spine, IVDS, and spinal fusion. As to additional factors contributing to disability, the examiner indicated that there is less movement than normal due to ankylosis, limitation or blocking, adhesions, instability of station, interference with sitting, and interference with standing. For the right lower extremity, muscle strength testing was normal except there was active movement against some resistance for the right hip flexion and active movement against gravity for the right great toe extension. For the left lower extremity, there was active movement against some resistance for the left hip flexion and great toe extension. The report indicates that the Veteran has muscle atrophy. The examiner specified that there is atrophy of the right lower extremity, 10 cm below the knee. The report indicates that the normal side measures 35.5 cm, and the atrophied side measures 31.5 cm. Reflex exams were all normal. Sensory exams were all normal except they were decreased for the right thigh/knee, lower leg/ankle and foot/toes. The report indicates that the examiner was unable to perform right or left straight leg test. The examiner indicated that the Veteran has radicular symptoms for both lower extremities. As noted, radicular symptoms of the right lower extremity will be discussed later in the decision. For the left lower extremity, the report indicates that there is mild constant and intermittent pain for the left lower extremity. The report indicates that there is no paresthesias and/or dysesthesias and no numbness noted. The report indicates that the sciatic nerve is involved for both lower extremities. The report indicates there is ankylosis. The examiner specified that there is unfavorable ankylosis of the entire thoracolumbar spine. The report indicates there are no other neurologic abnormalities related to thoracolumbar condition, such as bladder problems or pathologic reflexes. The examiner also indicated that the Veteran has IVDS but no episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The report notes use of assistive devices, specified as use of a brace constantly for lower back pain and a cane regularly for lower back pain and right lower extremity weakness. The examiner indicated that there are associated scares. The examiner also indicated that the scars are not painful and/or unstable nor is the total area of all related scars greater than 39 square cm (6 square inches). The examiner specified that there is a scar on the lumbar spine measuring 15x.25 cm. There are no additional treatment reports or examinations of record during this period of the appeal addressing the rating criteria. Nor are there any lay statements from the Veteran or his attorney addressing criteria for a higher rating. Given the findings of the January 2018 VA examination, the Board finds that a higher rating of 50 percent is warranted on and after January 29, 2018, for unfavourable ankylosis of the entire thoracolumbar spine. However, a higher rating of 100 percent is not warranted as there is no evidence of unfavourable ankylosis of the entire spine. Nor has the Veteran asserted that his entire spine is ankylosed. Absent competent evidence of ankylosis of the entire spine, a higher rating is not warranted. Nor is a higher rating warranted under the Formula for Rating IVDS Based on Incapacitating Episodes. The January 2018 VA examination indicates that there have been no incapacitating episodes due to IVDS. Nor has the Veteran suggested that he had any incapacitating episodes due to IVDS. As such, there is no basis for granting a 60 percent rating for IVDS. However, the Board finds that a separate rating is warranted for radiculopathy of the left lower extremity. The January 2018 VA examination indicates pain as a radicular symptom of the left lower extremity. The report also indicates decreased senses for the left lower extremity with sciatic nerve involvement. Radicular symptoms are not accounted for in either rating formula for disabilities of the spine. As such, a separate rating is warranted for these symptoms. The Board acknowledges that the January 2018 examination report indicates that the left lower extremity is “not affected.” However, for VA rating purposes, wholly sensory symptoms, which include pain, are rated as at least mild, which is commensurate with a 10 percent rating under Diagnostic Code 8520. 38 C.F.R. § 4.124a. As such, the Board finds that a separate rating of 10 percent is warranted for radiculopathy of the left lower extremity as of January 29, 2018. There is no basis for an additional separate rating. The medical evidence indicates that the Veteran did not have any other associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment. Nor does the Veteran suggest that he has bowel or bladder problems. A separate rating for associated scars is also not warranted. While the medical evidence indicates the Veteran has scars associated with his back disability, the clinical evidence indicates that the scar is not painful or unstable nor covers an area commensurate with a compensable rating. Given the evidence, the Board finds that a 50 percent rating, but no higher, is warranted for the Veteran’s back disability on and after January 29, 2018. Additionally, a separate rating of 10 percent is warranted for radiculopathy of the left lower extremity as of January 29, 2018. 2. Entitlement to an initial rating in excess of 20 percent for right foot drop, sciatic nerve involvement prior to January 29, 2018, and a rating in excess of 60 percent thereafter For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term “incomplete paralysis” with peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. The Veteran’s right foot drop with sciatic nerve involvement has been evaluated under Diagnostic Code 8520. 38 C.F.R. § 4.124a. Diagnostic Code 8520 provides that moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve; where the foot dangles and drops, no active movement possible of muscles below the knee, or flexion of knee is weakened or (very rarely) lost, is rated 80 percent disabling. While the rating schedule does not define terms such as “mild,” “moderate,” or “severe,” it does provide some guidance regarding neurological disabilities. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The rating schedule provides that cranial or peripheral neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating that may be assigned for neuritis not characterized by organic changes referred to above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Prior to January 29, 2018 As noted, the July 2014 VA back examination indicates that the Veteran has signs of radiculopathy of the right lower extremity. The report reflects the Veteran’s statements that he has right foot drop as a result of progression of his lumbar disorder. As to signs and symptoms of radiculopathy, the report indicates that the Veteran’s right foot drops. The report also specifies that the condition involves the sciatic nerve for the right side and is of moderate severity. The report indicates there is no constant pain, intermittent pain, or paresthesias and/or dysesthesias for the right lower extremity. The report notes moderate numbness for the right lower extremity. As also noted, the examination report indicates that the Veteran has muscle atrophy. The report specifies that there is muscle atrophy of the right calf with the normal side measuring 37cm and the atrophied side measuring 34 cm. Reflex exams were all normal. Sensory exams were all normal except there was decreased senses indicated for the right lower leg/ankle and foot/toes. There is no additional medical evidence of record regarding the Veteran’s sensory symptoms of the right lower extremity during this period of the appeal. Having reviewed the evidence of record, the Board finds that a 40 percent rating is warranted prior to January 29, 2018. The evidence during this period of the appeal reflects foot drop, numbness, muscle atrophy, and decreased senses for the right lower extremity. A rating for moderate symptoms is assigned for wholly sensory symptoms, such as numbness, tingling and pain. Here, the Veteran’s symptoms are not wholly sensory; he has muscle atrophy, and his foot drops. As such, the occurrence of symptoms that are not wholly sensory is logically consistent with assigning a rating higher than that assigned for wholly sensory symptoms. Under Diagnostic Code 8520, the next highest rating is for moderately severe symptoms, which is 40 percent. As such, the Board finds that a 40 percent rating is warranted. The Board acknowledges that the clinical evidence during this period of the appeal indicates that the Veteran has muscle atrophy of the right calf. Additionally, the measurements provided are similar to those provided in the January 2018 examination which, as will be discussed, the examiner indicated as marked muscle atrophy. However, while the Veteran had marked muscle atrophy during this period of the appeal, a higher rating is warranted for marked muscle atrophy associated with severe symptoms. As discussed, the evidence of record supports that the Veteran’s symptoms were moderately severe during this period of the appeal. As such, a 60 percent rating is not warranted. The assignment of at most a 40 percent rating during this period of the appeal is also in line with 38 C.F.R. § 4.123, which provides that the maximum rating that may be assigned for neuritis with sciatic nerve involvement not characterized by organic changes referred to in the provision (loss of reflexes, muscle atrophy, sensory disturbances, and constant pain) will be that for moderately severe, incomplete paralysis (which, as discussed, is 40 percent). As the symptoms listed in 38 C.F.R. § 4.123 are listed conjunctively, all symptoms must be present to warrant a higher rating than moderately severe incomplete paralysis for the sciatic nerve. While the record reflects that the Veteran experienced sensory disturbances and muscle atrophy during this period of the appeal, the record does not reflect any loss of reflexes or constant pain. To the contrary, the record reflects that the Veteran had normal reflexes and no pain during this period of the appeal. As such, a 60 percent rating is not warranted. Nor is an 80 percent rating warranted as the Veteran does not have complete paralysis of the right lower extremity. The Board acknowledges his assertions that his right foot drops. While “foot drop” is commensurate with an 80 percent rating, that rating refers to complete paralysis. Here, although the Veteran’s right foot drops, there is no competent evidence that he also has no active movement possible of muscles below the knee or weakened knee flexion. To the contrary, his reflex exams during this period of the appeal were normal for his right lower extremity. Lacking competent medical evidence of complete paralysis, an 80 percent rating is not warranted. Given the evidence, the Board finds that a rating of 40 percent, but no higher, is warranted for the Veteran’s right foot drop with sciatic nerve involvement prior to January 29, 2018. From January 29, 2018 As also noted, in January 2018, the Veteran underwent another VA back examination report, which also indicates that the Veteran has radicular symptoms of the right lower extremity. The report indicates that there is moderate constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness for the right lower extremity. The examiner indicated that the symptoms involve the sciatic nerve as well as the fibular nerve. The examiner indicated that the severity is severe for the right side. Additionally, the Veteran underwent a VA sensory examination in January 2018. The examiner provided diagnoses for right foot drop sciatic nerve involvement associated with invertebral disc syndrome. The examiner specified that the Veteran has had right foot drop since 2000 and denies changes in the past 18 months. As to current symptoms, the examiner indicated that the right lower leg/foot drops, and a brace is worn constantly. The report indicates that the symptoms are moderate constant pain for the right lower extremity. The report indicates moderate intermittent pain for the right lower extremity. The report also indicates severe paresthesias and/or dysesthesias and moderate numbness for the right lower extremity. Muscle strength testing was all normal. The examiner indicated there is no muscle atrophy. The Board notes that this finding is inconsistent with the January 2018 back conditions VA examination indicating that there is atrophy of the right calf. However, the sensory conditions report also indicates that there is severe marked muscle atrophy. As such, the Board finds that the discrepancy that there is no muscle atrophy is a typo/oversight. The examination report indicates that reflex exams were all normal except they were hypoactive for the right knee and ankle. Sensory exams were all normal except they were decreased for the right thigh/knee, lower leg/ankle, and foot/toes. The report also indicates that the Veteran has trophic changes. The examiner specified that the hair to the right leg is sparse in comparison to the left leg, and the skin is dry and flaky to bilateral legs. The report indicates that the Veteran has an abnormal gait and walks with a limp to the right leg. The examiner indicated that the Veteran’s right foot drops and that there is lower back pain. The report indicates that the Phalen’s test and the Tinel’s test were negative. The examiner indicated that the nerve involved is the sciatic nerve with incomplete paralysis that is severe and with marked muscle atrophy. The report also indicates severe incomplete paralysis of the right side for the external popliteal nerve, musculocutaneous nerve, anterior tibial nerve, internal popliteal nerve, and posterior tibial nerve. The report indicates mild incomplete paralysis of the right side for the anterior crural nerve and internal saphenous nerve. The examiner also noted use of assistive devices. The examiner specified that the Veteran uses a brace for right foot drop constantly and uses a cane regularly for lower back pain and right leg/foot weakness. The examiner indicated there is no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner indicated there are associated scars. The examiner indicated that the scars are not painful or unstable or cover a total area greater than or equal to 39 square cm (6 square inches). There is no additional medical evidence of record regarding the Veteran’s sensory symptoms of the right lower extremity during this period of the appeal. Having reviewed the evidence of record, the Board finds that a rating in excess of 60 percent is not warranted on and after January 29, 2018. During this period of the appeal, the Veteran’s nerve condition manifested in sensory disturbances, pain, trophic changes, marked muscle atrophy, and an abnormal gait. Per these symptoms, the Veteran is in receipt of the highest rating for incomplete paralysis, which is for severe symptoms. A rating of 80 percent requires complete paralysis. However, the evidence does not indicate that the Veteran has complete paralysis of the right lower extremity. As noted, the Board acknowledges his assertions that his right foot drops. As discussed, there is also no competent evidence that he also has no active movement possible of muscles below the knee or weakened knee flexion. Absent such evidence, there is no basis to establish that he has complete paralysis of the right lower extremity. Additionally, during this period of the appeal, his reflex exams continued to be normal for his right lower extremity. Lacking competent medical evidence of complete paralysis, an 80 percent rating is not warranted. The Board acknowledges that the January 2018 sensory conditions VA examination revealed trophic changes and an abnormal gait. 38 C.F.R. § 4.120 provides that in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. Here, as discussed, the Board has noted (given attention to) the Veteran’s symptoms of trophic changes, abnormal gait, and sensory disturbances in the 60 percent rating assigned for severe symptoms. However, these symptoms are not indicative of complete paralysis. The January 2018 VA examiner indicated that the Veteran has incomplete paralysis. Medical examiners are presumed competent to render the reports and opinions they provide. See Sickels v. Shinseki, 643 F.3d 1362 (Fed.Cir.2011). Thus, the Board defers to the medical knowledge and training of the examiner in assessing the difference between complete and incomplete paralysis. Moreover, the Veteran’s trophic changes involve hair loss and scaly skin. While the Veteran had an abnormal gait, having a gait, although abnormal, logically suggests that the extremity is not completely paralyzed. Also, as discussed, the Veteran’s reflex exams were normal. Given this evidence, the record does not support that there is complete paralysis of the right lower extremity. Thus, an 80 percent rating for complete paralysis is not warranted. CONTINUED ON THE NEXT PAGE Given the evidence, the Board finds that a rating of 60 percent, but no higher, is warranted for the Veteran’s right foot drop with sciatic nerve involvement on and after January 29, 2018 GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Smith, Associate Counsel