Citation Nr: 18156228 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 10-25 802 DATE: December 7, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is reopened. Entitlement to service connection for loss of use of bilateral lower extremities, to include as secondary to service-connected disabilities, is denied. Entitlement to service connection for PTSD is granted. Entitlement to service connection for asthma is denied. Entitlement to a disability rating in excess of 20 percent for chronic lumbosacral strain is denied. Entitlement to an initial disability rating in excess of 20 percent for radiculopathy to the left lower extremity is denied. Entitlement to an initial disability rating in excess of 10 percent for radiculopathy to the right lower extremity is denied. REMANDED Entitlement to service connection for a bilateral foot disability, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for loss of bowel control, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for condition of skeletal system, to include neck, also claimed as arthritis of the neck and cervical spine and rheumatology, is remanded. FINDINGS OF FACT 1. An August 2011 rating decision declined to reopen the claim of entitlement to service connection for PTSD; and the Veteran did not appeal that decision in a timely manner nor was any new and material evidence submitted within the appeal period. 2. Evidence added to the record since the final August 2011 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for PTSD. 3. The Veteran does not have loss of use of both lower extremities. 4. The medical evidence of record shows a diagnosis of PTSD based on a claimed in-service stressor. 5. The preponderance of the evidence is against finding that the Veteran’s obstructive lung disease suggestive of asthma is due to a disease or injury in service. 6. The Veteran’s chronic lumbosacral strain has been manifested by limitation of motion to, at most, 50 degrees forward flexion, 10 degrees extension, and 20 degrees bilateral lateral flexion and bilateral lateral rotation. Favorable or unfavorable ankylosis of the thoracolumbar spine was not shown 7. The Veteran’s radiculopathy to the left lower extremity has been manifested by symptomatology no worse than moderate incomplete paralysis of the sciatic nerves. 8. The Veteran’s radiculopathy to the right lower extremity has been manifested by symptomatology no worse than mild incomplete paralysis of the sciatic nerves. CONCLUSIONS OF LAW 1. The August 2011 rating decision that declined to reopen a claim of entitlement to service connection for PTSD is final. 38 U.S.C. § 7105(c) (2002), 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). 2. New and material evidence having been received, the claim for entitlement of service connection for PTSD is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.156(a) (2018). 3. The criteria for service connection for loss of use of bilateral lower extremities have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303 (2018). 4. The criteria for service connection for PTSD have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2018). 5. The criteria for service connection for asthma have not been met. 38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 6. The criteria for a disability rating in excess of 20 percent for chronic lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2018). 7. The criteria for an initial disability rating in excess of 20 percent rating for radiculopathy to the left lower extremity have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.124a, Diagnostic Code 8620 (2018). 8. The criteria for an initial disability rating in excess of 10 percent rating for radiculopathy to the right lower extremity have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.124a, Diagnostic Code 8620 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1979 to October 1979. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. New and Material Evidence Pertinent procedural regulations provide that “[n]othing in [38 U.S.C. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C. § 5108].” 38 U.S.C. § 5103A(f). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims (the Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA’s duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). In July 2004, the Veteran filed his original claim for entitlement to service connection for PTSD. The RO initially denied the claim in an April 2005 rating decision finding that the medical evidence failed to show that this condition was incurred in, caused by, or aggravated by his active duty military service. The Veteran filed applications to reopen the claim and the RO declined to reopen the claim in rating decisions dated January 2008, January 2010, and August 2011. The Veteran did not submit any evidence within one year of the August 2011 rating decision that last denied the claim, nor did he file a timely appeal to the August 2011 rating decision. Therefore, it is final. 38 U.S.C. § 7105(c) (2002), 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). The Veteran filed a petition to reopen the claim of service connection for PTSD in August 2012. The RO declined to reopen the claim in a February 2013 rating decision and re-adjudicated the claim continuing the denial in a February 2015 rating decision. The basis of the August 2011 prior final denial was the RO’s finding that the evidence did not show that this condition was noted in service and that an in-service stressor which may have caused PTSD could not be confirmed. Thus, in order for the Veteran’s claim to be reopened, evidence must have been added to the record since the August 2011 rating decision that addresses this basis. Pertinent evidence submitted and obtained since the August 2011 rating decision includes VA treatment records, a November 2016 VA examination report, Social Security Administration records, an opinion letter from the Veteran’s VA psychiatrist dated February 2016, and lay evidence. In particular, the February 2016 opinion letter, as well as a February 2016 VA psychology note provide an opinion that the Veteran has been diagnosed with PTSD as the result of military sexual trauma (MST). Without addressing the merits of this evidence, the Board finds that the additional evidence addresses whether the Veteran has a current PTSD diagnosis that may be related to his military service, to include the claimed MST, and is presumed credible for the limited purpose of reopening the claim. Justus, 3 Vet. App. at 512-13. Thus, this evidence is both “new,” as it has not previously been considered by VA, and “material,” as it raises the reasonable possibility of substantiating the Veteran’s claim. The Board thus finds that new and material evidence has been submitted to reopen the issue of entitlement to service connection for PTSD since the August 2011 rating decision. On this basis, the issue of entitlement to service connection for PTSD is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. § 1113(b) (2012); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Generally, in order to establish service connection for the claimed disorders, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In certain circumstances, lay evidence may also be competent to establish a medical diagnosis or medical etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). 2. Entitlement to service connection for loss of use of bilateral lower extremities. The Veteran is seeking service connection for loss of use of his lower extremities associated with service-connected chronic lumbosacral strain. He contends that he cannot walk and he has to use a wheelchair due to back pain and pain and numbness in knees, legs and feet. He has reported that he used a wheelchair or a cane at all times. However, the Veteran’s lower extremity neurological impairment associated with his service-connected lumbar spine disability is already service-connected by direction of the Rating Schedule. See 38 C.F.R. § 4.71a, General Formula for Diseases and Injuries of the Spine (2017). Loss of use of the lower extremities is not itself a disability for which service connection can be granted. Apart from its specific meaning in the provisions governing special monthly compensation ratings, it is merely a description of functional impairment resulting from a disability or group of disabilities. VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. VA needs to identify a disability, not symptoms of a disability. The Veteran has not identified any additional nonservice-connected disabilities that result in loss of use of the lower extremities. Service connection was last denied for right and left knee conditions in February 2015, but the Veteran did not file a notice of disagreement with respect to those issues. Additionally, the medical evidence of record does not show loss of use of bilateral lower extremities. An October 2015 private treatment record from Friend Family Health Center reflects that on physical examination, the Veteran had normal range of motion and strength in both lower extremities. The Board recognizes that the Veteran uses a motorized wheelchair for walking, thus, his mobility is very limited. However, an October 2016 VA examination report reflects that the Veteran uses a cane for mobility at home and for short distances, which reflects that he retained use of lower extremities. Accordingly, service connection cannot be granted for symptoms of a disability or for functional impairment which is inherently part of any service-connected disability. Thus, there remains no issue to be resolved regarding service connection for loss of use of the lower extremities. The claim must be denied due to a lack of legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 3. Entitlement to service connection for PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and an in-service stressor. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. Otherwise, the law requires verification of a claimed stressor. The provisions of 38 C.F.R. § 3.304(f)(3) are limited to stressors arising from hostile military or terrorist acts toward the U.S. military committed by individuals or entities, rather than acts of one service member directed at another service member. Hostile criminal actions, such as the harassment and personal assault stressors alleged by a veteran are contemplated under the provisions of § 3.304(f)(5), which addresses evidentiary considerations where PTSD is alleged to have resulted from an in-service personal assault. Acevedo v. Shinseki, 25 Vet. App. 286 (2012). VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran’s military records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). In cases involving personal assault, the existence of a stressor in service does not have to be proven by the “preponderance of the evidence” because this would be inconsistent with the benefit of the doubt, or equipoise, doctrine contained in 38 U.S.C. § 5107(b). YR v. West, 11 Vet. App. 393, 399 (1998); Patton v. West, 12 Vet. App. 272, 279-280 (1999). If a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(5). The Veteran claims PTSD based on military sexual trauma. Specifically, he has reported that on his birthday, he was robbed and sexually assaulted by three Marines while attending Infantry Training School in Camp Pendleton in June 1979; he reported to the authorities for robbery but “they did absolutely nothing,” and just took him to his duty station. He also reported that at the same time, the skin on his face broke out and he was ridiculed by his superiors; he felt ashamed, depressed and socially isolated. He stated that after this incident, his duty performance deteriorated and he was discharged from the military soon thereafter. A review of the Veteran’s service treatment records does not reflect that he reported or was treated for any sexual assaults. Service personnel records reflect that the Veteran was discharged from service for convenience of the government because he was suffering from a condition not considered a disability interfering with his performance of duty. It was noted that the Veteran received treatment for pseudofolliculitis barbae (PFB) without results. VA treatment records reflect that the Veteran has been receiving mental health treatment and has had numerous hospitalization for depression and suicidal ideation since 1996. The records show that PTSD was first suspected in 2002 and diagnoses of PTSD related to MST was diagnosed in 2004. An October 2004 VA PTSD initial evaluation report states that the Veteran had difficulty engaging in outpatient treatment in the past, most likely because of necessity of making very difficult disclosure of his MST. It was noted the Veteran had recently revealed the presence of MST, which finally allowed the staff to understand the intensity of his disorder; without knowing about his MST, he appeared to be schizoaffective, with a lot of rage and isolation from others. In a February 2016 VA psychology note, a VA psychologist, Dr. J.Y. stated that he has known the Veteran as his clinical psychologist and psychotherapist in PTSD clinic since September 2004 and reviewing his clinical documentation, the Veteran had suffered from PTSD for many years before that time. The psychologist observed that the Veteran detailed his military sexual trauma experience in his claims file, and opined that “[i]n my opinion, [the Veteran] is 100% SC disabled with PTSD as a result of Military Sexual Trauma, and is totally unemployable.” In support of this opinion, the VA psychologist remarked that “I am completely satisfied that his PTSD symptoms correspond exactly to the claimed MST stressor. … He currently exhibits severely disabling PTSD symptoms in all cardinal DSM V categories, including intrusive recollections, avoidance of resembling stimuli, negative alterations in mood and cognition, and hypervigilance and hyperarousal phenomena.” In addition, in a February 2016 letter, a VA staff psychiatrist, Dr. C.S. indicated that he has treated the Veteran at the VA PTSD clinic since January 2008, and the Veteran has been diagnosed with PTSD. In this regard, it was noted that the Veteran presented with the symptoms of intrusive recollections; recurring distressing dreams; flashbacks with associated auditory hallucinations; psychologic distress and physiologic reactivity to cues; avoidance of thoughts, feelings, people, and places that might trigger symptoms; anhedonia; detachment from others; restricted range of affect; foreshortened sense of future; irritability; insomnia; hypervigilance; and exaggerated startle response. The psychiatrist provided the following opinion: [The Veteran] was in the Marines in 1979. Shortly after arriving at Camp Pendleton, he was assaulted by a group of fellow marines. It is likely that [the Veteran’s] psychiatric symptoms are directly related to this traumatic experience. In contrast, a November 2016 VA examiner noted the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria and diagnosed unspecified depressive disorder. At the examination, the Veteran reported that he was ‘raped’ by three Marines while stationed at Camp Pendleton in 1979 but he did not wish to give details of the assault. The examiner opined that the Veteran’s diagnosis of unspecified depressive disorder was most likely related to social and personal issues rather than to military service issue given the fact that the Veteran started mental health care in 1997, which is 18 years post service. Drs. Y. and S. and the November 2016 VA examiner are all medical professionals and equally competent to render an opinion regarding the Veteran’s psychiatric disorder. Although Drs. Y. and S. did not indicate that they had the opportunity to review the Veteran’s entire claims file, Dr. Y. stated that the Veteran’s detailed military sexual trauma was properly documented in his claims file thereby implying that he reviewed the Veteran’s claims file as well as his VA mental health treatment records. In addition, both Drs. Y. and S. had been treating the Veteran as his clinical psychologist and psychiatrist for over 10 years. Thus, they were very knowledgeable about the Veteran’s past medical history and the Veteran’s current diagnosis based on ongoing clinical experience with the Veteran on a long-term basis. The Board, therefore, finds their opinions highly probative of a PTSD diagnosis based on the claimed MST. The Board notes that the Veteran is competent to report the circumstances of the assault he experienced in service because they are based on his own direct observations. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of her personal knowledge). Moreover, the Board finds these statements to be credible, as the Veteran has reported a consistent history of the in-service stressor in describing the stressor throughout the period on appeal. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007) (holding that as a finder of fact, the Board, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the veteran, and the veteran’s demeanor when testifying at a hearing). The Veteran’s reports of his military sexual assault have been consistent throughout the record, and the Board finds no reason to disbelieve that the reported MST in fact occurred. Although there is little contemporaneous evidence available to verify the Veteran’s stressor, the Board finds that the medical opinions provided by his PTSD clinical psychologist and psychiatrist are persuasive as to the existence of the Veteran’s stressor. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that although “the lack of contemporaneous medical records may be a fact that the Board can consider and weigh against a veteran’s lay evidence, the lack of such records does not, in and of itself, render lay evidence not credible.”). Moreover, it is based on facts supported by the record as well as clinical findings at the examination and contains an adequate rationale. In sum, the Board finds that the evidence of record is at least in relative equipoise. That is, there is at least an approximate balance of evidence both for and against the actual occurrence of the in-service stressor. Under such circumstances, all reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Because a diagnosis of PTSD based on an in-service stressor has been offered, and because competent and credible supporting evidence that the in-service stressor occurred has been offered, service connection for PTSD is warranted. 4. Entitlement to service connection for asthma. The Veteran contends that he injured his back in service in 1979, during which he pulled his back and hurt his chest, which in turn caused right sided short of breath and pain with breathing. He stated this condition has persisted since service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of obstructive lung disease suggestive of asthma, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. § 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Private treatment records show the Veteran was first diagnosed with asthma in the late 1990s, decades after his separation from service. While the Veteran is competent to report having experienced symptoms of breathing symptoms since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of asthma or obstructive lung disease. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body as well as interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the November 2016 VA examiner opined that the Veteran’s current breathing symptoms, which was found on the October 2014 pulmonary function test suggestive of obstructive lung disease, are not at least as likely as not related to an in-service injury, event, or disease, including the right-sided chest pain while in service. The rationale was that the Veteran was not diagnosed with asthma or any other respiratory condition in service but he was diagnosed with muscle strain, which is not related to his obstructive lung condition. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). For these reasons, the Board finds that the preponderance of the evidence is against the claim. There is no doubt to be resolved, and service connection is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Evaluation of a service-connected disability requires a review of a veteran’s medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 5. Entitlement to a disability rating in excess of 20 percent for chronic lumbosacral strain. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40, 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Veteran’s chronic lumbosacral strain has been evaluated as 20 percent disabling under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5237 refers to lumbosacral strain and it directs that this condition be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, at 38 C.F.R. § 4.71a, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire (thoracolumbar and cervical) spine. 38 C.F.R. § 4.71a, General Rating Formula. These ratings are made 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. Id. The General Rating Formula also provides further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Id. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Note (4) provides that each range of motion measurement is to be rounded to the nearest five degrees. Note (6) directs to separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. VA treatment records dated from August 2011 to July 2017 show complaints of chronic lower back pain and leg pain, increased with prolonged sitting, standing, and walking. At a January 2013 VA spine examination, the Veteran reported flare-ups impacting the function of the thoracolumbar spine due to pain to both lower extremities. He stated he was in severe pain and could not perform range of motion exercises. It was noted that the Veteran had functional loss of less movement. The examiner indicated that the Veteran’s complaints were in excess of the findings. On physical examination, the Veteran had localized tenderness or pain to palpation for the paraspinous area, with no abnormal gait, spinal contour, or guarding. The Veteran did not have intervertebral disc syndrome (IVDS). He occasionally used a wheelchair and constantly used a walker. Imaging of the back revealed disc protrusion at T12-L1, L1-L2, and L4-L5. The examiner noted that the Veteran could perform sedentary work despite pain. An October 2015 private treatment record shows that the Veteran was seen for back pain. On physical examination of the back, he had good flexion with minimal back discomfort with leg raising and psoas flexion, bilaterally. At an October 2016 VA spine examination, the Veteran reported persistent back pain with activities that require prolonged sitting, standing, and walking. He had been followed in the pain clinic and described temporary relief of back pain and leg pain taking Vicodin. He reported flare-ups of back pain that was 10/10 level but he usually had a baseline level of back pain that is 8/10 level. He required frequent position changes to attempt to get comfortable and described increased back pain with lying in bed, forward bending, and lifting loads. On range of motion (ROM) testing, forward flexion was to 50 degrees, extension was to 10 degrees, right and left lateral flexion were to 20 degrees, and right and left lateral rotation were to 20 degrees. Pain was noted on examination, with forward flexion and extension, but did not cause functional loss. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing with 3 repetitions, with no additional limitation in ROM. The Veteran was not examined immediately after repetitive use over time or during a flare-up but the examiner indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or during a flare-up. There was no ankylosis of the spine. The Veteran occasionally used a wheelchair and a cane, and regularly used a walker. The examiner found that the Veteran could have problems in an occupational setting performing jobs that require physical work but he could tolerate work that fell in the sedentary duty ranges of physical demand. The examiner remarked that the ranges of motion during passive, active, and repetitive motions were the same and there was no limitation secondary to weakness, fatigability, incoordination, or flare-ups. There were no incapacitating episodes requiring overnight hospitalization or prescription of bed rest by a healthcare provider. The Veteran did not report episodes of loss of sensation, weakness in his limbs, balance problems, or disturbance in his bowel and bladder function. After consideration of the pertinent evidence of record, the Board concludes that a disability rating greater than 20 percent is not warranted for the Veteran’s lumbar spine disability. A review of the record shows that during the rating period on appeal, the Veteran’s lumbar strain has been manifested by a functional loss that more closely resembled forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. This level of impairment more closely corresponds to the criteria warranting a 20 percent rating. Here, the Board finds that there is no indication of forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine, to warrant a rating in excess of 20 percent. See 38 C.F.R. § 4.71a, General Rating Formula. Regarding the criteria for orthopedic manifestations under the General Rating Formula, considering pain, the Board finds that the Veteran’s forward flexion was at most limited to 50 degrees. Specifically, the Veteran was found to have forward flexion to 50 degrees at the October 2016 VA examination. He was noted to have good flexion in October 2015. The next higher 40 percent rating requires showing of forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Ankylosis is the “immobility and consolidation of a joint due to disease, injury, surgical procedure.” See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). Despite its pronounced symptomatology, the Veteran’s thoracolumbar spine retained some range of motion, with forward flexion greater than 30 degrees and no ankylosis of the thoracolumbar spine was shown. In making this determination, the Board considered any functional loss caused due to flare-ups of pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237; DeLuca v. Brown, 8 Vet. App. 202 (1995). Concerning this, the October 2016 VA examiner indicated that the ranges of motion during passive, active, and repetitive motions were the same and there was no limitation secondary to weakness, fatigability, incoordination, or flare-ups. Therefore, the Board believes the ROM findings noted on the October 2016 VA examination report represent the Veteran’s functional loss in the lumbar spine following repetitive use or during a flare-up. The examiner also noted that there was no evidence of pain with weight bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). As to the functional aspect of his back disability, the Veteran has reported pain with prolonged sitting, standing, walking, bending, or lifting loads. However, pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain indeed must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. However, as discussed above, the evidence of record does not show functional limitation greater than those noted on the VA examination is caused due to pain. Accordingly, a disability rating greater than 20 percent is not warranted on this basis. Consideration has been given to an increased rating for the Veteran’s lumbar spine disability under other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1995). Spine conditions may also be rated under Diagnostic Code 5243 for IVDS. The criteria for IVDS rates the disability according to the number of “incapacitating episodes” suffered per year. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An “incapacitating episode” is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). However, the October 2016 VA examination report specifically indicates that the Veteran does not have IDVS requiring bed rest. See 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5243. 6. Entitlement to an initial disability rating in excess of 20 percent for radiculopathy to the left lower extremity. 7. Entitlement to an initial disability rating in excess of 10 percent for radiculopathy to the right lower extremity. The February 2013 rating decision granted separate ratings for the Veteran’s right and left lower extremities as a neurological manifestation associated with his service-connected lumbar spine disability, from August 23, 2012, with a 10 percent rating for right lower extremity and a 20 percent for left lower extremity. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1); 38 U.S.C. § 4.124a, Diagnostic Codes 8620. The Veteran disagrees with these initial ratings assigned. Radiculopathy of the lower extremities is rated based on the degree of paralysis of the sciatic nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8620. Under this code, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve; a 60 percent rating is assigned for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, which contemplates foot dangles and drops, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Code 8620 refers to neuritis of the sciatic nerve, while Diagnostic Code 8720 refers to neuralgia of the sciatic nerve. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated in proportion to the impairment of motor, sensory, or mental function. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, and sensory disturbances. 38 C.F.R. § 4.120. The term “incomplete paralysis,” with respect to nerve injuries, indicates a degree of loss or impaired function substantially less than the type pictured for “complete paralysis” given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See id. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating to be assigned for neuralgia, usually characterized by a dull and intermittent pain of typical distribution so as to identify the nerve, will be that equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Turning to the evidence of record, the Board observes that VA treatment records from August 2012 to July 2017 reflect pain in the legs and feet. During the January 2013 VA spine examination, motor, sensory, and reflex examinations were normal, with no muscle atrophy. The Veteran had moderate constant pain, intermittent pain, and paresthesias and/or dysesthesias, and mild numbness in both lower extremities. The examiner indicated that the Veteran had radiculopathy that was mild in the right lower extremity and moderate in the left lower extremity. The Veteran underwent a VA peripheral nerves examination in October 2016. Muscle strength testing and reflex examination were normal with no muscle atrophy. Sensory examination revealed decreased sensation with thigh/knee (L3/4), lower leg/ankle (L4/L5/S1), and foot/toes (L5). The Veteran’s radicular symptoms consisted of moderate constant pain, intermittent pain, and paresthesias and/or dysesthesias, and mild numbness in both lower extremities. The Veteran displayed a slow, rigid gait pattern with minimal foot clearance of the floor, bilaterally. He reported problems with gait due to persistent bilateral knee pain, back pain, and fear of falling. He used a Rollator in the clinic for mobility but he stated he used a straight cane at home for short distances. The radiculopathy resulted in mild incomplete paralysis involving the L4/L5/S1/S2/S3 nerve roots (sciatic nerve) in both lower extremities. As detailed above, the medical evidence reflects the Veteran’s complaints of radiating pain, mild and numbness symptoms in the lower extremities, as well as evidence of decreased sensation in the thighs and slightly decreased motor function. The Veteran’s bilateral lower extremity symptoms are compatible with an incomplete paralysis of the sciatic nerves that is no more than mild in degree. Both the January 2013 and October 2016 VA examinations reported that muscle strength examinations were normal throughout. Further, no muscle atrophy was shown at any times. Additionally, the record lacks evidence of decreased reflexes or any organic changes resulting from the lower spinal disorder. Deep tendon reflexes were shown to be normal at all times. Other neurological symptoms have been intermittent, at times nonexistent. During the course of the appeal, the Veteran has reported pain and numbness his lower extremities. However, at the January 2013 VA examination, sensory examination was normal. Upon examination in October 2016, there was decreased sensation in the thigh/knee, lower leg/ankle, and foot/toes. Furthermore, the VA examiner in January 2013 characterized the Veteran’s radiculopathy as “mild” on the right side and “moderate” on the left side. The October 2016 VA examiner noted the Veteran’s radiculopathy resulted in mild incomplete paralysis involving the sciatic nerve roots in both lower extremities. Although this characterization of the severity of the Veteran’s radiculopathy is not dispositive or outcome-determinative, the Board attaches significant probative value to such characterization in this case as the reported examination findings are fairly consistent with mild radiculopathy of the lower extremities for the reasons explained above. Therefore, based on the absence of impaired motor strength or reflexes and wholly sensory deficits on examinations, the Board finds that the evidence supports a finding of no worse than mild, incomplete paralysis of the sciatic nerve of right lower extremity and no worse than moderate in left lower extremity during the entire course of the appeal. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. As such, a rating in excess of 10 percent is not warranted for radiculopathy of right lower extremity. A rating in excess of 20 percent is not warranted for left lower extremity as moderately severe incomplete paralysis of the sciatic nerve is not shown. If an exceptional case arises where a rating based on the disability rating schedule is found to be inadequate, consideration of an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). However, an extraschedular analysis is not required in every case. When extraschedular consideration is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted.” Yancy v. McDonald, 27 Vet. App. 484, 494 (2016); see also Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances to raise the extraschedular issue). Here, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND 8. Entitlement to service connection for a bilateral foot disability, to include as secondary to service-connected disabilities, is remanded. The Board remanded this claim in January 2015 to obtain a new VA opinion discussing the presumption of soundness and addressing whether the Veteran’s pes planus is a disease or defect if it is found to be congenital. Pursuant to the January 2015 Board’s remand, a medical opinion was obtained in October 2016. However, this VA medical opinion is inadequate and does not comply with the Board’s remand directive. Stegall v. West, 11 Vet. App. 268 (1998) (a previous remand confers upon the claimant, as a matter of law, the right to compliance with the remand orders). Concerning this, the VA examiner provided an opinion that it is not at least as likely as not that the Veteran’s congenital pes planus was permanently worsened by service beyond its natural progression. The VA examiner also opined that the Veteran’s foot condition in service was congenital pes planus and congenital conditions, by definition, occur at birth and not during or due to service. However, the examiner did not address the significance of the March 1979 in-service diagnosis of pes planus and the April 15, 2014 VA diagnosis of adult acquired bilateral flatfoot deformity as directed by the Board’s remand. The examiner also did not indicate whether the Veteran’s pes planus is a defect or disease. Given these deficiencies in the October 2016 VA medical opinion, a supplemental medical opinion is required to adequately decide the merits of the claim.   9. Entitlement to service connection for loss of bowel control is remanded. The Veteran is seeking service connection for loss of bowel control associated with his service-connected chronic lumbosacral strain. The record contains conflicting medical evidence as to whether the Veteran currently has loss of bowel control. Specifically, in a February 2011 VA treatment record, the Veteran complained of stool incontinence and VA treatment records dated December 2011 note chronic bowel incontinence. However, the January 2013 and October 2016 VA spine examination reports indicate that the Veteran did not have bowel problems; however, this seems to be inconsistent with the statements reporting bowel problems. As there is evidence of a potential bowel problem that was not considered by the most recent VA examiner, the Board finds it must remand the claim for a new examination ascertaining any bowel impairment. In addition, an opinion must be provided to specifically ascertain whether the Veteran’s bowel incontinence is secondary to any other service-connected disabilities, to include service-connected lumbar spine disability. 10. Entitlement to service connection for condition of skeletal system, to include neck, also claimed as arthritis of the neck and cervical spine and rheumatology, is remanded. The medical evidence of record shows the Veteran’s complaints of neck pain, the context of back pain radiating to the neck in November 2004 and April 2005. An April 2007 VA examination report notes that the Veteran’s back pain radiates to his shoulders and neck. In March 2009, C5-6 discogenic disease was diagnosed on magnetic resonance imaging (MRI) and history of cervical stenosis was noted in a May 2010 VA treatment record. Additionally, an October 2015 private treatment record shows the Veteran’s complaint of “back and neck pain from accident.” Based on the foregoing evidence, the Board finds that a VA examination is warranted to determine the secondary relationship between the Veteran’s claimed neck disability to his service/service-connected lumbar spine disability. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file any updated treatment records relating to the Veteran from the VA Medical Center in Hines, Illinois, and any associated outpatient clinics, dated from July 2017 to the present. 2. Thereafter, forward the Veteran’s claims file to an examiner of the appropriate expertise to obtain a medical opinion to determine the nature and etiology of the Veteran’s bilateral foot disability. The examiner must review the Veteran’s claim file and the examination report should indicate that the claims file was reviewed. If the examiner determines that another examination would be helpful, the Veteran should be scheduled for a examination. After reviewing the records, the examiner should provide an opinion as to (i) whether the Veteran’s pes planus is congenital, and (ii) if so, whether it is a defect or disease [Note: a disease generally refers to a condition that is considered capable of improving or deteriorating, while a defect is generally not considered capable of improving or deteriorating. VAOPGCPREC 82-90 (1990)]. In rendering this opinion, the examiner must consider and comment on the significance, if any, of the March 20, 1979 in-service diagnosis of adult acquired bilateral flatfoot deformity. IF IT IS A CONGENITAL DEFECT: Then explain whether it is at least as likely as not (a 50 percent or greater probability) that there was a superimposed injury or disease in service that resulted in an additional foot disability. IF IT IS A CONGENITAL DISEASE: Then state whether it is clear and unmistakable (obvious, manifest, and undebatable) that congenital pes planus preexisted active service. (a) If congenital pes planus preexisted active service, is it clear and unmistakable that it WAS NOT aggravated (permanently worsened beyond its natural progression) during the Veteran’s service; OR (b) Is it clear and unmistakable that any increase was due to the natural progression of the disease? (c) If any responses above are negative, is it at least as likely as not (50 percent or greater probability) that congenital pes planus manifested in or is related to the Veteran’s period of active service. A complete rationale should be provided for all opinions and conclusions, including a discussion of the facts and medical principles involved. 3. Schedule the Veteran for a VA examination to determine the likely etiology of his bowel incontinence disability. The Veteran’s claims file and any other pertinent records should be made available to the examiner. After review of the evidence, the examiner should determine whether the Veteran suffers from a bowel disorder. If so, the examiner should determine whether it is at least as like as not (50 percent or more probability) that his bowel incontinence is etiologically related to his active duty service. If the Veteran’s bowel incontinence is not etiologically related to his active duty service, then the examiner should determine whether it is at least as likely as not (50 percent or more probability) that the Veteran’s bowel incontinence is caused or aggravated by his service-connected chronic lumbosacral strain. The examiner should consider the lay statements of record along with the February and December 2011 VA treatment reports noting chronic bowel incontinence. A complete explanation for all opinions must be provided. 4. Schedule the Veteran for appropriate examination to determine the nature and etiology of his claimed cervical spine disability. The claims folder contents must be made available to the examiner for review. Following examination and review of the claims folder, the examiner is requested to address the following: Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed cervical spine condition had onset during service or is otherwise related to service. Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed cervical spine condition is proximately due to, or chronically aggravated by, a service-connected disability, specifically his service-connected chronic lumbosacral strain. Aggravation is defined as a permanent worsening beyond the natural progression of the disease. A complete rationale must be provided for any opinion stated, to include reference to current clinical findings and/or documents in the claims file. The examiner should review the claims folder and this fact should be noted in the accompanying medical report. 5. After completing the above development, and any other development deemed necessary, readjudicate the issues on appeal taking into consideration any newly acquired evidence. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. L. CHU Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. J. In, Counsel