Citation Nr: 18156283 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 14-21 249 DATE: December 7, 2018 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for congestive heart failure, to include as due to hypertension, is granted. Entitlement to an initial disability rating in excess of 10 percent for a lower back disability prior to May 20, 2014 is denied. Entitlement to a 40 percent disability rating for a lower back disability from May 20, 2014 to December 22, 2017 is granted. Entitlement to a disability rating in excess of 40 percent for a lower back disability from December 22, 2017 is denied. Entitlement to an initial compensable rating for cervical spine degenerative disc disease prior to February 11, 2016, is denied. Entitlement to a 10 percent disability rating for cervical spine degenerative disc disease from February 11, 2016 to December 21, 2017 is granted. Entitlement to a 20 percent disability rating for cervical spine degenerative disc disease from December 22, 2017 is granted. Entitlement to an initial disability rating in excess of 10 percent for a left knee strain with shin splints is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran currently has hypertension that had its onset during service. 2. The Veteran’s congestive heart failure is proximately due to the Veteran’s hypertension. 3. Prior to May 20, 2014, the Veteran’s lower back disability demonstrated forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. 4. From May 20, 2014, the Veteran’s lower back disability demonstrated forward flexion of the thoracolumbar spine less than 30 degrees. 5. For the period prior to February 11, 2016, the Veteran’s cervical spine degenerative disc disease demonstrated forward flexion, extension, and right and left lateral flexion of 45 degrees or greater, as well as right lateral rotation and left lateral rotation of 80 degrees or greater. 6. For the period from February 11, 2016 to December 21, 2017, the Veteran’s cervical spine degenerative disc disease was manifested by painful motion, loss of range of motion, functional loss, weakness and fatiguability. 7. For the period from December 22, 2017, the Veteran’s cervical spine degenerative disc disease demonstrated forward flexion greater than 15 degrees but not greater than 30 degrees. 8. For the entire period on appeal, the Veteran’s left knee strain with shin splints was manifested by painful motion. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for entitlement to service connection for congestive heart failure, to include as secondary to hypertension, have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.102, 3.310. 3. For the period prior to May 20, 2014, the criteria for a disability rating in excess of 10 percent for the Veteran’s lower back disability are not met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5242-5243 (2017). 4. For the period from May 20, 2014 to December 21, 2017, the criteria for a 40 percent disability rating for the Veteran’s lower back disability are met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242-5243. 5. For the period from December 22, 2017, the criteria for a disability rating in excess of 40 percent for the Veteran’s lower back disability are not met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242-5243. 6. For the period prior to February 11, 2016, the criteria for a compensable disability rating for Veteran’s cervical spine degenerative disc disease are not met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243. 7. For the period from February 11, 2016 to December 21, 2017, the criteria for a 10 percent disability rating for the Veteran’s cervical spine degenerative disc disease are met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243. 8. For the period from December 22, 2017, the criteria for a 20 percent disability rating for the Veteran’s cervical spine degenerative disc disease are met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243. 9. For the entire period on appeal, the criteria for a disability rating of 10 percent for the Veteran’s left knee strain with shin splints are not met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5268. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come to the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision that denied service connection for hypertension and congestive heart failure. It granted service connection for a left knee strain with shin splints and assigned a disability rating of 10 percent. It also granted service connection for lumbar osteoarthritis and granted a disability rating of 10 percent, and it granted service connection for cervical degenerative joint disease and assigned a noncompensable rating. The Veteran appealed these matters and, in a September 2017 decision, the Board remanded them in order to provide the Veteran with new VA examinations. It also remanded the matter of entitlement to a TDIU, which it determined was raised by the record pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). These matters now return to the Board for adjudication. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease that was incurred or aggravated during active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). In general, service connection requires: (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When a disability is initially diagnosed after separation from service and not within any applicable presumptive period, service connection may be granted if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic disease” in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With regard to hypertension, where a veteran served ninety days or more of active service and this condition becomes manifest to a degree of 10 percent or more within one year after the date of separation from such service, it shall be presumed to have been incurred in service, even though there is no evidence of it during the veteran’s period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In that instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence of record, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154(a); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must resolve reasonable doubt in favor of the veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for hypertension The Veteran asserts that he currently suffers from hypertension that had its onset during active duty service. The medical evidence of record indicates that the Veteran is currently diagnosed with hypertension. His service treatment records indicate that he experienced elevated blood pressure readings on multiple occasions throughout service, although no diagnosis of hypertension is noted. Such readings included those as high as 140/100, 130/98, 160/110, 150/100, 132/104, 140/96, and 195/75. In its September 2017 decision, the Board remanded this claim for a VA examination to discuss the etiology of the Veteran’s hypertension and to determine, specifically, whether it is linked to the elevated readings during service. In a January 2018 private examination that followed, the examiner found that the Veteran’s hypertension was at least as likely as not incurred in or otherwise related to his active duty service. He based this conclusion on the evidence of elevated blood pressure readings during service, the fact that there is no indication that the Veteran had hypertension prior to service, and the evidence of current, chronic and continuous treatment and care for hypertension. In assigning probative weight to a medical opinion, the Board must consider whether it is: (1) based on sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). It may also consider whether the examiner had access to the claims file, reviewed prior clinical records and pertinent evidence, and provided a thorough, detailed and definitive opinion supported by a detailed rationale. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The January 2018 opinion is adequate to address the Veteran’s claim. It is predicated on a review of the claims file and the medical records contained therein, it is based on a thorough in-person examination of the Veteran, and it contains an adequate medical opinion along with reasons and bases for the opinion rendered. Accordingly, it is entitled to great probative weight. Based on the foregoing, the Board finds that the requirements for service connection are met with regard to this matter and service connection for hypertension is, therefore, granted. 2. Entitlement to service connection for congestive heart failure, to include as secondary to hypertension The Veteran asserts that he suffers from congestive heart failure that is due to his hypertension. In a January 2018 examination, the examiner confirmed that the Veteran suffers from congestive heart failure and concluded that this condition is at least as likely as not proximately due to or the result of the Veteran’s hypertension. Specifically, he explained that the current severity of the Veteran’s hypertension warrants, by proximity, association of the claimed secondary congestive heart failure, and that this condition began subsequent to the Veteran’s hypertension and is the direct result of it. He noted that the medical literature supports this conclusion. As above, the January 2018 opinion is adequate to address the Veteran’s claim because it provides adequate reasons and bases for its opinion that is based on a review of the Veteran’s claims file and a thorough in-person examination. Accordingly, it is entitled to great probative weight. Based on the foregoing, the Board finds that service connection is established for the Veteran’s congestive heart failure, as secondary to his service-connected hypertension. Increased Ratings Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event. It may find that the preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 1. Entitlement to increased disability ratings for the Veteran’s lower back disability The Veteran’s lower back disability was rated under DC 5242 (degenerative arthritis of the spine) when it was classified as lumbar osteoarthritis prior to December 2017. It was rated under DC 5243 (invertebral disc syndrome) when the Veteran’s diagnosis changed to thoracolumbar spine arthritis with invertebral disc syndrome (IVDS). Both diagnostic codes are evaluated using the same of two rating formulas. They can either be evaluated according to the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or according to the Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episodes Formula). 38 C.F.R. § 4.71a, DC 5235-5243. Under the General Formula, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or for a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater that 235 degrees. It may also be assigned for muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or for a 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 for a combined range of motion not greater than 120 degrees. It can also be assigned if there are muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The General Formula applies for rating purposes with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease. When rating according to the General Formula, any associated objective neurologic abnormalities are rated separately under their respective diagnostic codes. See 38 C.F.R. § 4.71a, General Formula, Note (1). For the purposes of rating, 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. Thus, the normal combined range of motion for the thoracolumbar spine is 240 degrees. See 38 C.F.R. § 4.71a, General Formula, Note (2). The Veteran’s lower back disability can also be rated using the Incapacitating Episodes Formula under DC 5243. This formula allows for a 20 percent rating for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months; a 40 percent rating for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past twelve months; and a 60 percent rating for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243, Incapacitating Episodes Formula. For the purposes of this formula, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Incapacitating Episodes Formula, Note (1). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected body part. 38 C.F.R. § 4.40. Weakness is as important as limitation of motion; and, as such, a body part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is considered an important factor of joint disability, and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints in question are tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but it may result in functional loss if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In November 2012, the Veteran underwent a VA examination regarding his lower back. The examiner diagnosed the Veteran with lumbar osteoarthritis. The Veteran reported that it is sometimes hard to walk, but that he does not experience flare-ups. His forward flexion was measured at 70 degrees with painful motion at 70 degrees, and his extension was measured at 10 degrees with painful motion at 10 degrees. Other measurements included: right lateral flexion at 20 degrees with painful motion beginning at 20 degrees, left lateral flexion at 25 degrees with painful motion beginning at 25 degrees, right lateral rotation at 20 degrees with painful motion beginning at 20 degrees, and left lateral rotation at 20 degrees with painful motion beginning at 20 degrees. The Veteran was noted as experiencing functional impairment as indicated by less movement than normal and pain on movement; as well as localized tenderness or pain to palpation. In addition, he experiences guarding or muscle spasm of the thoracolumbar spine, but this does not result in abnormal gait or spinal contour. The examiner noted that the Veteran did not have IVDS and he does not use any assistive devices. Treatment notes indicate that, in 2013, the Veteran reported pain that radiated from his lower back through his leg. He described it as “almost unbearable.” A range of motion chart dated May 20, 2014, shows that the Veteran’s back on passive motion was measured “0-25” with regard to extension, right and left lateral bending, and right and left lateral rotation. His flexion is noted as measuring at “0-2.” It appears as though a second digit was mistakenly left out of this measurement. It is reasonable to assume that the correct notation is either “0-20” or “0-25.” The Veteran’s back condition was evaluated by another VA examiner in December 2017. At that time, the examiner diagnosed the Veteran with invertebral disc syndrome as well as lumbar osteoarthritis. He noted that the Veteran experiences flare-ups that involve pain shooting down his legs on a daily basis to a severe degree for 30 minutes, and that he experiences functional loss in the form of difficulty walking due to pain, inability to bend over, and disturbance of sleep. The Veteran’s forward flexion was measured at 0 to 30 degrees, while his extension was measured at 0 to 15 degrees. His right lateral flexion and rotation were measured at 0 to 15 degrees, but the examiner was unable to test the Veteran’s left lateral flexion and rotation because of pain. He noted that the Veteran is limited in bending, stooping, pushing, pulling, carrying and lifting moderate objects. The examiner also noted localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. In addition, he found that the Veteran does not suffer from ankylosis, but he does have IVDS with no incapacitating episodes. Based on the foregoing, the Board finds that the Veteran’s lower back disability demonstrated forward flexion of the thoracolumbar spine of 30 degrees or less since May 20, 2014 and, as such, it meets the criteria for a 40 percent rating since that date. A 50 percent rating is not warranted because the Veteran did not experience unfavorable ankylosis of the entire thoracolumbar spine. Prior to May 20, 2014, the Veteran’s condition demonstrated forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees and, as such, it meets the criteria for a 10 percent rating. A 20 percent rating is not warranted because the Veteran did not experience forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or a combined range of motion not greater than 120 degrees. In addition, the Veteran did not experience muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. The Board has considered the Veteran’s back disability under DeLuca, given the Veteran’s report of experiencing flare-ups of pain and the objective evidence of painful motion. In addition, as noted, the evidence shows that the Veteran experiences some degree of functional impairment due to his lower back disability. However, the Board finds that any functional impairment experienced by the Veteran is adequately contemplated by the ratings currently assigned, as they are based upon objective findings of painful, limited motion, and the functional impairment caused thereby. There is no lay or medical evidence of record that shows the Veteran’s condition results in any additional impairment beyond what is contemplated by the current ratings. Accordingly, entitlement to a disability rating in excess of 10 percent for the Veteran’s lower back disability is denied for the period prior to May 20, 2014. A rating of 40 percent, but no greater, is granted for the period from May 20, 2014 to December 22, 2017. A rating in excess of 40 percent for the period from December 22, 2017 is denied. 2. Entitlement to an initial compensable disability rating for cervical spine degenerative disc disease The Veteran’s cervical spine degenerative disc disease is rated under DC 5243 (invertebral disc syndrome). This diagnostic code is evaluated using the same two rating formulas already explained above; however, the measurements that are used to determine the level of disability are different. 38 C.F.R. § 4.71a, DC 5235-5243. Under the General Formula, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or for a combined range of motion greater than 170 degrees but not greater that 335 degrees. It may also be assigned for muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or for a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned when forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees, or the combined range of motion is not greater than 170 degrees. It can also be assigned if there are muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 30 percent rating is warranted when there is forward flexion of the cervical spine that is 15 degrees or less, or where there is favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. For the purposes of rating disabilities of the cervical spine, normal forward flexion, extension, and left and right lateral flexion of the cervical spine are zero to 45 degrees. Left and right lateral rotation are zero to 80 degrees. Thus, the normal combined range of motion for the cervical spine is 340 degrees. See 38 C.F.R. § 4.71a, General Formula, Note (2). The Veteran’s cervical spine, as with the thoracolumbar spine, can also be rated using the Incapacitating Episodes Formula under DC 5243 explained above. In November 2012, the Veteran was provided a VA examination regarding his cervical spine. The examiner diagnosed the Veteran with cervical degenerative disc disease. His forward flexion, extension, and right and left lateral flexion were measured at 45 degrees or greater with no objective evidence of painful motion. Similarly, his right lateral rotation and left lateral rotation were measured at 80 degrees or greater with no objective evidence of painful motion. The examiner noted no functional loss, no localized tenderness or pain to palpation for joints or soft tissue of the cervical spine, and no guarding or muscle spasm of the cervical spine. The Veteran’s treatment records show that, as late as April 2014 and September 2014, the Veteran denied neck pain. In May 2014, the Veteran’s range of motion for his neck measured the same as at his November 2012 examination, and the examiner noted his range of motion as “normal.” In October 2014, however, the Veteran was diagnosed with neck pain and cervical spine degeneration with disc spur complexes. By November 2014, the Veteran, in response to a nervousness and anxiety questionnaire that asked whether he experiences headaches, neck and back pain, answered “most or all of the time.” Medical records from March 2015 confirm that the Veteran sought treatment for multilevel degenerative changes and neck pain, and that he was diagnosed with cervical spine stenosis. In February 2016, the Veteran saw his doctor for chronic neck pain, and he reported that his pain was worse in the morning and worse with any neck movement (flexion, extension, lateral rotation). The doctor noted also that the Veteran saw two spine surgeons in the last year and discussed surgery. In July 2016, the Veteran is noted as experiencing chronic neck pain, and that trigger point injections have been helpful. In February 2017, the Veteran reported that his neck pain increased and that he continued to have trigger point injections to help the pain. In December 2017, the Veteran’s cervical spine condition was reexamined. The examiner confirmed the Veteran’s cervical degenerative disc disease diagnosis and added that the Veteran has IVDS of the cervical spine that does not result in incapacitating episodes. The examiner noted that the Veteran experiences flare-ups during which his neck will lock and stiffen, making it difficult for him to move his head. The Veteran’s forward flexion was measured at 0 to 25 degrees, his extension was measured at 0 to 45 degrees. Other measurements include the Veteran’s right lateral flexion at 0 to 35 degrees, left lateral flexion at 0 to 25 degrees, right lateral rotation at 0 to 50 degrees and left lateral rotation at 0 to 45 degrees. The examiner noted pain on examination that causes functional loss, mild paraspinal tenderness to the left side of the neck, no guarding, no localized tenderness, guarding or muscle spasm of the cervical spine, and no ankylosis. Based on the foregoing, the Board finds that prior to February 11, 2016, a compensable rating is not warranted. The medical evidence of record does not reveal forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, nor does it show a combined range of motion greater than 170 degrees but less than 335 degrees. As noted above, when rating disabilities of the musculoskeletal system, VA must consider whether a higher rating is warranted to account for functional loss due to pain, weakened movement, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 202. In this regard, on February 11, 2016, the Veteran’s doctor reported that the Veteran experiences neck pain that is worse in the morning and worse with any neck movement (flexion, extension, lateral rotation). He noted also that the Veteran saw two spine surgeons in the last year and discussed surgery. As such, a rating of 10 percent is warranted based on functional loss due to pain for the period from February 11, 2016 to December 22, 2017. As for the period from December 22, 2017, the Board finds that a 20 percent disability rating is warranted. On that date, the Veteran’s VA examination revealed that the Veteran’s neck disability demonstrates forward flexion of no more than 25 degrees. As mentioned above, a 20 percent rating is appropriate when forward flexion is greater than 15 degrees but not greater than 30 degrees. A 30 percent rating is not warranted because the Veteran’s condition does not demonstrate forward flexion of the cervical spine at 15 degrees or less or favorable ankylosis of the entire cervical spine. The Board has considered the cervical spine disability under DeLuca for the period from December 22, 2017. However, the Board finds that any functional impairment experienced by the Veteran is adequately contemplated by the ratings currently assigned, as they are based upon objective findings of painful, limited motion, and the functional impairment caused thereby. There is no lay or medical evidence of record that shows the Veteran’s condition results in any additional impairment beyond what is contemplated by the current ratings. Therefore, the Board finds that, for the period prior to February 11, 2016, the Veteran’s claim for a compensable rating for cervical spine degenerative disc disease is denied. However, for the period from February 11, 2016 to December 21, 2017, a 10 percent rating is granted; and for the period from December 22, 2017, a disability rating of 20 percent is also granted. 3. Entitlement to an initial rating in excess of 10 percent for a left knee strain with shin splints The Veteran is currently rated at 10 percent for a left knee strain with shin splits under DC 5260. Pursuant to DC 5260, disability ratings are assigned based on the degree of limitation of motion caused by the knee condition in question. For reference, the normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Under DC 5260, limitation of flexion of a leg to 60 degrees warrants a zero percent rating. A 10 percent rating requires that flexion be limited to 45 degrees, a 20 percent rating requires that flexion be limited to 30 degrees, and a 30 percent rating is warranted when flexion is limited to 15 degrees. Regarding limitation of extension, a noncompensable rating is assigned when extension is limited to 5 degrees. Under DC 5261, which measures limitation of extension, a 10 percent rating requires that extension be limited to 10 degrees, a 20 percent rating requires that extension be limited to 15 degrees, a 30 percent rating requires that extension be limited to 20 degrees, a 40 percent rating requires that extension be limited to 30 degrees, and a 50 percent rating requires that extension be limited to 45 degrees. As with the disabilities described above, when evaluating joint disabilities rated on the basis of limitation of motion, including for disabilities of the knee, the Board must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and when those factors are not contemplated by the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca, 8 Vet. App. 202. 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, 1 Vet. App. at 592. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, 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. 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, the Board must determine the overall functional impairment due to these factors. The Veteran is currently assigned the minimum compensable evaluation of 10 percent based on painful motion of the knee pursuant to 38 C.F.R. § 4.59 and malunion of the tibia and fibular with slight knee disability. At his September 2012 VA examination, the Veteran was diagnosed with a left knee strain and shin splints. He did not report flare ups. His left knee flexion was measured at 130 degrees with objective evidence of painful motion beginning at 130 degrees. His left knee extension was measured at 0 degrees or any degree of hyperextension and there was no objective evidence of painful motion. The examiner noted no additional limitation in range of motion of the knee following repetitive use testing and no functional loss or functional impairment. No arthritis or patellar subluxation was identified. Nevertheless, the Veteran reported pain around the left knee cap that had gotten worse. The Veteran’s knee disability was reassessed in January 2018. At that time, the Veteran’s diagnosis of a left knee strain with shin splints was confirmed. The Veteran’s flexion was measured at 0 to 110 degrees and his extension was measured at 110 to 0 degrees. The examiner noted pain on examination that causes functional loss, and moderate tenderness to the anterior knee. He also noted that the Veteran is limited in running, kneeling, crawling, squatting, and high impact activities. In addition, the Veteran experiences left knee pain, but he cannot tell if it is the pain is from the shin splints or the nerve. The pain is sharp, such that the Veteran needs to sit and rest when pain flares up. The Veteran uses a cane to walk and he must brace himself so that he does not fall when he feels sudden pain. These flare ups take place daily to a moderate or severe degree and they last four to five minutes. The Veteran is also noted as experiencing functional loss such that he has difficulty to walk and a risk of falling. He is unable to stand or walk for than 50 yards without pain. Finally, the examiner noted no ankylosis or subluxation. With regard to the Veteran’s shin splints, the examiner noted that this condition does not affect the range of motion of the knee. The Board notes that treatment records from 2017 indicate that the Veteran may suffer from osteoarthritis in his knees, but following the Veteran’s January 2018 VA examination, the examiner noted that x-rays of both knees were conducted and they were both “normal.” Based on the foregoing, the Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent because his range of motion is not limited to the extent required for a 20 percent rating. Specifically, his flexion is not limited to 30 degrees (required for a 20 percent rating under DC 5260) and his extension is not limited to 15 degrees (required for a 20 percent rating under DC 5261). Rather, his limitation of motion was measured, at its worst, at 110 degrees, and this far exceeds the requirements for any compensable ratings under these diagnostic codes. However, the Veteran has consistently complained of limitation of motion due to pain throughout the appeal period. Accordingly, he continues to be entitled to a 10 percent rating on this basis, as 10 percent is the minimum compensable rating available for limitation of motion of the knee. 38 C.F.R. § 4.59. The Board notes the Veteran’s assertion that his shin splints should be rated separately from his left knee strain. However, as explained above, the examiner specifically noted in his report that the Veteran’s shin splints do not affect the range of motion of the knee. In addition, he remarked that he is unable to tell if the pain the Veteran experiences is from shin splints or the nerve. As for any pain that the Veteran experiences due to his shin splints, the Veteran is already being compensated for pain as described above. In considering the applicability of other diagnostic codes, the Board finds that DC 5256 (ankylosis of the knee), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum) are not applicable in this case because the evidence does not show that the Veteran has any of these conditions. Specifically, the Veteran’s VA examinations specifically state that the Veteran does not have ankylosis of the left knee. Additionally, the evidence, including treatment records and VA examination, fails to demonstrate any findings of genu recurvatum or any impairment of the tibia and fibula. Therefore, the Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent for a left knee strain with shin splints, and the Veteran’s claim is denied. REASONS FOR REMAND Entitlement to a TDIU is remanded. In its September 2017 decision, the Board noted that the issue of a TDIU was raised by the record and it remanded this issue to the regional office (RO) because it was inextricably intertwined with other matters that had not yet been adjudicated. On remand, appropriate notice was sent to the Veteran regarding this claim and the Veteran was prompted to complete a VA Form 21-8940 Application for Increased Compensation Based on Unemployability. Although the Board sincerely regrets the additional delay, this matter must be remanded once again for further development. The record shows that the Veteran’s claim for service connection for traumatic brain injury (TBI) (claimed as “head trauma”) is still being adjudicated by the RO. Consideration of entitlement to a TDIU depends, in part, on the impact that the Veteran’s TBI has on his ability to obtain or retain substantially gainful employment. Accordingly, the matter of a TDIU is inextricably intertwined with this claim not presently before the Board and remand of the TDIU claim is, therefore, required. Harris v. Derwinski, 1 Vet. App. 180 (1991). Moreover, the Board notes that the Veteran completed two VA Forms 21-8940 in March 2018 and December 2017 but he did not include the names of any of his previous employers. Records from the Social Security Administration disclose that the Veteran left his job in 2012 because his employer put him “on disability.” On remand, the nature of the Veteran’s previous employment should be verified. The matters are REMANDED for the following action: 1. Give the Veteran another opportunity to complete a VA Form 21-8940. When the application is completed and returned, verify the nature of the Veteran’s employment history, work schedule, and income consistent with the procedures outlined in the M-21 VA Adjudication Procedure Manual. 2. Then review the expanded record and adjudicate the claim for a TDIU. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Freda J. F. Carmack, Associate Counsel