Citation Nr: 18156745 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 17-10 975A DATE: December 10, 2018 ORDER Service connection for bilateral pes planus is denied. The reduction of the 20 percent disability rating to 10 percent for left knee chondromalacia (left knee disability) was not proper, and restoration of the 20 percent rating for the left knee disability effective from July 1, 2014, is granted. A higher (compensable) initial disability rating for right knee surgical scars for the entire rating period is denied. An increased disability rating higher than 30 percent for residuals of right knee torn meniscus with chondromalacia (right knee disability) is denied. An initial disability rating higher than 70 percent for adjustment disorder with mixed anxiety and depressed mood (psychiatric disability) for entire rating period is denied. An initial disability rating higher than 10 percent for lumbar degenerative disc disease with spondylosis (back disability) is denied. An initial disability rating higher than 10 percent for right lower extremity radiculopathy is denied. An effective date earlier than July 1, 2014 for the award of a 30 percent rating for the right knee disability is denied. FINDINGS OF FACT 1. The Veteran sustained a foot injury and was treated for foot diseases during service; no pes planus symptoms were manifested during service; pes planus was manifested many years after service and is not causally or etiologically related to service. 2. A July 2014 rating decision reduced the rating for the service-connected left knee disability from 20 percent to 10 percent, effective July 1, 2014; the overall disability rating was unchanged after the rating reduction; as of July 1, 2014, the 20 percent rating for the service-connected left knee disability had been in effect for more than five years; at the time that the reduction in the disability rating was effectuated, the service-connected left knee disability had not undergone sustained improvement under the ordinary conditions of life and work. 3. For the entire rating period from July 1, 2014, the evidence shows that the right knee surgical scars were manifested by two well-healed, superficial scars one centimeter linear to the anterior right knee with no erythema, edema, or keloid formation, no pain on palpation or skin breakdown, normal sensation, normal skin texture, and no limitation of motion or function caused by the scars. 4. For the entire rating period from July 1, 2014, the right knee disability was manifested by pain and knee flexion limited to 90 degrees and knee extension limited to 20 degrees, with no ankylosis. 5. For the entire rating period from August 2, 2013, the service-connected psychiatric disability was manifested by symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, speech intermittently illogical, obscure, or irrelevant, and disturbances of mood, as well as a history of divorce after a 21-year marriage and a current girlfriend of 10 years and having lived together for many years, and unemployment since a 2002 TBI with residual mild cognitive impairment and due to a combination of orthopedic and mental problems. 6. For the entire rating period from April 30, 2009, the back disability was manifested by forward flexion limited no more than 70 degrees and a combined range of motion of 210 degrees, with flare-ups four to five times per year, low back tenderness on palpation, no muscle spasms, normal gait and posture, and treated with muscle relaxants and acetaminophen. 7. For the entire rating period from April 30, 2009, the evidence shows that right lower extremity radiculopathy was manifested by intermittent pain and decreased sensation without any muscle or motor deficit. 8. The VA examination report dated on July 1, 2014 showed right knee extension limited to 20 degrees and created an informal claim for an increased rating for the right knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral pes planus are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The reduction of the disability rating for the service-connected left knee disability from 20 percent to 10 percent was not proper, and the 20 percent disability rating is restored effective July 1, 2014. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Code (DC) 5257. 3. The criteria for an initial compensable rating for the right knee surgical scars are not met or approximated for any period from July 1, 2014. U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, DC 7805. 4. The criteria for an increased disability rating higher than 30 percent for the service-connected right knee disability are met for the entire rating period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5261. 5. The criteria for an initial disability rating higher than 70 percent for the service-connected psychiatric disability have not been met for the entire rating period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, DC 9499-9413. 6. The criteria for an initial disability rating higher than 10 percent for the service-connected back disability have not been met or approximated for the entire rating period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243. 7. The criteria for an initial disability rating higher than 10 percent for right lower extremity radiculopathy are not met or approximated for the entire rating period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.27, 4.124a, DC 8520. 8. The criteria for an effective date earlier than July 1, 2014 for the grant of a 30 percent rating for the right knee disability have not been met. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400 (o)(2). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service in the U.S. Marine Corps from December 1971 to September 1976. This matter is on appeal from June 2014, July 2014, May 2015, and June 2015 rating decisions. In this case, the Board finds that the duties to notify and assist have been satisfied. Neither the Veteran nor the evidence has raised any specific contentions regarding the duties to notify or assist. Service Connection Legal Authority Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a direct basis when there is competent, credible evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Holton v. Shinseki, 557 F. 3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303(a), (d). Service connection may be established on a presumptive basis for chronic diseases listed under 38 C.F.R. § 3.309(a) if chronic symptoms of the disease were shown in service; the disease was manifested to a compensable degree with a presumptive period, usually one year after service separation; or continuous symptoms of the disease were manifested since service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.33(b), 3.307, 3.309(a); see also Walker v. Shinseki, 708 F. 3d 1131 (Fed. Cir. 2013). Because the current diagnosis of bilateral pes planus is not listed as a chronic disease under 38 C.F.R. § 3.303(b), the presumptive service connection provisions are not applicable. 1. Service Connection Analysis for Bilateral Pes Planus The Veteran contends that bilateral pes planus (i.e., flat feet) is causally related to service. Flat foot is defined as a condition in which one or more of the arches of the foot have been lowered and flattened out; therefore, it is a condition capable of lay diagnosis. See Dorland's Illustrated Medical Dictionary 709 (30th ed. 2003). After review of all the lay and medical evidence of record, the Board finds that the Veteran sustained a foot injury and was treated for foot diseases during service; however, the weight of the evidence is against finding that pes planus was manifested during service. The Veteran's service treatment records, which are complete, show treatment for several foot problems during service such as athlete’s feet in January 1972, an ingrown toenail in February 1973, and a cut on left foot in April 1975; however, there was no report, complaint, diagnosis, or treatment of pes planus, or symptoms related thereto, during service. At the November 1975 service examination performed less than a year before service separation, the feet were clinically evaluated as normal. Because the service treatment records are complete, the Veteran received in-service treatment for the aforementioned foot problems with no report, indication, or mention of pes planus, and the feet were clinically evaluated at the November 1975 service examination and determined to be normal, the Board finds that pes planus is a condition that would have ordinarily been recorded during service, if it had been present; therefore, the lay and medical evidence contemporaneous to service is of significant probative value and weighs against a finding of pes planus or pes planus symptoms during service. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803 (7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded). The weight of the evidence is against finding that pes planus is otherwise causally or etiologically related to service. The November 1976 VA examination performed approximately two months after service separation specifically noted that no abnormalities of the feet were then demonstrated, which provides additional evidence against finding that pes planus was manifested during service. Rather, the evidence suggests that pes planus symptoms were first manifested in 1984 (i.e., 13 years after service separation). See August 1999 private treatment record (noting that the Veteran reported that he had been fitted for four different orthotics over the past 15 years). Considered together with the lay and medical evidence contemporaneous to service and shortly after service separation showing no pes planus or pes planus symptoms, the approximate 13-year period between service separation in 1971 and the onset of pes planus symptoms approximately in 1995 is an additional factor that weighs against service incurrence. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Although the Veteran has asserted that pes planus is causally related to service, he is a lay person and does not have the requisite medical training or credentials to be able to render an opinion regarding the cause of pes planus under the specific facts of this case, which show no in-service pes planus symptoms, negative findings at the November 1975 service examination and November 1976 VA examination, and documented post-service onset of pes planus symptoms approximately 13 years after service. A competent opinion on the likely etiology of pes planus would require knowledge of foot disabilities and their development and progression. For these reasons, the Veteran's unsupported lay opinion is of no probative value. Thus, the weight of the evidence is against a finding that pes planus was caused by active service. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the appeal of service connection for pes planus; consequently, the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Rating Reduction Criteria and Restoration Analysis In July 2014, the RO reduced the 20 percent rating for the service-connected left knee disability to 10 percent, effective July 1, 2014. Because the rating reduction decision did not affect the Veteran's overall disability rating, the due process protections of 38 C.F.R. § 3.105(e) do not apply. VAOPGCPREC 71-91 (Nov. 1991); Stelzel v. Mansfield, 508 F.3d 1345, 1347-49 (Fed. Cir. 2007). The Board will now consider the propriety of the rating reduction. At the time the reduction became effective, July 1, 2014, the 20 percent rating for the left knee disability had been continuously in effect for more than five years. As such, the provisions of 38 C.F.R. § 3.344(a) and (b) are applicable. In this regard, the rating may be reduced only if the examination upon which the reduction is based is at least as full and complete as the examination used to establish the prior higher evaluation. A rating that has been in effect for more than five years will not be reduced on any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. A rating reduction is not proper unless the Veteran’s disability shows actual improvement in his or her ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 349 (2000). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated (although post-reduction medical evidence may be considered in the context of considering whether actual improvement was demonstrated). Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). The Veteran need not demonstrate that retention of the higher evaluation is warranted; rather, it must be shown by a preponderance of the evidence that the reduction was warranted. See Brown v. Brown, 5 Vet. App. 413, 418 (1993). The question of whether a disability has improved involves consideration of the applicable rating criteria. The question of whether a disability has improved involves consideration of the applicable rating criteria. At the time of the rating reduction, the left knee disability had been rated under the criteria found at 38 C.F.R § 4.71a, DC 5257 for other impairment of the knee. DC 5257 provides for a 10 percent rating when there is evidence of slight impairment of the knee manifested by recurrent subluxation or lateral instability, a 20 percent rating for moderate impairment of the knee manifested by recurrent subluxation or lateral instability, and a 30 percent rating for severe impairment of the knee manifested by recurrent subluxation or lateral instability. 38 U.S.C. § 4.71a. In this case, the Board finds that the weight of the evidence does not demonstrate sustained improvement of the left knee disability under the ordinary conditions of life and work at the time of the reduction; therefore, the rating reduction was not proper, and the criteria for restoration of a 20 percent rating for the left knee disability, effective from July 1, 2014, are met. Historically, in the August 2002 rating decision, the RO increased the disability rating for the left knee disability from 10 percent to 20 percent rating under DC 5260 effective from August 21, 2001 based evidence of left knee chondromalacia patella with internal derangement manifested by pain, a slight (noncompensable) loss of range of motion on flexion (i.e., flexion limited to 120 degrees), minimal hypertrophic spurring and calcification, a positive McMurray’s test with negative valgus and varus stress testing and drawer’s sign, and magnetic resonance imaging (MRI) evidence of a horizontal tear of the posterior horn on the lateral meniscus and thinning of the patellar cartilage near the apex and small joint effusion. The RO found that the symptoms and impairment associated with the left knee disability approximated moderate impairment of the knee manifested by recurrent subluxation or lateral instability, so that a 20 percent schedular rating under DC 5257 was warranted. At the time of the rating reduction decision in July 2014, the evidence showed that the rating criteria for a 20 percent schedular rating under DC 5258 for the left knee disability were approximated. The July 2014 VA examination report showed that the left knee disability was manifested by reported symptoms of constant pain, locking, popping, and grinding, left knee flexion limited to 120 degrees and left knee extension limited to 5 degrees after consideration of Deluca factors, meniscal tear with frequent episodes of joint pain and frequent episodes of joint effusion, and no left knee instability demonstrated during anterior instability, posterior instability, and medial-lateral instability testing. The July 2014 VA examiner also noted that the last MRI showed a torn lateral meniscus on the left. When compared to the evidence of record when the 20 percent rating was initially awarded for the left knee disability in August 2002, the probative evidence at the time of the rating reduction did not show a sustained improvement of the left knee disability. Rather, the relevant findings at the July 2014 VA examination are essentially unchanged from the findings at the March 2002 VA examination. The Board also notes that the July 2014 VA examination report showed left knee meniscal tear with episodes of locking and frequent episodes of joint pain and effusion, and DC 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; therefore, the 20 percent rating criteria under DC 5258 for the right knee disability are also approximated. Although the Board notes that October 2013 VA examination findings suggested some improvement of left knee flexion and, the October 2013 VA examination report was not adequate for rating purposes because it inaccurately noted that the left knee had no current or past meniscus condition. In consideration thereof, the Board finds that the weight of the evidence does not establish sustained improvement in the service-connected left knee disability, including under the ordinary conditions of life and work. Because the burden of proof is on VA to establish that a reduction is warranted by the weight of the evidence, and the weight of the evidence of record in this case shows no sustained improvement in the left knee disability at the time of the July 2014 rating reduction decision, the Board finds that the reduction of the 20 percent rating to 10 percent rating effective from July 1, 2014, was not proper; therefore, restoration of the 20 percent disability rating is warranted. Disability Rating Legal Authority Disability ratings are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. 3. Initial Rating Analysis for Right Knee Surgical Scars For the entire initial rating period (from July 1, 2014), the right knee surgical scars have been rated at 0 percent under the criteria found at 38 C.F.R § 4.118, DC 7805. Under DC 7805, other scars and other effects of scars rated under DCs 7800, 7801, 7802, and 7804 are to be rated based on disabling effects not considered in a rating provided under DCs 7800-7804 under the appropriate diagnostic code. 38 C.F.R. § 4.118. After review of all the lay and medical evidence, the Board finds that the evidence weighs against finding that the criteria for an initial compensable rating under DC 7805 are met or approximated for the entire rating period. Throughout the rating period, the evidence shows that the right knee surgical scars were manifested by two well-healed, superficial scars one centimeter linear to the anterior right knee with no erythema, edema, or keloid formation, no pain on palpation or skin breakdown, normal sensation, normal skin texture, and no limitation of motion or function caused by the scars. See July 2014 VA examination report. Because the evidence shows two well-healed, superficial, and linear right knee scars measuring 1 centimeter that are asymptomatic and cause no functional impairment, an initial compensable rating under DC 7805 for the right knee surgical scars is not warranted for any period. 4. Increased Rating Analysis for Right Knee Disability For the entire increased rating period (from July 1, 2014), the right knee disability has been rated at 30 percent under the criteria found at 38 C.F.R § 4.71a, DC 5261. DC 5261 provides for assignment of a 0 percent rating for extension limited to 5 degrees, a 10 percent rating for extension limited to 10 degrees, a 20 percent rating for extension limited to 15 degrees, a 30 percent rating for extension limited to 20 degrees, a 40 percent rating for extension limited to 30 degrees, and a 50 percent rating for extension limited to 45 degrees. 38 C.F.R. § 4.71a. DC 5260 provides for a 0 percent rating when there is flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Normal range of motion for the knee is from 140 degrees flexion to 0 degrees extension. 38 C.F.R. § 4.71, Plate II. After review of all the lay and medical evidence of record, the Board finds that the evidence weighs against finding that the criteria for an increased rating higher than 30 percent under DC 5261 for the right knee disability are met for the entire rating period. At the July 2014 VA examination, right knee flexion was limited to 90 degrees and right knee extension was limited to 20 degrees after consideration of Deluca factors such as pain; therefore, an increased rating higher than 30 percent under DC 5261 for the right knee disability based on limitation of knee extension is not warranted. Because there is no limitation of right knee flexion to a compensable degree (10 percent), a separate rating for right knee limitation of flexion under DC 5260 is not warranted. See VAOPGCPREC 9-2004. Because the evidence for the entire rating period shows no right knee ankylosis, a stable right knee, no current dislocation of semilunar cartilage for the right knee, and no right knee genu recurvatum, DC 5256 (ankylosis), DC 5257 (impairment of the knee manifested by recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint), and DC 5263 (genu recurvatum) are not applicable. Although there is a history of removal of semilunar cartilage, the only residual symptom of right knee pain is already contemplated in the 30 percent rating under DC 5261 so the Board is precluded from assigning a separate 10 percent rating under DC 5259 (removal of symptomatic semilunar cartilage) for the same symptomatology. 38 C.F.R. § 4.14 (avoidance of pyramiding). 5. Initial Rating Analysis for Psychiatric Disability For the entire initial rating period from August 2, 2013, the psychiatric disability has been rated at 70 percent under the criteria at 38 C.F.R. § 4.130, DC 9499-9413 for a condition analogous to an unspecified anxiety disorder. Psychiatric disabilities are rated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 70 percent rating is provided when there is evidence that the psychiatric disability more closely approximates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 100 percent rating requires evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Effective August 4, 2014, VA revised the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). Global Assessment of Functioning (GAF) scores are inapplicable to psychiatric rating cases where the DSM-5 applies, such as in this case. See Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. February 23, 2018). After review of all the lay and medical evidence, the Board finds that the weight of the evidence is against finding that the criteria for a rating higher than 70 percent for the service-connected psychiatric disability are met or approximated for any period. The June 2014 VA examination report shows a psychiatric disability picture manifested by symptoms of depressed mood with long-standing depression, anxiety, chronic sleep impairment, mild memory loss, speech that is intermittently illogical, obscure, or irrelevant, and disturbances of mood, as well as a history of divorce after a 21-year marriage and a live-in girlfriend of many years, regular church attendance multiple times per week, and unemployment since a 2002 TBI with residual mild cognitive impairment and due to a combination of orthopedic and mental problems. The May 2015 VA examination report similarly reveals a psychiatric disability picture manifested by symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, speech intermittently illogical, obscure, or irrelevant, and disturbances of mood, as well as a history of divorce after a 21-year marriage and a current girlfriend of 10 years and having lived together for four years, and unemployment since a 2002 TBI with residual mild cognitive impairment and due to a combination of orthopedic and mental problems. The treatment records relevant to the rating period do not contain findings showing that psychiatric symptoms and impairment are more severe than reflected in the VA examination reports. The demonstrated psychiatric symptoms and impairment throughout the rating period are specifically contemplated by the 70 percent schedular rating criteria. The evidence does not show that psychiatric symptoms were of the frequency, severity, and duration contemplated by the schedular criteria for the 100 percent rating or that psychiatric symptoms cause total occupational and social impairment at any time during the rating period. Specifically, there is no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name for any portion of the period. There are no psychiatric symptoms of similar frequency severity, and duration for any period. Although there is some occupational and social impairment due to the psychiatric disability, no total occupational and social impairment due to psychiatric symptoms is demonstrated. The June 2014 and May 2015 VA examiners both opined that the psychiatric disability was not severe enough to have caused total occupational impairment during the period. Also, there was no total social impairment as evidenced by the Veteran’s long-term relationship with his live-in girlfriend during the period. In consideration thereof, the Board finds that the overall disability picture for psychiatric disability is more consistent with the 70 percent schedular rating criteria, not the rating criteria for 100 percent. 6. Initial Rating Analysis for Back Disability For the entire initial rating period from April 30, 2009, the back disability has been rated at 10 percent under the criteria at 38 C.F.R. § 4.71a, Diagnostic Code 5242 for degenerative arthritis of the spine; however, given the diagnosis of degenerative disc disease, the Board finds that the back disability is more appropriately rated under DC 5243 for intervertebral disc syndrome (IVDS). See VBA Training Letter 02-04 (October 24, 2002) (noting that IVDS may be referred to as slipped, herniated, ruptured, prolapsed, bulging, or protruded disc, degenerative disc disease (DDD), sciatica, discogenic pain syndrome, herniated nucleus pulposus, pinched nerve, etc.). Under the rating schedule, IVDS (preoperatively or postoperatively) is to be evaluated either under the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in the higher rating when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, DC 5243. Rating Based On Incapacitating Episodes In regard to the Formula for Rating Intervertebral Disc Syndrome, which based on a total of incapacitating episodes during a 12-month period, the rating criteria provide that a 10 percent rating is warranted if intervertebral disc syndrome is manifested by incapacitating episodes having a total duration of at least one week but less than two weeks during a 12 month period. 38 C.F.R. § 4.71a, DC 5243. A 20 percent rating is warranted if incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent rating is warranted if the total duration is at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is warranted if the total duration is at least six weeks during the past 12 months. Id. 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. 38 C.F.R. § 4.71a, DC 5243, Note (1). After review of all the lay and medical evidence, the Board finds that it weighs against finding that a rating higher than 10 percent is warranted for the back disability based on incapacitating episodes for any period. 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. 38 C.F.R. § 4.71a, DC 5243, Note (1). In this case, the evidence does not show, any physician-prescribed bed rest for a period of at least six weeks due to symptoms of back disability during a 12-month period at any time during the rating period; therefore, the criteria for a rating higher than 10 percent for the back disability based on incapacitating episodes have not been met or approximated for any period. 38 C.F.R. §§ 4.3, 4.7. Rating Based On General Rating Formula for the Spine Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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 under the General Rating Formula for Diseases and Injuries of the Spine. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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 40 percent rating is assigned for forward flexion of the thoracolumbar spine 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 spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is 0 to 30 degrees; left and right lateral flexion and rotation are zero 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. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. 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. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 5. After review of the lay and medical evidence of record, the Board finds that the evidence weighs against finding that the criteria for a rating higher than 10 percent have been met or approximated for the entire rating period under the rating formula for spine disabilities. For this period, the back disability was manifested by forward flexion limited no more than 70 degrees and a combined range of motion of 230 degrees after consideration of Deluca factors, with flare-ups four to five times per year, low back tenderness on palpation, no muscle spasms, normal gait and posture, and treated with muscle relaxants and acetaminophen. The back disability picture demonstrated for the rating period is consistent with the schedular criteria for a 10 percent rating; therefore, no rating higher than 10 percent is warranted for any period based on the formula for rating spine disabilities. As between the two methods for rating the back disability (i.e., based on incapacitating episodes and the general rating formula for rating spine disabilities), neither method is more advantageous to the Veteran. As explained above, the criteria for a higher rating for the back disability are not met or approximated for any period under either rating method. The Board has also considered whether a separate rating for left lower extremity radiculopathy as an associated neurological impairment is warranted, as has been argued by the Veteran; however, the July 2014 VA examiner opined that, despite the subjective left lower extremity radicular complaints, there were no objective medical findings on examination, and left lower extremity strength, reflexes and sensation were normal on examination. Because the July 2014 VA medical opinion was based on sufficient and accurate facts and supported by adequate rationale, it is of significant probative value. There is no competent medical opinion to the contrary or findings of left lower extremity radiculopathy of record, so a separate rating for left lower extremity radiculopathy is not warranted at this time. 7. Initial Rating Analysis for Right Lower Extremity Radiculopathy For the entire initial rating period from April 30, 2009, the right lower extremity radiculopathy is rated at 10 percent under the rating criteria found at 38 C.F.R § 4.124a, DC 8520, as a condition analogous to a disease of the sciatic nerve. DCs 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 20, 40, and 60 are warranted, respectively, for mild, moderate, moderately severe, and severe (with marked muscular atrophy) incomplete paralysis of the sciatic nerve. A disability rating of 80 percent is warranted for complete paralysis of the sciatic nerve: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. 38 C.F.R. § 4.124a. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. After review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that a rating higher than 10 percent under DC 8520 for right lower extremity radiculopathy is warranted for any period. During the initial rating period, the evidence showed that the right lower extremity radiculopathy was manifested by intermittent pain and decreased sensation in the lower leg/ankle and right foot/toes; however, ankle and knee reflexes and muscle strength testing for the lower extremities were normal so no motor or muscle deficits were shown. Because the evidence shows that right lower extremity radiculopathy is manifested by some sensory disturbance at times (i.e., wholly sensory) without any muscle or motor deficit demonstrated for the right lower extremity radiculopathy during the initial rating period, and the VA examiners specifically described the right lower extremity radiculopathy was mild, the Board finds that the disability picture more closely approximates mild, incomplete paralysis of the sciatic nerve for the right lower extremity, which is consistent with a 10 percent schedular rating under DC 8520. The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321(b) for any period for the initial and increased rating issues on appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the issues on appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Effective Date Legal Authority Generally, the effective date of a compensation award based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date for an award of direct service connection may be established on the day following separation from service or the date entitlement arose, if the claim is received within one year of separation from service; otherwise, the general rule applies. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b)(2)(i). The date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1 (r). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1 (p); 3.155. Effective dates for both primary and secondary conditions are governed by 38 C.F.R. § 3.400, which provides that the effective date is the later of the date the condition arose or the date a veteran applied for benefits. See Roper v. Nicholson, 20 Vet. App. 173 (2006). Determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997). A "claim" is defined as a formal or informal communication, in writing, requesting a determination of entitlement, or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). An informal claim is any communication or action indicating an intent to apply for one or more benefits. 38 C.F.R. § 3.155 (a). To obtain an increased disability rating earlier than the date of the claim, the evidence must show that the increase in disability occurred within the one-year period prior to the date of claim. If the evidence showed that the increase occurred more than one year prior to the date of the claim, then the effective date is no earlier than the date of the claim. 8. Earlier Effective Date Analysis for the Right Knee Disability Rating The Veteran generally seeks an effective date earlier than July 1, 2014 for the grant of a 30 percent rating for the right knee disability. He has advanced no specific argument as to why an earlier effective date should be granted. After review of all the lay and medical evidence, the Board finds that the VA examination report dated on July 1, 2014 is both the earliest informal claim for an increased disability rating for the service-connected right knee disability and the earliest evidence for which it is factually ascertainable that the criteria for a rating of 30 percent under the criteria found at 38 C.F.R. § 4.71a, DC 5261 for limitation of knee extension are met. As explained above, the July 2014 VA examination report showed right knee extension was limited to 20 degrees after consideration of Deluca factors, which was consistent the criteria for a 30 percent rating under DC 5261 were met at that time. Prior to July 1, 2014, the evidence showed right knee extension limited to 10 degrees or less, which is consistent with the 20 percent rating criteria under DC 5261. A 30 percent rating for the right knee disability is not shown to be warranted prior to July 1, 2014 under other potentially applicable diagnostic codes pertaining to the knee. For these reasons, an effective date earlier than July 1, 2014 for the award of the 30 percent rating for the right knee disability is not warranted. 38 U.S.C. § 5110 (b)(2); 3.400(o)(2). REMANDED An effective date earlier than August 2, 2013 for the grant of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND 9. Effective Date Earlier than August 2, 2013 for a TDIU From October 26, 2009 (i.e., the date of receipt of the TDIU claim) to August 2, 2013, the Veteran’s service-connected disabilities do not meet the threshold percentage requirements for TDIU under 38 C.F.R. § 4.16(a) because the combined 60 percent rating was not due to a single disability or a combination of disabilities from a common source or etiology; however, on the October 2009 VA Form 21-8940, the Veteran asserted that he was unable to secure or follow substantially gainful employment due to the service-connected right and left knee disabilities, sinusitis, back disability, and right lower extremity radiculopathy, as well as the (then) nonservice-connected psychiatric disability (i.e., service connection is not in effect for the now service-connected psychiatric disability until August 2, 2013). For the period at issue, service connection was in effect for the right knee disability, rated at 20 percent (excluding temporary total rating from January 27, 2012 to April 1, 2012); the left knee disability, rated at 20 percent; chronic rhinosinusitis with allergic rhinitis, rated at 10 percent; the back disability, rated at 10 percent; and right lower extremity radiculopathy, rated at 10 percent. The Veteran has four years of college education, past relevant work experience as a self-employed chiropractor, and last worked full-time in June 1995. There is some evidence to suggest that the service-connected disabilities had rendered the veteran unemployable during the period at issue. See, e.g., August 2004 SSA Disability Determination and Transmittal (finding that the Veteran had been disabled since March 3, 2002, and awarded disability benefits with a primary diagnosis of a osteoarthrosis and allied disorders and a secondary diagnosis of affective and mood disorders); June 2010 chiropractor letter (noting that the Veteran hired him in 1994 to take some of the workload from his practice and later told him in 1995 that he was unable to continue working due to joint problems, including knee and back problems). For these reasons, the Veteran’s claim for TDIU is being remanded and referred to VA’s Director of Compensation Service for extraschedular consideration. The matter is REMANDED for the following actions: 1. Refer the Veteran’s claim for TDIU to VA’s Director of Compensation Service for consideration of a TDIU under 38 C.F.R. § 4.16 (b) from October 26, 2009 to August 2, 2013. (Continued on the next page)   2. Thereafter, readjudicate the appeal. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Ferguson, Counsel