Citation Nr: 18157994 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 13-26 033 DATE: December 14, 2018 ORDER Entitlement to an initial rating higher than 20 percent, prior to November 25, 2015 and since February 1, 2018, for degenerative arthritis of the cervical spine, is denied. Entitlement to an initial 30 percent rating, but no higher, from November 25, 2015 through January 31, 2018, for degenerative arthritis of the cervical spine, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial 20 percent rating, but no higher, prior to November 25, 2015, and an initial 40 percent rating, but no higher, since November 25, 2015, for degenerative changes of the thoracolumbar spine, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 40 percent, since November 25, 2015, for degenerative changes of the thoracolumbar spine, is denied. Entitlement to an initial 10 percent rating, but no higher, since March 1, 2017, for sciatic radiculopathy of the left lower extremity, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 10 percent for sciatic radiculopathy of the left lower extremity is denied. Entitlement to an initial 10 percent rating, but no higher, since March 1, 2017, for sciatic radiculopathy of the right lower extremity, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 10 percent for sciatic radiculopathy of the right lower extremity is denied. Entitlement to an initial rating higher than 10 percent for patellofemoral syndrome of the left knee is denied. Entitlement to an initial rating higher than 10 percent for patellofemoral syndrome of the right knee is denied. FINDINGS OF FACT 1. From the May 17, 2011 effective date of service connection through November 24, 2015 and since February 1, 2018, the Veteran’s degenerative arthritis of the cervical spine is manifested by limitation of forward flexion of the cervical spine to at most 30 degrees; there is competent and credible evidence of cervical spine pain and flare ups, but there is no significant or sustained additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, incoordination, or flare ups during these periods; there is no spinal ankylosis or incapacitating episodes due to intervertebral disc syndrome. 2. From November 25, 2015 through January 31, 2018, the Veteran’s degenerative arthritis of the cervical spine was manifested by limitation of forward flexion of the cervical spine to 10 degrees; there was no spinal ankylosis or incapacitating episodes due to intervertebral disc syndrome. 3. From the May 17, 2011 effective date of service connection through November 24, 2015, the Veteran’s degenerative changes of the thoracolumbar spine were manifested by limitation of forward flexion of the thoracolumbar spine to 70 degrees and limitation of the combined range of motion of the thoracolumbar spine to no more than 170 degrees, with additional limitation of motion during flare ups; there was no spinal ankylosis or incapacitating episodes due to intervertebral disc syndrome. 4. Since November 25, 2015, the Veteran’s degenerative changes of the thoracolumbar spine have been manifested by limitation of forward flexion of the thoracolumbar spine to between 10 and 15 degrees; there is no spinal ankylosis or incapacitating episodes due to intervertebral disc syndrome. 5. The Veteran’s sciatic radiculopathy of the left lower extremity has been manifested by no more than mild incomplete paralysis of the sciatic nerve since March 1, 2017, but there is no credible evidence of any left lower extremity neurological impairment prior to that date. 6. The Veteran’s sciatic radiculopathy of the right lower extremity has been manifested by no more than mild incomplete paralysis of the sciatic nerve since March 1, 2017, but there is no credible evidence of any right lower extremity neurological impairment prior to that date. 7. Since the May 17, 2011 effective date of service connection, patellofemoral syndrome of the left knee has been manifested by limitation of flexion of the knee to 90 degrees, with no limitation of extension; there is competent and credible evidence of left knee pain and flare ups, but there is no significant or sustained additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, incoordination, or flare ups; there is no knee ankylosis, recurrent subluxation or lateral instability, semilunar cartilage dislocation or removal, tibia or fibula impairment, or genu recurvatum. 8. Since the May 17, 2011 effective date of service connection, patellofemoral syndrome of the right knee has been manifested by limitation of flexion of the knee to 90 degrees, with no limitation of extension; there is competent and credible evidence of right knee pain and flare ups, but there is no significant or sustained additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, incoordination, or flare ups; there is no knee ankylosis, recurrent subluxation or lateral instability, semilunar cartilage dislocation or removal, tibia or fibula impairment, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 20 percent, prior to November 25, 2015 and since February 1, 2018, for degenerative arthritis of the cervical spine, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5242, 5243. 2. The criteria for an initial 30 percent rating, but no higher, from November 25, 2015 through January 31, 2018, for degenerative arthritis of the cervical spine, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5242, 5243. 3. The criteria for an initial 20 percent rating, but no higher, prior to November 25, 2015, and an initial 40 percent rating, but no higher, since November 25, 2015, for degenerative changes of the thoracolumbar spine, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5242, 5243. 4. The criteria for an initial rating higher than 40 percent, since November 25, 2015, for degenerative changes of the thoracolumbar spine, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.71a, DCs 5003, 5242, 5243. 5. The criteria for an initial 10 percent rating, but no higher, since March 1, 2017 (but no earlier), for sciatic radiculopathy of the left lower extremity, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8520. 6. The criteria for an initial rating higher than 10 percent for sciatic radiculopathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8520. 7. The criteria for an initial 10 percent rating, but no higher, since March 1, 2017 (but no earlier), for sciatic radiculopathy of the right lower extremity, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8520. 8. The criteria for an initial rating higher than 10 percent for sciatic radiculopathy of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124a, DC 8520. 9. The criteria for an initial rating higher than 10 percent for patellofemoral syndrome of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5256-5263. 10. The criteria for an initial rating higher than 10 percent for patellofemoral syndrome of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1995 to November 1998 and from January 2009 to March 2010. These matters come before the Board of Veterans’ Appeals (Board) from an October 2011 rating decision, in which the agency of original jurisdiction (AOJ) awarded service connection for degenerative disc disease of the cervical spine C4-5, degenerative disc disease of the thoraco-lumbar spine, and patellofemoral syndrome of the left and right knee and assigned initial noncompensable disability ratings, all from March 11, 2010. In July 2013, a Decision Review Officer (DRO) assigned 10 percent ratings for degenerative changes of the cervical spine and degenerative changes of the thoracolumbar spine, both from May 17, 2011. In January 2014, the AOJ assigned an effective date of May 17, 2011 for the award of service connection for degenerative changes of the cervical spine, degenerative changes of the lumbar spine, and patellofemoral syndrome of the left and right knee on the basis of clear and unmistakable error. In July 2017, the Board remanded the issues of entitlement to higher initial ratings for the service-connected neck, back, and bilateral knee disabilities for further development. In February 2018, the AOJ assigned 10 percent disability ratings for patellofemoral syndrome of the left and right knee, both from January 24, 2018. In March 2018, a DRO assigned a 20 percent disability rating for degenerative arthritis of the cervical spine, from May 17, 2011. In a later March 2018 decision, the AOJ assigned a 40 percent rating for degenerative changes of the thoracolumbar spine, from January 24, 2018. The AOJ also awarded service connection for sciatic radiculopathy of the left and right and lower extremities and assigned initial 10 percent disability ratings, both from February 5, 2018. In September 2018, the AOJ assigned an effective date of May 17, 2011 for the assignment of the 10 percent disability ratings for patellofemoral syndrome of the left and right knee. The Board notes that the Veteran had also perfected an appeal with regard to the issue of entitlement to service connection for left shoulder disability and the Board remanded this issue in July 2017 for further development. In the September 2018 rating decision, the AOJ awarded service connection for left shoulder strain, and thereby resolved the appeal as to this issue. As a final preliminary matter, the Board has included the separate issues of entitlement to higher initial ratings for sciatic radiculopathy of the left and right lower extremities because they are being considered as part of the appeal for a higher initial rating for the service-connected back disability. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (providing that associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code). Higher Initial Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be “staged.” Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be 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. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. 4.59 (2017). I. Degenerative Arthritis of the Cervical Spine, Degenerative Changes of the Thoracolumbar Spine, and Sciatic Radiculopathy of the Lower Extremities The Veteran’s degenerative arthritis of the cervical spine is rated under 38 C.F.R. § 4.71a, DC 5242 as degenerative arthritis of the spine. His degenerative changes of the thoracolumbar spine are rated under 38 C.F.R. § 4.71a, DCs 5242-5243. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of DCs 5242-5243 reflects that the Veteran’s back disability is partially described as intervertebral disc syndrome and that the rating assigned is based on limitation of motion of the thoracolumbar spine under DC 5242. Degenerative arthritis of the spine is rated under the same diagnostic criteria as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5242. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Limitation of motion of the cervical and thoracolumbar spine is rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 10 percent rating is warranted 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, combined range of motion of the entire 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. Id. A 20 percent rating is warranted 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, 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, if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion, extension, and left and right lateral flexion of the cervical spine are all zero to 45 degrees and left and right lateral rotation of the cervical spine are both zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all 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 cervical spine is 340 degrees and the normal combine range of motion of the thoracolumbar spine is 240 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. Alternatively, under the criteria for rating intervertebral disc syndrome, the following ratings apply: a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. For purposes of ratings under DC 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. 38 C.F.R. § 4.71a, DC 5243, Note (1). The Veteran’s sciatic radiculopathy of the left and right lower extremities is rated under 38 C.F.R. § 4.124a, DC 8520 as paralysis of the sciatic nerve. Paralysis of the sciatic nerve is rated as follows: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124a, DC 8520. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 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. In the present case, the Veteran reported during a July 2013 VA cervical spine examination that he experienced worsening pain and tightness in his neck. The pain was located from the mid cervical spine horizontally across the C-5 region. He was unable to drive due to his neck disability because he could not turn his neck. Flare ups of neck symptoms occurred when “tapping on the neck.” Examination revealed that the ranges of motion of the cervical spine (i.e. flexion, extension, left and right lateral flexion, and left and right lateral rotation) were all to 40 degrees, with no objective evidence of any painful motion. The ranges of motion all remained the same following repetitive use testing, there were no additional limitations in the ranges of motion following repetitive use testing, and there was no functional loss/functional impairment of the cervical spine. There was no localized tenderness or pain to palpation for joints/soft tissues of the cervical spine and there was no guarding or muscle spasm of the cervical spine. Muscle strength in the upper extremities was normal (5/5) bilaterally, upper extremity reflexes were all normal (2+) bilaterally, and upper extremity sensation was normal bilaterally. Overall, the Veteran did not experience any radicular pain or any other signs or symptoms due to radiculopathy. Also, he did not experience any other neurological abnormalities related to the cervical spine and he did not have intervertebral disc syndrome of the cervical spine. He did not use any assistive devices, there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis, and there were no scars related to the cervical spine disability. A diagnosis of degenerative disc disease of the cervical spine was provided. This disability impacted the Veteran’s ability to work in that it caused difficulty with driving. The report of a July 2013 VA back examination indicates that the Veteran reported that he experienced worsening back pain/tightness. The pain would sometimes wake him up while sleeping and he attempted to alleviate his symptoms by stretching and using natural substances. Flare ups of back symptoms occurred while sleeping and performing yardwork. The ranges of motion of the thoracolumbar spine were recorded as being flexion to 70 degrees, extension to 30 degrees or greater, and right and left lateral flexion and rotation all to 20 degrees. There was no objective evidence of any painful motion. After repetitive use testing, the ranges of motion were recorded as being flexion to 70 degrees, extension to 20 degrees, and right and left lateral flexion and rotation all to 30 degrees or greater. There were no additional limitations in the ranges of motion following repetitive use testing and there was no functional loss/functional impairment of the thoracolumbar spine. There was no localized tenderness or pain to palpation for joints/soft tissues of the thoracolumbar spine and there was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength in the lower extremities was normal (5/5) bilaterally, there was no muscle atrophy, lower extremity reflexes were all normal (2+) bilaterally, lower extremity sensation was normal bilaterally, and straight leg raise testing was negative bilaterally. Overall, the Veteran did not experience any radicular pain or any other signs or symptoms due to radiculopathy. Also, he did not experience any other neurological abnormalities related to the thoracolumbar spine and he did not have intervertebral disc syndrome of the thoracolumbar spine. He did not use any assistive devices, there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis, there were no scars related to the thoracolumbar spine disability, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having degenerative changes of the lumbar spine. This disability did not impact his ability to work. The examiner who conducted the July 2013 cervical spine and back examinations explained that the Veteran’s behavior was counterintuitive, that the passive ranges of motion were unchanged from the active ranges of motion, that the range of motion values remained the same following repetitive use testing (unless otherwise noted), and that there was no pain, fatigue, weakness, or incoordination. Also, the examiner was unable to report the extent of any additional range of motion limitations due to pain during flare ups because the Veteran was not experiencing a flare up at the time of the examinations. The report of a VA cervical spine examination dated on November 25, 2015 reflects that the Veteran experienced neck tightness that limited his ability to drive. Flare ups of tightness occasionally occurred in the morning. The ranges of motion of the cervical spine were recorded as being flexion to 10 degrees, extension to 5 degrees, right and left lateral flexion both to 10 degrees, and right and left lateral rotation both to 20 degrees. The examiner noted that the Veteran exhibited poor effort during the range of motion measurements and that fuller ranges of motion were observed throughout the examination. The range of motion limitations contributed to functional loss in that difficulty rotating could limit driving. There was no pain noted on examination, there was no evidence of pain with weight bearing, and there was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. The Veteran was not being examined immediately after repetitive use over time or during a flare up, and the examination was medically inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. As for repetitive use, the examiner explained that the Veteran exhibited poor effort with range of motion measurements. With respect to flare ups, sleeping position frequently affected cervical degenerative joint disease pain. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time without resort to mere speculation because the examination was limited. Pain, weakness, fatigability, or incoordination did not, however, significantly limit functional ability with flare ups. Moreover, examination revealed that there was muscle spasm and guarding, but that these symptoms did not result in an abnormal gait or abnormal spinal contour. There was no localized tenderness. Upper extremity muscle strength was normal (5/5) bilaterally, there was no muscle atrophy, upper extremity reflexes were normal (2+) bilaterally, upper extremity sensation was normal bilaterally, and the Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. There was no spinal ankylosis, the Veteran did not have any other neurological abnormalities related to his cervical spine disability, he did not have intervertebral disc syndrome, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars associated with the cervical spine disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. X-rays revealed cervical spine arthritis, but there was no vertebral fracture with loss of 50 percent or more of height. A diagnosis of degenerative joint disease of the cervical spine was provided. This disability impacted the Veteran’s ability to work in that it limited his ability to drive due to neck stiffness. A VA back examination report, also dated on November 25, 2015, indicates that the Veteran experienced worsening back pain which was controlled with medication (Meloxicam). Flare ups of back pain occurred a couple of times each day and he experienced difficulty laying down in one position for more than a few minutes at a time. The ranges of motion of the thoracolumbar spine were recorded as being flexion to 10 degrees, extension to 5 degrees, right and left lateral flexion both to 10 degrees, and right and left lateral rotation both to 30 degrees. The examiner noted that the Veteran exhibited poor effort during the range of motion measurements. The range of motion limitations did not themselves contribute to functional loss. There was no pain noted on examination, there was no evidence of pain with weight bearing, and there was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was not being examined immediately after repetitive use over time or during a flare up, and the examination was medically inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. As for repetitive use, the examiner explained that the Veteran’s limited range of motion was not consistent with his relatively moderate back pain. With respect to flare ups, the ranges of motion were inconsistent with the ranges of motion observed while the Veteran was re-dressing. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time or during flare ups. Additionally, there was no guarding or muscle spasm of the thoracolumbar spine, lower extremity muscle strength was normal (5/5) bilaterally, there was no muscle atrophy, lower extremity reflexes were normal (2+) bilaterally, lower extremity sensation was normal bilaterally, straight leg raise testing was negative bilaterally, and the Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. There was no spinal ankylosis, the Veteran did not have any other neurological abnormalities related to his thoracolumbar spine disability, he did not have intervertebral disc syndrome, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars associated with the thoracolumbar spine disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. X-rays revealed thoracolumbar spine arthritis, but there was no thoracic vertebral fracture with loss of 50 percent or more of height. The Veteran was diagnosed as having degenerative joint disease of the thoracic spine. This disability impacted his ability to work in that it may have limited his ability to bend and twist. The Veteran reported during a VA cervical spine examination conducted on February 1, 2018 that he had been experiencing chronic posterior neck pain for the previous 3 to 4 months. The pain was 7/10 in intensity, occasionally radiated down the spine and towards the shoulders, and was aggravated by walking around all day at work. He took medication (Advil), but it did not alleviate his symptoms. Flare ups of symptoms occurred, but their frequency was dependent upon activity and they were alleviated by avoiding or limiting precipitating factors. The Veteran did not report having any functional loss or functional impairment of the cervical spine. Examination revealed that the ranges of motion of the cervical spine were flexion to 30 degrees, extension to 10 degrees, right and left lateral flexion both to 20 degrees, and right and left lateral rotation both to 50 degrees. The ranges of motion did not themselves contribute to functional loss. There was pain noted with all ranges of spinal motion, but the pain did not result in/cause any functional loss. There was no pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the soft tissues of the paraspinal muscles of the cervical spine. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. He was not being examined immediately after repetitive use over time or during a flare up, but the examination was neither medically consistent or inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. The examiner specified that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time or during flare ups. There was no guarding or muscle spasm of the cervical spine, upper extremity muscle strength was normal (5/5) bilaterally, there was no muscle atrophy, upper extremity reflexes were normal (2+) bilaterally, upper extremity sensation was normal bilaterally, and the Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. There was no spinal ankylosis, the Veteran did not have any other neurological abnormalities related to his cervical spine disability, he did not have intervertebral disc syndrome, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars associated with the cervical spine disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. X-rays revealed cervical spine arthritis, but there was no vertebral fracture with loss of 50 percent or more of height. The Veteran was diagnosed as having degenerative joint disease of the cervical spine. This disability impacted his ability to work in that it limited his ability to drive due to neck stiffness. The examiner further noted that there was no evidence of pain on passive range of motion testing or when the cervical spine was used in non weight bearing. A March 2018 VA back examination report indicates that the Veteran experienced constant “bandlike” lower back pain which was sharp/achy in nature, 6-7/10 in intensity, was precipitated by prolonged standing, bending forward/laterally, and rotating, and was alleviated with oral medications and a back brace which used while working or driving. The back pain/discomfort radiated to both feet approximately 3 times per week and this was associated with foot numbness. These symptoms were alleviated by laying down. Also, the Veteran experienced dribbling of his urine when he had more severe back to groin/upper leg pain episodes. He also reported that he experienced increased back pain at the end of the day due to prolonged walking. He had last experienced a flare up of back pain approximately one year prior to the March 2018 examination. At that time, his pain was 8/10 in intensity, he went to the emergency room to receive an injection for pain control, and the medication was helpful for “leg pain.” Such flare ups were triggered by walking, bending, and twisting and were alleviated by laying down and engaging in non weight bearing activities. The Veteran estimated that flare ups caused severe functional impairment. The ranges of motion of the thoracolumbar spine were recorded as being flexion to 15 degrees, extension and right lateral flexion both to 10 degrees, left lateral flexion and right lateral rotation both to 15 degrees, and left lateral rotation to 5 degrees. There was pain noted with all ranges of spinal motion, the pain caused functional loss, there was evidence of pain with weight bearing, and there was evidence of localized tenderness or pain on palpation (even to light touch) of the lumbosacral area. There were moderate pain behavior responses consistent with the Veteran’s prior self-reported symptoms. He was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. He was being examined immediately after repetitive use over time and pain significantly limited functional ability with repeated use over time. He was not being examined during a flare up, the examination was neither medically consistent or inconsistent with his statements describing functional loss during flare ups, and pain significantly limited functional ability during flare ups. Moreover, there was guarding of the thoracolumbar spine which resulted in an abnormal gait or abnormal spinal contour, but there were no muscle spasms. Lower extremity muscle strength was normal (5/5) bilaterally, there was no muscle atrophy, lower extremity reflexes were normal (2+) bilaterally, lower extremity sensation was normal bilaterally, and straight leg raise testing was negative bilaterally. The Veteran reported that he experienced moderate intermittent pain and paresthesias/dysesthesias in both lower extremities and moderate right lower extremity numbness, but that he did not experience any constant lower extremity pain. Overall, there was mild bilateral sciatic radiculopathy. There was no spinal ankylosis and the Veteran did not have any other neurological abnormalities related to his thoracolumbar spine disability. He had intervertebral disc syndrome, but he had not experienced any episodes of acute signs and symptoms due to intervertebral disc syndrome that required bed rest prescribed by a physician and treatment by a physician during the previous 12 months. He regularly used a back brace during work hours and long drives due to back pain. There was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis, there were no scars associated with the thoracolumbar spine disability, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. X-rays revealed thoracolumbar spine arthritis, but there was no thoracic vertebral fracture with loss of 50 percent or more of height. A diagnosis of degenerative changes of the thoracolumbar spine was provided. The Veteran was employed on a full-time basis at a light duty job. 1. Entitlement to an initial rating higher than 20 percent for degenerative arthritis of the cervical spine Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran manifested cervical spine symptoms of the type and extent, frequency, and/or severity, as appropriate, to warrant a 30 percent rating (but no higher) during the period from November 25, 2015 through January 31, 2018. A rating higher than 20 percent is otherwise not warranted at any time during the remainder of the claim period from the May 17, 2011 effective date of service connection through November 24, 2015 and since February 1, 2018. During the periods from the May 17, 2011 effective date of service connection through November 24, 2015 and since February 1, 2018, forward flexion of the cervical spine was to 40 degrees during the July 2013 examination and to 30 degrees during the February 2018 examination. These ranges of motion, by themselves and without consideration of potential functional impairment, are contemplated by no more than a 20 percent rating under the General Rating Formula. As for functional impairment, there was no pain during the July 2013 examination, the ranges of spinal motion remained the same following repetitive use testing during that examination, and there was otherwise no functional loss/impairment of the cervical spine. During the February 2018 examination, there was pain associated with cervical spine motion, but the pain did not result in/cause any functional loss, there was no additional loss of function or range of motion following repetitive use testing, the examiner specified that functional ability was not significantly limited by pain, weakness, fatigability, or incoordination with repetitive use, and the Veteran reported that he did not experience any functional loss/impairment of the cervical spine. Also, there was no pain with weight bearing or non weight bearing and there was no evidence of pain on passive range of motion testing. The Veteran reported flare ups when “tapping the neck” during the July 2013 examination and flare ups that were dependent upon activity during the February 2018 examination. Nevertheless, the examiner who conducted the February 2018 examination specified that functional ability was not significantly limited by pain, weakness, fatigability, or incoordination during flare ups. Overall, the ranges of spinal motions during the July 2013 and February 2018 cervical spine examination, by themselves, are contemplated by no more than a 20 percent rating under the General Rating Formula. Moreover, the Board finds that the reported functional impairments during these examinations were not so severe, frequent, and/or prolonged to warrant the next higher percent rating (30 percent). In other words, even considering functional loss due to pain, flare ups, and other factors, during the periods from the May 17, 2011 effective date of service connection through November 24, 2015 and since February 1, 2018, the Veteran’s cervical spine symptoms are not shown to be so disabling as to actually or effectively result in limitation of flexion of the cervical spine to 15 degrees or less-the range of motion requirement for a 30 percent rating under the General Rating Formula. As for the period from November 25, 2015 through January 31, 2018, forward flexion of the cervical spine was to 10 degrees during the November 2015 VA examination. The examiner who conducted this examination briefly noted that the Veteran exhibited poor effort during range of motion testing. Nevertheless, in light of the range of motion measurements that were objectively measured during the November 2015 examination and resolving all reasonable doubt in the Veteran’s favor, the Board finds that the symptoms of his service-connected cervical disability most closely approximated the criteria for a 30 percent rating under the General Rating Formula (which contemplates limitation of flexion of the cervical spine to 15 degrees or less). It is unclear exactly when the more severe symptomatology began following the July 2013 VA examination and the earliest that it is factually ascertainable that the Veteran’s cervical disability warranted at least a 30 percent rating is November 25, 2015 (the date of the November 2015 VA examination). Hence, an initial 30 percent rating for degenerative arthritis of the cervical spine is warranted for the entire period from November 25, 2015 through January 31, 2018 (the day prior to the February 2018 VA examination). The 30 percent rating that has been awarded for the Veteran’s service-connected cervical spine disability from November 25, 2015 through January 31, 2018 is the maximum schedular rating for limitation of motion of the cervical spine (absent ankylosis) under the General Rating Formula, and the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59) do not provide a basis for any rating higher than 30 percent. See Johnston, 10 Vet. App. at 85. Moreover, there has been no showing of any ankylosis at any time during the claim period and the Veteran has not experienced any incapacitating episodes of intervertebral disc syndrome. Ankylosis is defined in general as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland’s Illustrated Medical Dictionary (28TH Ed. 1994) at 86). The rating criteria provide that 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). There is no evidence that the Veteran’s cervical spine has been fixed in position or ankylosed at any time during the claim period, he has retained the ability to move his spine (albeit a limited ability), and the absence of cervical spine ankylosis was specifically noted during the November 2015 and February 2018 examinations. Also, there is no evidence that he has experienced any symptoms of intervertebral disc syndrome that required bed rest prescribed by a physician and treatment by a physician. Therefore, ratings in excess of 20 percent, from May 17, 2011 through November 24, 2015 and since February 1, 2018, and in excess of 30 percent, from November 25, 2015 through January 31, 2018, are not warranted on the basis of ankylosis or intervertebral disc syndrome. Lastly, there is no evidence of any neurological impairment associated with the service-connected cervical spine disability at any time during the claim period. Hence, no separate ratings are warranted on the basis of any cervical spine related neurological impairment. Thus, an initial 30 percent rating (but no higher), from November 25, 2015 through January 31, 2018, for degenerative arthritis of the cervical spine is granted. An initial rating higher than 20 percent, from May 17, 2011 through November 24, 2015 and since February 1, 2018, for degenerative arthritis of the cervical spine, is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5242, 5243. 2. Entitlement to a higher initial rating for degenerative changes of the thoracolumbar spine, rated 10 percent disabling prior to January 24, 2018 and 40 percent disabling since that date Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested thoracolumbar spine symptoms of the type and extent, frequency, and/or severity, as appropriate to warrant a 20 percent rating (but no higher) during the period from the May 17, 2011 effective date of service connection through November 24, 2015 and a 40 percent rating (but no higher) during the period since November 25, 2015. During the period from the May 17, 2011 effective date of service connection through November 24, 2015, the July 2013 VA examination report reflects that forward flexion of the thoracolumbar spine was to no more than 70 degrees and the combined range of motion of the thoracolumbar spine was to no more than 170 degrees (when considering the ranges of motion measured both prior to and after repetitive use testing). These ranges of motion, by themselves and without consideration of potential functional impairment, are contemplated by no more than a 10 percent rating under the General Rating Formula. As for functional impairment, there was no pain, fatigue, weakness, or incoordination associated with the ranges of spinal motion and there was otherwise no functional loss/functional impairment of the thoracolumbar spine. The Veteran did report during the July 2013 examination, however, that he experienced flare ups of back pain while sleeping and performing yardwork and that the pain would sometimes wake him up while sleeping. The examiner who conducted the July 2013 VA examination did not provide any opinion as to the extent of any additional functional impairment of the thoracolumbar spine (in terms of additional degrees of limited motion) during flare ups. Rather, the examiner only noted that such an opinion was not possible because the Veteran was not experiencing a flare up at the time of the examination. In light of this fact, the fact that forward flexion of the thoracolumbar spine was to 70 degrees during the July 2013 examination, the Veteran’s reports of flare ups of back symptoms, and resolving all reasonable doubt in his favor, the Board finds that the symptoms of the Veteran’s service-connected back disability most closely approximated the criteria for a 20 percent rating under the General Rating Formula (which contemplates flexion of the thoracolumbar spine to greater than 30 degrees, but not greater than 60 degrees) during the entire period from the May 17, 2011 effective date of service connection through November 24, 2015. A rating higher than 20 percent is not warranted at any time during this period on the basis of limitation of spinal motion because although the Veteran reported flare ups of back pain associated with his back disability, he was able to perform forward flexion of the spine to 70 degrees during the July 2013 VA examination. The Board finds that the reported functional impairments were not so severe, frequent, and/or prolonged to warrant the next higher percent rating (40 percent). In other words, even considering functional loss due to pain, flare ups, and other factors, prior to November 25, 2015, the Veteran’s thoracolumbar spine symptoms were not shown to be so disabling as to actually or effectively result in limitation of flexion to 30 degrees or less-the range of motion requirement for a 40 percent rating under the General Rating Formula. As for the period since November 25, 2015, forward flexion of the thoracolumbar spine was to 10 degrees and 15 degrees during the November 2015 and March 2018 VA examinations, respectively. The examiner who conducted the November 2015 examination noted that the Veteran exhibited poor effort during range of motion testing. Nevertheless, in light of the range of motion measurements that were objectively measured during the November 2015 and March 2018 examinations and resolving all reasonable doubt in the Veteran’s favor, the Board finds that the symptoms of his service-connected back disability most closely approximated the criteria for a 40 percent rating under the General Rating Formula (which contemplates limitation of flexion of the thoracolumbar spine to 30 degrees or less) at the time of the November 2015 examination. It is unclear when the more severe symptomatology began following the July 2013 VA examination and the earliest that it is factually ascertainable that the Veteran’s back disability warranted at least a 40 percent rating is November 25, 2015 (the date of the November 2015 VA examination). Hence, an initial 40 percent rating for degenerative changes of the thoracolumbar spine is warranted for the entire period since November 25, 2015. The 40 percent rating that has been awarded for the Veteran’s service-connected back disability since November 25, 2015 is the maximum schedular rating for limitation of motion of the thoracolumbar spine (absent ankylosis) under the General Rating Formula. Thus, the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59) do not provide a basis for any rating higher than 40 percent. See Johnston, 10 Vet. App. at 85. Moreover, there is no evidence that the Veteran’s thoracolumbar spine has been fixed in position or ankylosed at any time during the claim period, he has retained the ability to move his spine (albeit a limited ability), and the absence of thoracolumbar spine ankylosis was specifically noted during the November 2015 and March 2018 examinations. Also, he has not experienced any symptoms of intervertebral disc syndrome that have required bed rest prescribed by a physician and treatment by a physician. Therefore, ratings in excess of 20 percent, from May 17, 2011 through November 24, 2015, and in excess of 40 percent, since November 25, 2015, are not warranted on the basis of ankylosis or intervertebral disc syndrome. Lastly, the Board notes that the Veteran reported during the March 2018 examination that he experienced dribbling of his urine when he had more severe back to groin/upper leg pain episodes. However, there is no evidence that any urinary symptoms are associated with his back disability and no evidence that any such urinary frequency is severe enough so as to warrant a compensable rating under the appropriate diagnostic criteria (i.e., 38 C.F.R. § 4.115a). Also, there is no evidence of any bowel impairment associated with the service-connected back disability. Hence, a separate rating on the basis of bowel or bladder impairment is not warranted at any time during the claim period. In sum, an initial 20 percent rating (but no higher), from May 17, 2011 through November 24, 2015, and an initial 40 percent rating (but no higher), since November 25, 2015, for degenerative changes of the thoracolumbar spine, is granted. An initial rating higher than 40 percent, since November 25, 2015, for degenerative changes of the thoracolumbar spine, is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5242, 5243. 3. Entitlement to initial ratings higher than 10 percent, since February 5, 2018, for sciatic radiculopathy of the left and right lower extremities Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested right and left lower extremity neurological symptoms of the type and extent, frequency, and/or severity, as appropriate to warrant no more than 10 percent ratings, since March 1, 2017 (but no earlier), for sciatic radiculopathy of the left and right lower extremities. The above evidence indicates that during the entire claim period, the Veteran has reported occasional (reported as approximately 3 days per week during the March 2018 VA back examination) radiation of his back pain/discomfort to both lower extremities and occasional foot numbness. Examinations conducted during the claim period have consistently revealed normal lower extremity muscle strength, reflexes, and sensation bilaterally. Also, straight leg raise testing has been negative bilaterally and there is no evidence of any lower extremity muscle atrophy. The examiner who conducted the March 2018 VA examination concluded that the Veteran had mild bilateral sciatic radiculopathy. In light of the radiating back pain and lower extremity numbness reported by the Veteran, the conclusion of the examiner who conducted the March 2018 VA back examination, and the otherwise normal lower extremity neurological findings observed during the claim period, the Board finds that the Veteran’s sciatic radiculopathy of the left and right lower extremities warrants no more than 10 percent ratings under DC 8520 (indicative of mild incomplete paralysis of the sciatic nerve). It is unclear exactly when this neurological symptomatology began during the claim period. The earliest evidence of potential lower extremity neurological symptomatology is an October 2015 “Application for Disability Compensation and Related Compensation Benefits” form (VA Form 21-526EZ), on which the Veteran noted bilateral sciatic pain down the legs. He is competent to report such symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless, the Board points out that during the subsequent November 2015 VA back examination, the Veteran reported that he did not have any radicular pain or any other signs or symptoms due to radiculopathy. Also, there was no pain noted during this examination and all lower extremity neurological findings were normal. During the March 2018 VA back examination, the Veteran reported that he had last experienced a flare up of back pain approximately one year prior to the March 2018 examination and that medication which was administered at that time was helpful for “leg pain.” In light of the information obtained during the November 2015 back examination which is inconsistent with the Veteran’s October 2015 report of sciatic pain, the Board finds that there is no credible evidence of any lower extremity neurological impairment at any time during the claim period prior to March 1, 2017. Rather, based on the Veteran’s report during the March 2018 VA examination that he had been treated for leg pain associated with his most recent flare up of back symptoms (which occurred approximately one year prior to the March 2018 examination), the findings of the March 2018 examiner, and resolving all reasonable doubt in the Veteran’s favor, the Board finds that the earliest that it is factually ascertainable that the Veteran’s sciatic radiculopathy of the left and right lower extremities warranted at least 10 percent ratings is March 1, 2017. Ratings higher than 10 percent for sciatic radiculopathy of the left and right lower extremities are not warranted at any time since March 1, 2017. Specifically, the radiating back pain and lower extremity numbness reported by the Veteran has been intermittent and all lower extremity neurological testing has been normal. Also, the examiner who conducted the March 2018 VA examination concluded that there was only mild bilateral sciatic radiculopathy. In sum, initial 10 percent ratings under DC 8520, since March 1, 2017 (but no earlier), for sciatic radiculopathy of the left and right lower extremities, are granted. Ratings higher than 10 percent are not warranted at any time during this period. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.7, 4.124a, DC 8520. II. Patellofemoral Syndrome of the Left and Right Knee The Veteran’s patellofemoral syndrome of the left and right knee are both rated under 38 C.F.R. § 4.71a, DC 5260 as limitation of leg flexion. Under DC 5260, limitation of knee flexion is rated as follows: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. VA’s General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Limitation of knee extension is rated as follows: a noncompensable rating is warranted when it is limited to 5 degrees; a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. In the present case, the Veteran reported during a July 2013 VA knee examination that he experienced pain along the lateral aspect of both knees. There was no swelling and he had not noted much changes in his knees since he was discharged from service. Flare ups of knee symptoms occurred with squatting and bending of the knees. Examination revealed that knee flexion was to 90 degrees bilaterally and that right knee extension was to 0 degrees. There was no objective evidence of any pain associated with flexion of either knee or associated with left knee extension. There was pain at 0 degrees of right knee extension. The Veteran was able to perform repetitive use testing with 3 repetitions of motion and the ranges of knee motion were recorded as being flexion to 90 degrees and extension to 0 degrees bilaterally. There was no additional limitation in the ranges of motion of the knees and lower legs following repetitive use testing and the Veteran did not have any functional loss or functional impairment of either knee or lower leg. Moreover, there was no tenderness or pain to palpation for joint line or soft tissues of either knee, muscle strength associated with knee flexion and extension was normal (5/5) bilaterally, joint stability testing was normal bilaterally, and there was no evidence or history of any recurrent patellar subluxation/dislocation. The Veteran did not have any shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairment. He had not experienced any meniscal conditions or undergone any surgical procedures for a meniscal condition, he had not undergone any total knee joint replacement, he did not have any scars related to his knee disabilities, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. He did not use any assistive devices and x-rays did not reveal any arthritis or evidence of patellar subluxation. The Veteran was diagnosed as having bilateral patellofemoral syndrome. This disability did not impact his ability to work. The examiner who conducted the July 2013 examination explained that the Veteran resisted any passive range of motion that was attempted during the examination. His behavior compromised the examination such that the reported ranges of motion were not likely a true representation of his disability. Unless otherwise documented, the passive ranges of motion were unchanged from the active ranges of motion, the range of motion values remained unchanged from baseline following repetitive use testing, and there was no pain, fatigue, weakness, or incoordination. Also, the examiner was unable to report the additional range of motion limitation due to pain during flare ups without resort to mere speculation because the Veteran was not experiencing a flare up at the time of the examination. The report of a VA knee examination dated in February 2018 indicates that the Veteran experienced pain under the knee caps and at the superior anterior edge of the patella. Mild to moderate flare ups of knee pain occurred after being on his feet for more than 30 minutes. The flare ups mildly to moderately affected function and lasted for less than 24 hours at a time. The Veteran did not report having any functional loss or functional impairment of the knees. The ranges of motion of both knees were recorded as being flexion to 90 degrees and extension to 0 degrees. There was pain associated with left and right knee flexion, but the pain did not result in/cause any functional loss. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of both knees and there was evidence of pain with weight bearing with the left knee, but there was no evidence of pain with weight bearing of the right knee. The Veteran was able to perform repetitive use testing with at least 3 repetitions and there was no additional functional loss or range of motion loss of either knee after three repetitions. He was not being examined immediately after repetitive use over time or during a flare up and the examination was neither medically consistent or inconsistent with his statements describing functional loss with repetitive use over time or during flare ups. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability of either knee with repeated use over time or during flare ups. Furthermore, muscle strength associated with knee flexion and extension was normal (5/5) bilaterally, there was no muscle atrophy, and joint stability testing was normal bilaterally. The Veteran did not have any recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairment. He had not experienced any meniscal (semilunar cartilage) conditions, there were no scars related to his knee disabilities, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. He did not use any assistive devices and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. X-rays did not reveal any arthritis or evidence of patellar subluxation. The Veteran was diagnosed as having bilateral patellofemoral syndrome of the knees. He was employed as a nursing assistant and he occasionally needed to sit down due to his knee disabilities. Moreover, the examiner noted that there was no evidence of pain on passive range of motion or when the knees were used in non weight bearing. Entitlement to initial ratings higher than 10 percent for patellofemoral syndrome of the left and right knee Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran manifested left and right knee symptoms of the type and extent, frequency, and/or severity, as appropriate, to warrant no more than 10 percent ratings for patellofemoral syndrome of the left and right knee since the May 17, 2011 effective date of service connection. The above evidence reflects that the Veteran’s right and left knee disabilities have been manifested by pain and limited motion. Knee flexion has been limited to at most 90 degrees bilaterally and knee extension has been to 0 degrees bilaterally. There was pain occasionally associated with knee flexion and/or extension bilaterally, but any pain associated with knee extension was not until the end point of motion (i.e., 0 degrees) and the knee pain did not otherwise cause any functional loss. The Veteran reported occasional flare ups of knee symptoms during the July 2013 and February 2018 examinations, but he specified during the February 2018 examination that the flare ups only caused mild to moderate functional impairment. Also, the examiner who conducted the February 2018 examination specified that pain, weakness, fatigability, or incoordination did not significantly limit functional ability of either knee with repeated use over time or during flare ups. The Veteran is competent to report the symptoms associated with his service-connected knee disabilities and the extent of his impairment during flare ups of symptoms and the Board has no reason to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1372; Buchanan, 451 F.3d at 1331. Regardless of the competent and credible reports of flare ups and pain and despite the fact that painful motion has been documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran’s knee symptoms have most closely approximated the criteria for a 10 percent rating since the effective date of service connection. Specifically, the above evidence reflects that the flare ups have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion to 30 degrees or limitation of knee extension to 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. Lastly, there has been no evidence of any knee ankylosis, recurrent subluxation or lateral instability, cartilage dislocation or removal, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. Therefore, separate/higher ratings are not warranted under DCs 5256, 5257, 5258, 5259, 5262, or 5263 at any time during the claim period. Overall, the Veteran’s patellofemoral syndrome of the left and right knee have resulted in impairments that are no more than 10 percent disabling under the appropriate diagnostic criteria during the entire period since the May 17, 2011 effective date of service connection and higher initial ratings are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5256-5263. III. Additional Considerations As a final point, the Board notes that in conjunction with the appeal for higher initial ratings for the service-connected cervical spine, back, lower extremity neurological, and bilateral knee disabilities, neither the Veteran nor his representative has raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Elwood, Counsel