Citation Nr: 21000855 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 13-22 122 DATE: January 6, 2021 ORDER Entitlement to an initial rating in excess of 10 percent disabling for a lumbar spine disability diagnosed as foraminal narrowing at L4-5 is denied. Entitlement to an initial rating in excess of 20 percent disabling for right lower extremity radiculopathy of sciatic nerve is denied. Entitlement to an initial rating in excess of 20 percent disabling for left lower extremity radiculopathy of the sciatic nerve is denied. Entitlement to an initial rating in excess of 20 percent disabling for radiculopathy of right lower extremity femoral nerve is denied. Entitlement to an initial rating in excess of 20 percent disabling for radiculopathy left lower extremity femoral nerve is denied. FINDINGS OF FACT 1. The Veteran’s has forward flexion of the thoracolumbar spine greater than 60 degrees; with a combined range of motion of the thoracolumbar spine greater than 120 degrees; and no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. The Veteran’s right lower extremity radiculopathy of sciatic nerve is manifested by no more than moderate incomplete paralysis. 3. The Veteran’s left lower extremity radiculopathy of sciatic nerve is manifested by no more than moderate incomplete paralysis. 4. The Veteran’s right lower extremity radiculopathy of femoral nerve is manifested by no more than moderate incomplete paralysis. 5. The Veteran’s left lower extremity radiculopathy of femoral nerve is manifested by no more than moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for lumbar spine disability diagnosed as foraminal narrowing at L4-5 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5243. 2. The criteria for a disability rating in excess of 20 percent for right lower extremity radiculopathy of sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720. 3. The criteria for a disability rating in excess of 20 percent for left lower extremity radiculopathy of sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720. 4. The criteria for a disability rating in excess of 20 percent for right lower extremity radiculopathy of femoral nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526, 8626, 8726. 5. The criteria for a disability rating in excess of 20 percent for left lower extremity radiculopathy of femoral nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526, 8626, 8726. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1972 to November 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for a lumbar spine disorder and assigned an initial 10 percent rating. The Veteran testified before the undersigned in a June 2015 hearing. A hearing transcript was associated with the claims file and reviewed. The Board remanded this matter for further development in September 2015 and again in March 2018, during which decision the Board also disposed of an appellate issue of entitlement to an increased rating for bicep tendonitis, but remanded the lumbar spine and TDIU issues for further development. Following such development which was found to be incomplete, the Board remanded this matter again in January 2020. In a July 2020 rating, the RO granted TDIU effective the date of initial entitlement, December 14, 2010. This constitutes a total grant of this issue on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). The record currently before the Board contains no indication that the Veteran initiated an appeal as to the rating or effective date assigned. Thus, this matter is no longer in appellate status. In June 2017, while this appeal was pending, the RO granted service connection for bilateral radiculopathy of the lower extremities, assigning a disability rating of 10 percent for the femoral nerve radiculopathy and a separate 10 percent for sciatic nerve neuropathy of the right leg; and 10 percent for the femoral nerve radiculopathy and a separate 10 percent for sciatic nerve neuropathy of the left leg. These ratings were all effective June 16, 2015. In October 2019 the RO increased the separate ratings for the sciatic nerve and femoral nerve radiculopathies for each leg to 20 percent effective April 26, 2019, with the 10 percent ratings each remaining in effect prior to that date. Subsequently, in the same July 2020 rating that granted TDIU, the RO granted the 20 percent rating for each separately rated radiculopathy of the sciatic nerve and femoral nerve for the bilateral lower extremities dating back to initial entitlement date of December 14, 2010. Although the Veteran did not appeal the ratings addressing the evaluations assigned for the right and left lower extremity lumbar radiculopathies, these matters are under the Board’s jurisdiction as part and parcel with the evaluation of the spine. The requested development has been completed and this matter is returned to the Board for further consideration. The Board notes that additional VA medical records received in November 2020 after the most recent adjudication pertain to other medical issues aside from his lumbar spine disability. Thus, there is no prejudice to the Veteran in adjudicating this matter. Factual Background Lumbar Spine and Neurological Manifestations The Veteran contends that his lumbar spine disorder is more severe than currently evaluated. At his June 2015 hearing he alleged that his spine condition has gotten worse, it sometimes affects his balance and he falls down sometimes if he has to make a sudden turn. He also alleged having no sensation in his lower extremities and was learning to use a cane. He also sometimes had spasms in his back. Transcript pg. 6-9. Board shall address the factual background encompassing the lumbar spine disability and the neurological manifestations together prior to addressing the questions of whether an increased rating is warranted for such disabilities from the period of initial entitlement of December 14, 2010. Evidence from 2010 discloses that the Veteran was seen for pain in his bilateral legs and feet in September 2010, with a description of his toes turning up on him and needing to look to see where his feet are. He also described burning in his feet and a history of falling twice this year. He was assessed with peripheral neuropathy. An October 2010 vocational rehabilitation record noted the Veteran to be job hunting, but he could not do anything strenuous or physically demanding. Because of peripheral neuropathy he reported he couldn’t keep his balance without falling at times. He could not stand on his legs or feet for prolonged period of time. Another record from October 2010 described his pain at a 9/10 level in his legs. Lumbar spine X-rays from February 2011 showed normal alignment with degenerative disc disease (DDD) at L4-5, with remaining intervertebral discs normal and no other vertebral abnormalities. A state disability examination from the same month included observations of the Veteran arising from sitting without difficulty, with his gait normal. He could stand on one leg bilaterally and stand on his toes and heels. He could bend forward (forward flexion) 70 degrees, extend 15 degrees, and had lateral flexion 30 degrees bilaterally (thoracolumbar). Paravertebral lumbar was nontender bilaterally. He could elevate legs 70 degrees and had normal hip rotations. He did have 2+ patellar and Achilles reflexes bilaterally. He also had moderate cogwheeling of upper and lower extremities bilaterally. Diagnoses included Parkinson’s, peripheral neuropathy of feet bilaterally by history. The report of a February 2011 VA examination gave a history of having had right leg radiculopathy rated as 8/10 when it flared up, ever since his service injury. Bending and lifting caused flares. He did not use cane or brace. He could walk 15 minutes or a couple of blocks before he has to stop. He had no treatments or surgery. This did affect his daily activities. He was working and had no bed rest for the past 12 months; there was no effect on bowel or bladder. On examination, there was some paraspinal muscle soreness at the lumbar spine but otherwise there was no tenderness to palpation. Forward flexion was 90 degrees; extension was 20 degrees. Left lateral flexion was 0 to 30 degrees; right lateral flexion 0 to 30 degrees; left lateral rotation 0 to 30 degrees and right lateral rotation 0 to 30 degrees. There was no change with three repetitions. The combined range of motions added to 230 degrees. He did have a mildly positive straight leg raise on the right. Otherwise, he had 5/5 strength with hip flexion and knee extension. He had 4/5 strength with right knee flexion. He had 5/5 strength with bilateral ankle flexion and extension and EHL. He was noted to have dense neuropathy to bilateral feet and legs and thus the examiner was unable to assess dermatome accurately. He had diminished but symmetrical patellar tendon and Achilles tendon reflexes. His capillary refill was 2 seconds and present bilaterally. X-rays of the lumbar spine showed no fractures or dislocation. Some frontal narrowing at L4-5 was noted on the lateral. Otherwise, for the most part there was good disc space of the lumbar spine of note The assessment of the lower back indicated that the patient does have some foraminal narrowing and what sounds like may be radiculopathy to the right lower extremity but this is difficult to assess secondary to his dense neuropathy which he reported is secondary to alcohol neuropathy. An October 2011 MRI of the lumbar spine for pain in the right low back with radiation to the right ankle yielded an impression of mild DDD but no evidence of stenosis in patient with large bony canal. The report of a January 2013 VA examination diagnosed lumbar strain. The Veteran reported that symptoms began to bother him about 6 years ago and had gotten worse. Flareups impacted the function of thoracolumbar spine--pain with prolonged activity. On physical examination his range of motion was 80 degrees flexion. He had 30 degrees of extension, as well as the 30 degrees for the remainder of motions (bilateral lateral flexion and bilateral rotation). He had pain at the ends of motion for all movements, except that he had no pain at left lateral rotation. There was no additional limitation of motion after repetitive use testing. The combined range of motions added to 230 degrees. His functional impairment was less movement than normal and pain on movement. He had pain on palpation of the right flank area. There was no guarding or muscle spasm of thoracolumbar spine. He had 5/5 muscle strength throughout his bilateral lower extremities including hip flexion, knee extension, ankle plantarflexion and dorsiflexion, great toe extension. No muscle atrophy was present. His deep tendon reflexes (DTRs) were 2+ knees and ankles. Sensory exam was normal throughout the bilateral lower extremities from the from upper thigh, thigh/knee, lower leg/ankle and toes. Straight leg raise (SLR) was negative, and there was no radicular pain or other signs/symptoms of radiculopathy. No other neurological abnormalities were noted. The examiner indicated that there was no intervertebral disc syndrome (IVDS) of thoracolumbar spine and accordingly the examiner did not answer question of incapacitating episodes. In this examination, as well as all subsequent VA examinations it was noted that no assistive devices were used and that functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner noted that arthritis was documented but there was no vertebral fracture. Functional impact was limited only for very physically demanding jobs. VA treatment records dated in February 2013 noted a report of a small degree of right low back pain at all times which intermittently became more painful, including up to 9/10 in intensity once or twice a week and occasionally lasting up to a week. He was observed to arrive by walking and his back showed 90 degrees flexion. He was assessed with right sciatica. Other records from that date described him as having constant pain in his legs of greater than 3/10. The report from a June 2016 VA examination noted symptoms of shooting pain down the right leg. The Veteran was unable to get out of bed and had instability. No treatment was noted. Flareups were of pain up and down the lower part of back. Functionally, he was unable to stand or sit for long periods. On examination his range of motion (ROM) was abnormal, with 90 degrees flexion, 5 degrees extension, 20 degrees right lateral flexion, 20 degrees left lateral flexion, 30 degrees right rotation, 30 degrees left rotation. There was no change with three repetitions. The combined range of motions added to 195 degrees. ROM may be possibly related to age. The abnormal ROM did not contribute to functional loss. Pain was noted on examination but did not cause functional loss. He had pain on flexion and extension only. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine, shown by guarding and grimacing. The tenderness of in the lower back and was of moderate severity. No pain was shown on weight bearing. The Veteran was not being examined immediately after repetitive use over time or during a flareup and the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to state without speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time or during flareup. This was because ROM did not replicate the Veteran’s reports from repetitive use over time and the exam was not completed immediately after repetitive use. For this reason, examiner unable to describe functional loss in terms of range of motion. There was no guarding or muscle spasm of the thoracolumbar spine. Localized tenderness and guarding did not result in abnormal gait or abnormal spinal contour. No ankylosis of the spine was shown. Additional factors contributing to disability included disturbance of locomotion, interference with sitting and interference with standing. Muscle strength was 4/5 hip flexion on right side, but 5/5 for rest of muscle testing for the bilateral lower extremities(knee, ankle, great toe and L hip all 5/5). There was no muscle atrophy. The Veteran’s reflexes were 2+ bilaterally. Sensory examination for the right leg was normal in the upper thigh but there was decreased sensation of the thigh/knee, lower leg/ankle and foot/toes. The sensory examination of the left leg was of a normal upper thigh and lower leg/ankle, but decreased lower leg/ankle and foot/toes. Other sensory findings included complaints of burning from the ankles to toes bilaterally. Straight leg raise was positive bilaterally. The Veteran had radicular pain/other signs or symptoms due to radiculopathy. For the right lower extremity, he had mild intermittent pain, paresthesias and numbness. For the left lower extremity, he had constant moderate pain, moderate paresthesias and numbness. The specific nerve roots involved were involvement of L2/L3/L4 nerve roots (femoral nerve) bilaterally. There was also involvement of L4/L5/S1/S2/S3nerve roots (sciatic nerve) bilaterally. The severity of the radiculopathy and side affected was mild for the right lower extremity and moderate for the left lower extremity. No other neurologic abnormalities were noted. The examiner says he doesn’t have IVDS of spine and didn’t answer questions about incapacitating episodes. No imaging was performed, and there was no vertebral fracture with loss of 50 percent or more of height. There were complaints of burning and tingling to both lower legs from ankles to feet. On straight leg testing he described pain in both ankles and he appeared stiff during ROM exercises and became unstable with standing. The examiner opined that the diagnosis of lumbar spine foraminal narrowing at L4-5 was a progression of the original service-connected diagnosis, stating that radiculopathy is a progression of the original service-connected diagnosis. Stenosis is directly related to radiculopathy due to compression, inflammation and/or injury to the spinal nerve roots. Occupationally, the Veteran would be unable to work due to being unable to lift, sit for long periods or walk great distances. The examiner also noted that in the February 2011 and January 2013 examination the Veteran reported flareups in back symptoms with prolonged activity, bending and lifting. He also noted increased symptoms with his back in the mornings when getting out of bed. In October 2018 the Veteran was seen in physical therapy consult to determine whether he qualified for a handicap bathroom. He confirmed that he walked without any assistive device. However, at times he used a cane. At this time, he did not meet the medical criteria for such accommodations since he could walk, and transfer. He was advised to use certain aids such as grab bars, shoehorn, sock aid and bedside commode. The October 2018 records included a pain screen with him report experiencing pain on a scale of 10/10. He stated that the pain was uncontrolled. The location of the pain was legs and feet. The pain was aching, with numbness. It interfered with sleep and physical activity. The report of an April 2019 VA examination addressed the diagnosis of lumbar spine foraminal narrowing at L4-5; radiculopathy, right lower extremity; sciatic nerve radiculopathy, left lower extremity; femoral nerve radiculopathy, left lower extremity; femoral nerve radiculopathy, right lower extremity. Current symptoms were of pain with repetitive or prolonged activity, with radiation of pain both lower extremities associated with tingling and numbness. He took no medications as he did not believe in doing so. A 2011 MRI supported the current diagnoses. The Veteran denied flareups of the thoracolumbar spine. ROM was 80 degrees flexion, while he had 20 degrees of extension, bilateral lateral flexion, and bilateral rotation. There was no additional limitation of motion after repetitive use testing. The combined range of motions added to 180 degrees. Functionally, he could not bend all the way down. There was no pain on examination, no tenderness on palpation and no pain with weight bearing. The examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flareups (exam not done during flareup or repetitive use over time). The pain significantly limited functional ability with repeated use over a period of time. The functional loss limited his motion to the following: 68 degrees flexion and 17 degrees for the remaining motions (extension, bilateral lateral flexion and bilateral rotation). The combined range of motions added to 153 degrees. There was no functional loss due to flare ups because no flares reported. He had paraspinal muscle spasm of the thoracolumbar spine not resulting in abnormal gait or abnormal spinal contour. No ankylosis was present. Additional factors contributing to disability included disturbance of locomotion, interference with sitting and interference with standing. Additional contributing factors of disability included being unable to sit, stand, or walk for long. Muscle strength testing disclosed 5/5 hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion and great toe extension BLE. There was no muscle atrophy. DTRs were 2+ knees and ankles. Sensory exam revealed normal right and left upper thigh, thigh/knee, lower leg/ankle, foot/toes bilaterally. Straight leg raise was positive bilaterally. The Veteran had moderate intermittent radicular pain, paresthesias, and numbness for the right lower extremity and left lower extremity. No other signs or symptoms of radiculopathy. The specific nerve roots involved were involvement of L2/L3/L4 nerve roots (femoral nerve) bilaterally. There was also involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) bilaterally. The severity of the radiculopathy was moderate for the left and right and no other neurological abnormalities were shown. The examiner stated that there was no IVDS of the thoracolumbar spine and thus did not answer the question of whether there were any episodes of acute signs and symptoms due to IVDS. The 2011 MRI supports current diagnoses with the examiner noting that foraminal narrowing is considered to be arthritis. The functional impact was that he was unable to sit, stand, or walk for long. He cannot run, jog, jump, bend, squat, kneel, hike, or climb. Regarding Correia criteria, there was no objective evidence of pain on non-weight bearing. Passive ROM was the same as active ROM. The examiner stated that there was no change in the service-connected diagnosis and no additional diagnosis have been rendered. A February 2020 addendum stated that while the Veteran does have IVDS of the thoracolumbar spine, he did not have any episodes of acute signs and symptoms due to IVDS that required bedrest prescribed by a physician and treatment by a physician in the past 12 months. Records dated in 2019 and 2020 address other medical issues with no significant relevant medical evidence pertaining to the lumbar spine or associated radiculopathies. 1. Increased rating for lumbar disability The Veteran contends that he is entitled to a higher rating for his lumbar spine disability diagnosed as foraminal narrowing at L4-5. The Veteran’s lumbar spine foraminal narrowing at L4-5 is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 for lumbar strain. Because there is evidence of intervertebral disc syndrome (IVDS) however, with the radicular symptoms and nerve root involvement, the Board shall further evaluate this disability under 38 C.F.R. § 4.71a, Diagnostic Code 5243, for intervertebral disc syndrome (IVDS). Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. [Include any other relevant Note(s) to DC 5243. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted 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. A 20 percent rating is warranted 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 warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for foraminal narrowing at L4-5 based on incapacitating episodes. Although the Veteran has evidence of IVDS, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. Again, the examination opinion from the February 2020 addendum stated that while the Veteran does have IVDS of the thoracolumbar spine, he did not have any episodes of acute signs and symptoms due to IVDS that required bedrest prescribed by a physician and treatment by a physician in the past 12 months. Likewise, the February 2011 VA examination indicated that he did not require bedrest for his spine disability. The other examinations did not address this question as they determined he did not have IVDS. The records also do not reflect that he needed bedrest prescribed by a physician for his lumbar spine symptoms. The preponderance of the evidence is also against a rating in excess of 10 percent for foraminal narrowing at L4-5 under the General Rating Criteria. The Board acknowledges the Veteran’s lay reports of symptoms and the evidence of functional loss due to pain reported throughout the treatment records and examinations, as well as incoordination described in his hearing testimony as causing falls. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that would not result in limitation of motion more nearly approximating 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. His combined range of motion was repeatedly shown to be 230 degrees, while his flexion was 90 degrees and 80 degrees, respectively, in the February 2011 and January 2013 VA examinations. The combined range of motions added to 195 degrees in the June 2016 VA examination, which again showed his flexion to be 90 degrees. The most severe restrictions of motion were shown in the most recent VA examination of May 2019 which disclosed flexion to 80 degrees and combined range of motion to 180 degrees, while determining that functional loss with repetitive use over time limited his motion to the following: 68 degrees flexion and a combined range of motion of 153 degrees. Thus, even the most severely restricted motion contemplated by such functional loss is still shown to not meet the criteria for a 20 percent rating. Additionally, the evidence does not show muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Again, the examinations of February 2011, January 2013, June 2016 and May 2019, as well as the treatment records discussed above, fail to show such manifestations of abnormal spinal contour or abnormal gait resulting from his lumbar spine symptoms. Additionally, the examination reports, treatment records and radiological reports repeatedly showed no evidence of spinal fracture or ankylosis throughout the pendency of this appeal. As for neurological abnormalities the only associated neurological manifestations involve the bilateral lower extremities, which have been separately service-connected and shall be discussed separately. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for foraminal narrowing at L4-5. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Increased rating for right lower extremity radiculopathy of sciatic nerve The Veteran contends that he is entitled to a higher rating for right lower extremity radiculopathy of the sciatic nerve, which is currently rated 20 percent disabling. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. 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 is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating that may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. Regarding impairment of motor functions, the evidence throughout the pendency of the appeal does not disclose an impairment of motor function that resembles moderately severe incomplete paralysis. Generally, his muscle strength was shown to be in the range of normal 5/5 in all examinations in February 2011, January 2013, June 2016 and May 2019, except that in June 2016, he had 4/5 hip flexion on right side. The treatment records also do not reflect an impairment in motor function that would be equal to a moderately severe incomplete paralysis. Although an October 2010 vocational rehabilitation record noted subjective reports of being unable to keep his balance or stand for a long time, the physical findings from a February 2011 state disability examination disclosed he walked with a normal gait, used no assistive device and could stand on one leg at a time and stand on heels and toes. Later in October 2018 when seen in physical therapy consult, he was noted to walk without any assistive device, although reportedly at times he used a cane. The evidence disclosed that his impairment of motor function was such that his ability to walk for long periods was restricted, consistent with moderate disability but the objective findings do not reflect impairment consistent with moderately severe incomplete paralysis. The records and VA examination reports discussed above also show no evidence of muscle atrophy or of trophic changes. Regarding loss of reflexes, the only evidence of such loss was in the examinations in February 2011, which noted diminished but symmetrical patellar tendon and Achilles tendon reflexes. However, the examinations from January 2013, June 2016 and May 2019, repeatedly showed normal 2+ reflexes for the lower extremities. Such generally normal findings are not suggestive of an impairment consistent with moderately severe incomplete paralysis. The medical evidence in addition to the examinations does not reflect a loss of reflexes. Regarding pain and other sensory issues, the evidence discloses his pain to generally be constant in the right lower extremity, and fluctuating in severity. This pain is shown to specifically affect the right lower extremity in the February 2011 VA examination, which indicated that it could flare up to 8/10 intensity. Other records including in October 2010, February 2013, disclosed pain flaring up to 9/10 intensity, while a pain screen in October 2018 showed him reporting uncontrolled pain on a scale of 10/10. However, the VA examination of January 2013 disclosed normal sensory findings throughout the bilateral lower extremities from the upper thigh and continuing all the way to the toes and found no radicular pain or other signs/symptoms of radiculopathy. The June 2016 VA examination revealed mild intermittent pain, paresthesias and numbness. Other sensory findings were complaints of burning from the ankles to toes bilaterally. The June 2016 VA examination deemed the severity of the radiculopathy as mild for the right lower extremity. Finally, the April 2019 VA examination showed sensory examination findings of normal right upper thigh, thigh/knee, lower leg/ankle, foot/toes bilaterally. The Veteran had moderate intermittent radicular pain, paresthesias, and numbness for the right lower extremity and no other signs or symptoms of radiculopathy. The fluctuating severity of the pain and sensory manifestations evident in the records and VA examination reports is consistent with no more than a moderate incomplete paralysis of the sciatic nerve even with consideration of the provisions for neuritis or neuralgia under 38 C.F.R. §§ 4.123 and 4.124. Regarding complete paralysis, the evidence fails to show evidence consistent with that of a complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Again, none of the evidence in the records and examination reports disclose a disability of the right lower extremity/left lower extremity consistent with such findings. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by an impairment of motor functions, trophic changes, sensory disturbance, loss of reflexes, pain, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to no more than a moderate incomplete paralysis of the sciatic nerve/femoral nerve. The Board has considered all other potentially applicable diagnostic codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for sciatic/femoral nerve radiculopathy of the right lower extremity/left lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Increased rating for left lower extremity radiculopathy of the sciatic nerve The Veteran contends that he is entitled to a higher rating for left lower extremity radiculopathy of the sciatic nerve, which is currently rated 20 percent disabling. The pertinent rating criteria for sciatic nerve radiculopathy is set forth in the discussion addressing the right lower extremity radiculopathy of the sciatic nerve above and need not be repeated here. Regarding impairment of motor functions, the evidence throughout the pendency of the appeal does not disclose an impairment of motor function that resembles moderately severe incomplete paralysis. Muscle strength was shown to be in the range of normal 5/5 in all examinations in February 2011, January 2013, June 2016 and May 2019, for the left lower extremity. The treatment records also do not reflect an impairment in motor function that would be equal to a moderately severe incomplete paralysis. Although an October 2010 vocational rehabilitation record noted subjective reports of being unable to keep his balance or stand for a long time, the physical findings from a February 2011 state disability examination disclosed he walked with a normal gait, used no assistive device and could stand on one leg at a time and stand on heels and toes. Later in October 2018 when seen in physical therapy consult, he was noted to walk without any assistive device, although reportedly at times he used a cane. The evidence disclosed that his impairment of motor function was such that his ability to walk for long periods was restricted, consistent with moderate disability but the objective findings do not reflect impairment consistent with moderately severe incomplete paralysis. The records and VA examination reports discussed above also show no evidence of muscle atrophy or of trophic changes. Regarding loss of reflexes, the only evidence of such loss was in the examinations in February 2011, which noted diminished but symmetrical patellar tendon and Achilles tendon reflexes. However, the examinations dated in January 2013, June 2016 and May 2019, repeatedly showed normal 2+ reflexes for the lower extremities. Such generally normal findings are not suggestive of an impairment consistent with moderately severe incomplete paralysis. The medical evidence in addition to the examinations does not reflect a loss of reflexes. Regarding pain, the evidence discloses his pain to generally be constant in the left lower extremity, and fluctuating in severity. The February 2011 VA examination did not mention left lower extremity pain when it noted right lower extremity pain of 8/10 severity. Other records including in October 2010, February 2013, disclosed pain flaring up to 9/10 intensity, while a pain screen in October 2018 showed him reporting uncontrolled pain on a scale of 10/10. However, the VA examination of January 2013 disclosed a normal sensory examination throughout the bilateral lower extremities from the upper thigh and continuing all the way to the toes and found no radicular pain or other signs/symptoms of radiculopathy. The June 2016 VA examination revealed normal sensory findings of the left leg, including a normal upper thigh and lower leg/ankle, but decreased lower leg/ankle and foot/toes. Other sensory findings were complaints of burning from the ankles to toes bilaterally. For the left lower extremity, he had constant moderate pain, moderate paresthesias and numbness. The June 2016 VA examination deemed the severity of the radiculopathy as moderate for the left lower extremity. Finally, the April 2019 VA examination showed normal sensory findings of the left upper thigh, thigh/knee, lower leg/ankle, and foot/toes bilaterally. The Veteran had moderate intermittent radicular pain, paresthesias, and numbness in the left lower extremity and no other signs or symptoms of radiculopathy. The severity of the radiculopathy was moderate for the left sciatic nerve and no other neurological abnormalities were shown. The fluctuating severity of the pain and sensory manifestations evident in the records and VA examination is consistent with no more than a moderate incomplete paralysis of the sciatic nerve even with consideration of the provisions for neuritis or neuralgia under 38 C.F.R. §§ 4.123 and 4.124. Regarding complete paralysis, the evidence fails to show evidence consistent with that of a complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Again, none of the evidence in the records and examination reports disclose a disability of the right lower extremity/left lower extremity consistent with such findings. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by an impairment of motor functions, trophic changes, sensory disturbance, loss of reflexes, pain, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to no more than a moderate incomplete paralysis of the sciatic nerve/femoral nerve. The Board has considered all other potentially applicable diagnostic codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for sciatic nerve radiculopathy of the left lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Increased rating for radiculopathy of right lower extremity femoral nerve The Veteran contends that he is entitled to a higher rating for right lower extremity radiculopathy of the femoral nerve, which is currently rated 20 percent disabling. Paralysis of the anterior crural nerve, e.g., the femoral nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8626 and 8726. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 percent disabling. Complete paralysis of the quadriceps extensor muscles is rated as 40 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. 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 is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Regarding impairment of motor functions, the evidence throughout the pendency of the appeal does not disclose an impairment of motor function that resembles moderately severe incomplete paralysis. Generally, his muscle strength was shown to be in the range of normal 5/5 in all examinations in February 2011, January 2013, June 2016 and May 2019, except that in June 2016, he had 4/5 hip flexion on right side. The treatment records also do not reflect an impairment in motor function that would be equal to a moderately severe incomplete paralysis. Although an October 2010 vocational rehabilitation record noted subjective reports of being unable to keep his balance or stand for a long time, the physical findings from a February 2011 state disability examination disclosed he walked with a normal gait, used no assistive device and could stand on one leg at a time and stand on heels and toes. Later in October 2018 when seen in physical therapy consult, he was noted to walk without any assistive device, although reportedly at times he used a cane. The evidence disclosed that his impairment of motor function was such that his ability to walk for long periods was restricted, consistent with moderate disability but the objective findings do not reflect impairment consistent with moderately severe incomplete paralysis. The records and VA examination reports discussed above also show no evidence of muscle atrophy or of trophic changes. Regarding loss of reflexes, the only evidence of such loss was in the examinations in February 2011, which noted diminished but symmetrical patellar tendon and Achilles tendon reflexes. However, the examinations from January 2013, June 2016 and May 2019, repeatedly showed normal 2+ reflexes for the lower extremities. Such generally normal findings are not suggestive of an impairment consistent with moderately severe incomplete paralysis. The medical evidence in addition to the examinations does not reflect a loss of reflexes. Regarding pain, the evidence discloses his pain to generally be constant in the right lower extremity, and fluctuating in severity. This pain is shown to specifically affect the right lower extremity in the February 2011 VA examination, which indicated it could flare up to 8/10 intensity. Other records including in October 2010, February 2013, disclosed pain flaring up to 9/10 intensity, while a pain screen in October 2018 showed him reporting uncontrolled pain on a scale of 10/10. However, the January 2013 VA examination disclosed normal sensory findings throughout the bilateral lower extremities from the upper thigh and continuing all the way to the toes and found no radicular pain or other signs/symptoms of radiculopathy. The June 2016 VA examination revealed sensory findings of the right lower extremity of mild intermittent pain, paresthesias, and numbness. Other sensory findings were complaints of burning from the ankles to toes bilaterally. The June 2016 VA examination deemed the severity of the radiculopathy as mild for the right lower extremity. Finally, the April 2019 VA examination showed sensory examination findings of normal right upper thigh, thigh/knee, lower leg/ankle, and foot/toes bilaterally. The Veteran had moderate intermittent radicular pain, paresthesias, and numbness in the right lower extremity and no other signs or symptoms of radiculopathy. The fluctuating severity of the pain and sensory manifestations evident in the records and VA examination is consistent with no more than a moderate incomplete paralysis of the femoral nerve even with consideration of the provisions for neuritis or neuralgia under 38 C.F.R. §§ 4.123 and 4.124. Regarding complete paralysis, the evidence fails to show evidence consistent with that of a complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Again, none of the evidence in the records and examination reports disclose a disability of the right lower extremity/left lower extremity consistent with such findings. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by an impairment of motor functions, trophic changes, sensory disturbance, loss of reflexes, pain, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to no more than a moderate incomplete paralysis of the femoral nerve. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for femoral nerve radiculopathy of the right lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Increased rating for radiculopathy left lower extremity femoral nerve The Veteran contends that he is entitled to a higher rating for left lower extremity radiculopathy of the femoral nerve, which is currently rated 20 percent disabling The pertinent rating criteria for femoral nerve radiculopathy is set forth in the discussion addressing the right lower extremity radiculopathy of the femoral nerve above and need not be repeated here. Regarding impairment of motor functions, the evidence throughout the pendency of the appeal does not disclose an impairment of motor function that resembles moderately severe incomplete paralysis. His muscle strength was shown to be in the range of normal 5/5 in all examinations in February 2011, January 2013, June 2016 and May 2019, for the left lower extremity. The treatment records also do not reflect an impairment in motor function that would be equal to a moderately severe incomplete paralysis. Although an October 2010 vocational rehabilitation record noted subjective reports of being unable to keep his balance or stand for a long time, the physical findings from a February 2011 state disability examination disclosed that he walked with a normal gait, used no assistive device, and could stand on one leg at a time and stand on heels and toes. Later in October 2018 when seen in physical therapy consult, he was noted to walk without any assistive device, although reportedly at times he used a cane. The evidence disclosed that his ability to walk for long periods was restricted, consistent with moderate disability but the objective findings do not reflect impairment consistent with moderately severe incomplete paralysis. The records and VA examination reports discussed above also show no evidence of muscle atrophy or of trophic changes. Regarding loss of reflexes, the only evidence of such loss was in the examinations in February 2011, which noted diminished but symmetrical patellar tendon and Achilles tendon reflexes. However, the examinations in January 2013, June 2016 and May 2019, repeatedly showed normal 2+ reflexes for the lower extremities. Such generally normal findings are not suggestive of an impairment consistent with moderately severe incomplete paralysis. The medical evidence in addition to the examinations does not reflect a loss of reflexes. Regarding pain, the evidence discloses his pain to generally be constant in the left lower extremity, and fluctuating in severity. The February 2011 VA examination did not mention left lower extremity pain when it noted right lower extremity pain of 8/10 severity. Other records including in October 2010, February 2013, disclosed pain flaring up to 9/10 intensity, while a pain screen in October 2018 showed him reporting uncontrolled pain on a scale of 10/10. However, the VA examination of January 2013 disclosed a normal sensory exam throughout the bilateral lower extremities from the upper thigh and continuing all the way to the toes and found no radicular pain or other signs/symptoms of radiculopathy. The June 2016 VA examination revealed normal upper thigh and lower leg/ankle sensory findings, but showed decreased sensory findings in the lower leg/ankle and foot/toes. Other sensory findings were complaints of burning from the ankles to toes bilaterally. For the left lower extremity, he had constant moderate pain, moderate paresthesias, and numbness. The June 2016 VA examination deemed the severity of the radiculopathy as moderate for the left lower extremity. Finally, the April 2019 VA examination showed sensory exam findings of normal left upper thigh, thigh/knee, lower leg/ankle, foot/toes bilaterally. The Veteran had moderate intermittent radicular pain, paresthesias, and numbness for the left lower extremity and no other signs or symptoms of radiculopathy. The severity of the radiculopathy was moderate for the left femoral nerve and no other neurological abnormalities were shown. The fluctuating severity of the pain and sensory manifestations evident in the records and VA examination is consistent with no more than a moderate incomplete paralysis of the femoral nerve even with consideration of the provisions for neuritis or neuralgia under 38 C.F.R. §§ 4.123 and 4.124. Regarding complete paralysis, the evidence fails to show evidence consistent with that of a complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Again, none of the evidence in the records and examination reports disclose a disability of the left lower extremity consistent with such findings. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by an impairment of motor functions, trophic changes, sensory disturbance, loss of reflexes, pain, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to no more than a moderate incomplete paralysis of the femoral nerve. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for femoral nerve radiculopathy of the left lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Eckart The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.