Citation Nr: 21063118 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 16-14 936 DATE: October 13, 2021 ORDER Entitlement to service connection for deep vein thrombosis (DVT) of the left lower extremity, claimed as blood clots, is denied. Entitlement to an increased rating for right knee strain with degenerative arthritis based upon motion loss, currently rated as 10 percent prior to December 18, 2018 and 20 percent thereafter, is denied. Entitlement to a 40 percent rating, but no higher, from March 2, 2016, but no earlier, for lumbosacral strain with degenerative changes is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to a separate 10 percent rating, but no higher, from May 3, 2018, but no earlier, for left lower extremity lumbar radiculopathy is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to a total disability rating based upon individual unemployability (TDIU) exclusively based on service-connected lumbosacral strain with degenerative changes from March 2, 2016 is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s)(1) is denied. FINDINGS OF FACT 1. The most probative evidence shows that the Veteran was not diagnosed with left leg DVT until July 2012. 2. The recurrent left leg DVT is not otherwise related to service or service-connected left ankle disability. 3. Throughout the appeals period, the limitation of motion for right knee flexion did not more nearly approximate 45 degrees at worst, to include with consideration of functional impairment. 4. Prior to December 18, 2018, the limitation of motion right knee extension did not more nearly approximate 10 degrees, to include consideration of functional impairment. 5. From December 18, 2018, the limitation of motion right knee extension more nearly approximated 15 degrees with consideration of functional loss; at no time did it more nearly approximate 20 degrees, to include consideration of functional impairment. 6. From March 2, 2016, the Veteran's lumbar spine disability symptomatology more nearly approximates flexion to 30 degrees or less with consideration to functional impairment but does not more nearly approximate unfavorable ankylosis of the thoracolumbar spine or the entire spine to include consideration of functional impairment. 7. From May 3, 2018, the Veteran had left lower extremity lumbar radiculopathy approximating no more than mild incomplete paralysis of the sciatic nerve. 8. From March 2, 2016, the Veteran's service-connected lumbosacral strain alone rendered him unable to secure and follow a substantially gainful occupation. 9. The Veteran does not have additional service-connected disabilities or disabilities independently ratable at 60 percent, separate and distinct from the service-connected lumbosacral strain disability. CONCLUSIONS OF LAW 1. The criteria for service connection for DVT of the left lower extremity, claimed as blood clots, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Prior to December 18, 2018, the criteria for a rating in excess of 10 percent for right knee disability based upon limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5260, 5261. 3. From December 18, 2018, the criteria for a rating in excess of 20 percent for the right knee disability based upon limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5260, 5261. 4. Resolving reasonable doubt in the Veteran's favor, from March 2, 2016, but no earlier, the criteria for entitlement to an increased rating of 40 percent, but no higher, for lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.10, 4.40, 4.45, 4.59, 4.71, DCs 5237, 5242. 5. Resolving reasonable doubt in the Veteran's favor, from May 3, 2018, but no earlier, the criteria for a separate 10 percent rating, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 5237 Note 1, 8520. 6. From March 2, 2016, the criteria for a TDIU based exclusively upon service-connected lumbosacral strain on an extraschedular basis under 38 C.F.R. § 4.16(b) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 7. The criteria for entitlement to SMC(s)(1) have not been met. 38 U.S.C. §§ 1114(s)(1), 5107; 38 C.F.R. § 3.350(i)(1). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1979 to April 1988. This case originally came to the Board of Veterans' Appeals (Board) on appeal from June 2013 and May 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The June 2013 rating decision denied service connection for blood clots, left lower extremity. The May 2016 rating decision continued the previously established ratings for the right knee strain and lumbosacral strain. In February 2019, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In September 2019, the Board issued a decision, which in pertinent part, denied service connection for DVT, partially granted an increased rating for right knee strain based upon motion loss, and remanded the increased rating claim for lumbosacral strain. It also granted entitlement to TDIU from March 2, 2016 due to service-connected disabilities as an issue implicitly raised by the rating claims. The Veteran appealed the portion of the September 2019 Board decision denying the above issues to the United States Court of Appeals for Veterans Claims (Court). Before the Court issued a decision, the parties filed a joint motion for partial remand (JMPR) that vacated the September 2019 Board decision with respect to the above denied issues and remanded them to the Board for adjudication consistent with the JMPR instructions. The Court granted the JMPR in July 2020. The July 2020 JMPR found that the issues of entitlement to TDIU exclusively due to lumbosacral strain and SMC under 38 U.S.C. § 1114(s)(1) were raised by the record, and the Board has added them as separate issues on appeal. In February 2021, the Board remanded the issues set forth on the title page for additional development. For the reasons indicated in the discussion below, the development has been completed to the extent possible, and the issues have returned for review. In April 2021, the VA Director of Compensation Service (Director) issued an Advisory Opinion recommending denial of entitlement to a TDIU exclusively due to lumbosacral strain on an extraschedular basis under 38 C.F.R. § 4.16(b). The Board has added the additional issues of entitlement to separate ratings for lower extremity radiculopathy in connection with the lumbar spine increased rating claim. See Chavis v. McDonough, 34 Vet. App. 1, 28-29 (2021). Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5103(a), 5103A; 38 C.F.R. § 3.159. The issues adjudicated in the instant decision are also subject to compliance with the September 2019 Board remand, July 2020 JMPR and February 2021 Board remand. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Remand compliance will be discussed below for each issue or group of issues as appropriate. For the lumbar spine disability, the September 2019 and February 2021 Board remands instructed that the Veteran have an opportunity to identify or submit medical evidence regarding physician directed bed rest, obtain updated VA treatment records, and furnish an updated VA lumbar spine examination. The agency of original (AOJ) was then to readjudicate the claim. The AOJ sent the Veteran a February 2021 letter requesting that he identify or submit any medical evidence regarding physician directed bed rest and if possible, a statement from the treating clinician about the frequency of such treatment. The Veteran did not respond. Updated VA treatment records were obtained, and the Veteran had a June 2021 VA-contract lumbar spine examination. The AOJ readjudicated the claim in June 2021. For the DVT and right knee disabilities, they are subject to the July 2020 JMPR and February 2021 Board remand. The July 2020 JMPR found for the service connection claim that additional pertinent evidence was received following the January 2016 statement of the case (SOC), specifically Social Security Administration (SSA) records and VA treatment records from February 2018. For both DVT and right knee disability, the July 2020 JMPR found that there were relevant outstanding private medical records from Dr. D.D. and a private orthopedist referred to in July 2016 VA kinesiotherapy records. Additional efforts were needed to obtain these records. In response, the AOJ sent the Veteran a February 2021 letter identifying Dr. D.D. and Dr. T from a July 2016 VA kinesiotherapy clinic report as outstanding private medical providers and requested that he submit releases for these private medical records or directly submit these records to VA. The Veteran did not respond. The AOJ readjudicated these claims in June 2021 with consideration to the SSA records and VA treatment records through June 2021. For the TDIU and SMC(s)(1) claims, the July 2020 JMPR and February 2021 Board remand, as applicable, directed that entitlement to TDIU based on service-connected lumbosacral strain with degenerative changes be referred to the Director of Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b). In April 2021, the Director issued an advisory opinion on this matter. The AOJ readjudicated these claims in June 2021. For the right knee and lumbar spine rating claims, the Board notes the legal guidance concerning functional impairment assessments in rating orthopedic disabilities. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). The Board finds that the Veteran is not prejudiced by any inadequacy from in determining functional impairment or accounting for incapacitating episodes for these claims. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009). For the lumbar spine disability, the Board has used the Veteran's estimate of motion loss during flare-up episodes to award the maximum schedular rating based upon motion loss and the instant decision effectively results in a total rating for service-connected lumbosacral strain through the single disability TDIU award. For the right knee, the demonstrated joint motion in both planes at issue is much greater than the contemplated motion loss by the next higher rating criteria. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of 38 C.F.R. § § 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 [or 4.73] criteria."). More information as to right knee functional impairment during this period would not overcome the large gap from the specified motion loss to more nearly approximate the higher ratings than those granted herein or substantiate additional benefits. For these reasons, any deficiency in the VA knee or lumbar spine examination reports is harmless error. See Shinseki, 556 U.S. at 409-10. For the above stated reasons, the issues are ready for appellate adjudication. Id. Service connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service treatment records (STRs) from May 1981 include a Walter Reed Army Medical Center (Walter Reed hospital) hospitalization report. It showed that the Veteran was hospitalized for approximately 6 weeks for an unstable left ankle. Shortly after his admission, the Veteran underwent an Evans lateral reconstruction of his left ankle. The postoperative course was benign. Three days following the surgery, the Veteran started using a walking cast and reported acute posterior pain. A phleborrheogram was performed and did not show deep vein thrombosis (DVT). At discharge, the cast was removed, and the wound appeared in fine shape with significantly decreased swelling. The discharge diagnosis was left ankle instability following left ankle Evans procedure with no neurovascular compromise. June 1981 STRs from the Redstone Arsenal clinic showed that the Veteran had increased pain and swelling following cast removal. Clinical evaluation revealed moderate edema, tenderness and a small area of skin breakdown without pus. The clinician assessed the wound as non-infected, but with postoperative edema and inflammation. He recommended rest for the next two days. August 1981 STRs from Redstone Arsenal noted that the Veteran complained about left ankle swelling with activity and muscle cramping. Left ankle clinical evaluation revealed a mild degree of swelling. The clinician assessed increased sensitization secondary to soft tissue adhesions. The Veteran received a temporary profile for rest. June 1982 STRs noted a mild left ankle sprain, apparently related to the surgery. Clinical evaluation revealed tenderness near the operative site and tendons. August 1982 STRs reported continuing left ankle pain and loss of sensation of the left foot and ankle. A Medical Evaluation Board (MEB) report from April 1987 assessed degenerative osteoarthritis of the left ankle. The Veteran had a history of multiple left ankle sprains, manifested by pain, swelling and impaired weight-bearing ability. He underwent ligamentous reconstruction surgery in 1981. No venous abnormality history was noted. July 2011 VA treatment records showed that the Veteran complained about left leg pain over the past two months. He denied trauma or breathing problems. Clinical evaluation of the left lower extremity showed mild swelling without redness. Left calf was non-tender. Varicose veins were noted. Dilated venous capillaries of both ankles showed the left greater than the right. Pulse were 2+ bilaterally. No ulcers or callouses were found. Sensation was intact. The clinician assessed edema, left leg and rule out DVT. She also noted possible chronic venous insufficiency/ varicose veins. The clinician ordered an ultrasound (US) to rule out DVT. A July 2011 addendum reported that the ultrasound was negative for DVT. The clinician recommended compression stockings and a podiatry referral for plantar fasciitis treatment. July 2012 private medical records showed that the Veteran was hospitalized for left leg swelling and pain. He had periodic VA treatment but denied ever having a Doppler test. He had a left leg ultrasound. He denied any DVT treatment for the past 10 years. He presented for emergency room (ER) treatment because his left leg exhibited increased swelling and pain. He also reported increased shortness of breath over the past month that had recently worsened. ER evaluation included a Doppler study confirming DVT in the upper calf of the left posterior tibial vein. The Veteran reported a history of left ankle fracture and repair with DVT complication. Most recently, he had a ventral hernia repair. Physical examination revealed enlarged left leg with good pulsation. No gangrene or ulcer was found. The physician assessed DVT, left leg and rule out pulmonary emboli. In the July 2012 private hospitalization summary, the physician listed left lower extremity DVT as a final diagnosis. He stated that the etiology was unclear. The Veteran had been sedentary prior to admission, and it was the only known risk factor. The physician also noted that the Veteran appeared to report a prior DVT following left ankle fracture. In June 2013, the Veteran had a VA artery and vein examination with nurse practitioner (NP). The NP diagnosed DVT, left leg with a July 2012 onset. The Veteran reported initially having a DVT in 1981 during left ankle surgery treatment at Walter Reed Hospital. He had a recurrence in 2011. He reported taking Coumadin for several months. He had three other surgeries without any DVT recurrence. Most recently, he had abdominal hernia repair surgery in November 2011. He was subsequent diagnosed with left leg DVT in 2012 and was hospitalized for about a week. He took coumadin for treatment. The NP reviewed the claims folder and detailed the STRs. She furnished a negative medical opinion. She stated that the STRs did not show that the Veteran developed DVT during service. Then, she noted other risk factors for DVT and determined that the left ankle disability was not a risk factor for DVT. She did not find any other evidence relating the left ankle disability to DVT. In his July 2013 notice of disagreement (NOD), the Veteran reported that being diagnosed with DVT in 1981 following left ankle surgery at Walter Reed Hospital. He requested review of these medical records. February 2018 VA pharmacy note listed the Veteran as having recurrent DVT in left lower extremity with first episodes occurring in 1980 on active duty, three months following surgery. In January 2019, the Veteran submitted two DVT medical articles in support of his claim. The first medical article was published in May 2011. As relevant, it identified surgery as a leading risk factor. However, it reported that leg blood clots following foot and ankle surgery were relatively rare. It reported that DVT was diagnosed with an ultrasound and required treatment to avoid recurrence. A second medical article published in December 2009 found that the risk of blood clot following surgery was higher and longer than previously thought. It noted elevated blood clot risk that lasted up to a year following surgery. In February 2019, the Veteran had a Board hearing. He reported that his blood clots were caused by the in-service left ankle surgery at Walter Reed Hospital. He recalled that he spent an additional month in the hospital due to left leg blood clots. He was now on chronic warfarin therapy. About three weeks following the left ankle surgery, he returned to his duty station (Redstone Arsenal). He then had to return Walter Reed Hospital and that was when the blood clot was found. He started blood thinner treatment, which resolved the problem. However, the treating clinicians informed him that the recurrence risk was very high. The Veteran was certain that treating clinicians informed him that his left ankle surgery caused the blood clot since the surgery involved bleeding near the blood clot. In March 2019, Dr. D, a treating podiatrist, furnished a letter in support of the claim. He reported that the Veteran had a history of left ankle fracture with surgical treatment and developed DVT post operatively. He opined that the venous disease was related to the left ankle surgery. In March 2019, Dr. H, a treating internist, furnished a letter in support of the claim. He noted the Veteran had surgery for a left ankle fracture and developed DVT afterwards. The Veteran currently had symptoms of venous disease. He believed the current left lower extremity swelling and venous disease were related to the left ankle surgery. For the following reasons, the Board finds the preponderance of the evidence weighs against a relationship between recurrent left leg DVT and active military service or service-connected left ankle disability. The disputed issue is a relationship to service or service-connected left ankle disability. The Board finds that establishing a left leg DVT diagnosis and identifying its cause requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). DVT is a complex internal venous process. It is beyond the readily observable cause and effect type relationships that the courts have deemed within the competence of lay reporters. See id. Thus, the Veteran's self-reports diagnosing DVT, or its cause are not competent. The Veteran is competent to relate his medical history and information given to him from treating clinicians in support of a diagnosis and relationship to service. Here, the Veteran contends he developed a left lower extremity blood clot as a postoperative complication from his April 1981 left ankle surgery. See February 2019 Board hearing. He reported initially having left ankle surgery at Walter Reed Hospital and then having to return from his regular duty station (Redstone Arsenal) to Walter Reed Hospital for additional hospitalization for DVT as a postoperative complication. Id. Treating clinicians warned him that the postoperative DVT complication following the April 1981 left ankle surgery made the likelihood of DVT recurrence very high. Since the Veteran is competent to relate the above medical history, the issue is the probative value of his recollections. It would be expected that if the Veteran had DVT or similar venous abnormality, such symptoms would be noted in STRs created within months of the surgery or the MEB report. Molitor v. Shulkin, 28 Vet. App. 397, 410 (2017) ("The absence of evidence only tends to prove the nonexistence of a fact if the fact would ordinarily have been recorded"). STRs do not support the Veteran's recollections of a military DVT diagnosis. The May 1981 hospitalization report stated that a specific test did not show DVT. It did not include any other indication for a venous postoperative complication following the April 1981 left ankle surgery. STRs from June 1981 and August 1981 at the Veteran's regular duty station (Redstone Arsenal) include no reference to the subsequent treatment reported by the Veteran at Walter Reed Hospital for a left leg DVT complication. Then, the April 1987 MEB report makes no reference to DVT or similar venous abnormality during active service. The Veteran's assertion that he had DVT as a postoperative complication following April 1981 left ankle surgery is not probative due to the inconsistency with contemporaneous medical records that would be expected to document the occurrence of DVT or similar left lower extremity venous disorder. Id. Accordingly, a relationship to service is not shown from the Veteran's recollections of his medical treatment history. From this determination that DVT was not manifested in service, the Board finds that the February 2018 VA pharmacy records and March 2019 private medical opinions are not probative to show a relationship to service. The medical history found in February 2018 VA pharmacy records is simply a transcription of the Veteran's self-reported medical history that has been deemed not probative. For the medical opinions, both clinicians relied on an inaccurate medical history that DVT was associated with the military left ankle surgery as their rationale. They did not independently review the STRs. They do not identify another military cause for post-service DVT. The Board has considered the submitted medical articles. Medical article and treatise evidence "can provide important support when combined with an opinion of a medical professional." Sacks v. West, 11 Vet. App. 314, 317 (1998). At best, the medical articles identified surgery as a leading DVT risk factor and that the risk lasted longer than initially thought, up to a year. In this case, the time lapse between surgery and symptom onset is many years. The medical articles do not in way suggest that DVT risk following surgery lasts for many years. For these reasons, the Board does not find the medical articles probative to suggest a relationship to service or warrant an additional medical opinion. The remaining medical opinion is from the June 2013 VA NP, and it weighs against a relationship to service. The NP found that recurrent DVT had an onset many years after service and was not otherwise related to service. She noted the Veteran's reports about military DVT treatment, but implicitly rejected them as inconsistent with the STRs. In other words, she did not find evidence for continuous symptoms from service or a military event for the post-service recurrent DVT. The NP provided a clear explanation as to why a military relationship or secondary relationship was not found. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Her rationale is consistent with the record which does not show in-service DVT or similar venous disorder but suggests a lengthy time lapse between initial suspicion for DVT in July 2011 from contemporaneous symptoms and active service. The Board finds that the June 2013 VA medical opinion is probative evidence weighing against a relationship to service. Briefly, an alternative theory of entitlement is that the 2011 DVT is secondary to the service-connected left ankle disability. The Board finds that the secondary relationship issue is inherently a complex medical question due to the time lapse and venous disease process underlying DVT. For this issue, the Veteran is competent to report his medical history, but not a relationship to service. Jandreau, 492 F.3d at 1377 n.4. The Veteran's description of his medical history above indicates that the April 1981 left ankle surgery, rather than the current left ankle disability, is the cause. The favorable medical opinions assume DVT developed following left ankle surgery and do not suggest the left ankle disability is a cause for the July 2012 left leg DVT. The record does not include any competent evidence that the left ankle disability itself caused or aggravated the 2011 left leg DVT. A secondary relationship will not be considered further. Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) ("Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). For the foregoing reasons, the preponderance of the evidence is against this claim. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for service connection for recurrent DVT, claimed as blood clots, must be denied. 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102. Increased rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate in any rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Right knee strain with degenerative arthritis The Veteran is service-connected for right knee strain with degenerative arthritis. This disability is currently rated as 10 percent disabling prior to December 18, 2018 and 20 percent thereafter based on limitation of extension. The Veteran also has a 10 percent rating for right knee instability under DC 5257. However, the July 2020 JMPR stated that an appeal for a higher right knee rating based upon instability would not be pursued. This issue of a rating based upon right knee instability will not be discussed further. The DCs pertaining to limited knee motion are found under DCs 5260 and 5261 for limitation of leg motion. 38 C.F.R. § 4.71a, DCs 5260, 5261. DC 5260, limitation of flexion of a leg, provides a 10 percent rating if flexion is limited to 45 degrees, and a 20 percent rating if flexion is limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion that is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261, limitation of extension of a leg, provides a 10 percent rating when extension is limited to 10 degrees and a 20 percent rating when extension is limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees and a 40 percent rating for extension limited to 30 degrees. A maximum 50 percent rating applies when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004. The Board notes the recent amendments to the rating schedule. 85 Fed. Reg. 76453 (November 30, 2020); 85 Fed. Reg. 85523 (Dec. 29, 2020). However, these amendments do not pertain to the DCs at issue and will raise any reasonable possibility of substantiating higher ratings. They will not be considered further. See Robinson, supra. There are additional knee DCs. However, in of this specific case, the service-connected right knee symptoms have not either manifested as or been attributed to ankylosis, meniscus disorder, impairment of the tibia or fibula, or genu recurvatum. Therefore, separate or higher ratings under the additional knee DCs 5256, 5258, 5262 or 5263 do not merit further consideration. 38 C.F.R. §§ 4.14, 4.71a, DCs 5256, 5258, 5262, 5263. The Veteran filed an increased rating claim for right knee disability on March 2, 2016. The rating period under consideration dates to March 2, 2015 to include the one year look back period for increased rating claims. 38 C.F.R. § 3.400(o). September 2015 VA treatment records included a pre-anesthesia screen for the Veteran prior to a colonoscopy. As relevant, the clinician noted that the Veteran used a cane for chronic right knee instability and bilateral foot pain. In April 2016, the Veteran had a VA knee examination with a NP. The NP listed a diagnosis of right knee strain. The Veteran reported persistent right knee pain with popping sounds. He stated that his right knee frequently locked up. He denied a history for physical therapy, injections or surgical treatment and flare-ups. However, he described functional impairment as limitations with prolonged standing, sitting, and walking. Right knee flexion was to 110 degrees and extension was complete. Pain was noted with flexion and extension but not deemed to cause functional loss. Left knee motion was slightly greater and without pain. Repetitive use testing did not show additional motion loss. The NP declined to estimate additional motion loss during periods of repeated use over time. She cited an inability to observe the Veteran. For additional factors contributing to disability, the NP reported less movement than normal due to ankylosis, adhesions, among others and disturbance of locomotion. Muscle strength testing was normal. Ankylosis was not found. Joint stability testing was normal. The NP noted constant use of a cane and cited service-connected back, knee and ankle disabilities as the cause. Right knee X-rays confirmed osteoarthritis. The NP reported functional occupational impact as limitations with prolonged standing, sitting and walking. July 2016 VA kinesiotherapy clinic records showed that the Veteran had a kinesiotherapy evaluation for bilateral knee degenerative joint disease (DJD). He reported a 15 year history of severe pain in both knees. It was aggravated by walking and relieved by rest. Range of motion (ROM) study for the right knee revealed 119 degrees flexion and normal extension. Right quadricep and hamstring strength was 4/5. Knee circumference was the same for both knees. Right knee valgus stress was noted as minimal. The clinician reviewed X-rays that showed moderate right knee DJD. The Veteran reported that a private orthopedist had recommended a brace. The clinician assessed coordination and balance as good. He refitted the Veteran's cane and issued knee orthoses for knee support. December 18, 2018 private medical records showed that right knee active flexion was to 90 degrees and extension was to 10 degrees. In his January 2019 substantive appeal, the Veteran stated that incapacitating episodes were not taken into account during the April 2016 VA knee examination. At the February 2019 hearing, the Veteran reported he had problems with moving his right knee forward and back, as well as instability. He reported falling because of his right knee giving out or locking up. It occurred randomly. He used a knee brace and cane. He estimated that his right knee instability episodes occurred a couple of times a month. (a) Limitation of motion prior to December 18, 2018 The Veteran has a 10 percent right knee rating based upon joint pain with noncompensable motion loss. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5261; see also Burton v. Shinseki, 25 Vet. App. 1 (2011). In order to receive a single rating in excess of 10 percent for motion loss, knee motion loss must more nearly approximate the 20 percent rating criteria in either leg flexion or extension plane. 38 C.F.R. § 4.14. This is because the currently assigned 10 percent rating for noncompensable motion loss contemplates right knee pain without compensable motion loss and would be incorporated into any 10 percent rating for compensable motion loss. Id. Again, the Veteran may demonstrate compensable motion loss in both the flexion and extension planes to warrant separate ratings without pyramiding symptoms. VAOPGCPREC 9-2004. The available ROM studies show that right knee flexion and extension is appreciably greater than the compensable leg flexion and extension motion loss rating criteria under DCs 5260 and 5261. 38 C.F.R. § 4.71a, DC 5260, 5261. The Board has considered functional impairment from flare-ups and repetitive use over time. English v. Wilkie, 30 Vet. App. 347 (2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran is competent to describe right knee functional impairment. Jandreau, 492 F.3d at 1377, n. 4. The Board finds his reports about right knee pain credible since joint pain is closely associated with the documented right knee osteoarthritis. The precise limitation of leg motion during periods of repetitive use or flare-ups is not clear. However, the evidence weighs against a finding that estimated motion loss from functional impairment more nearly approximates the 10 percent rating criteria for both flexion and extension to warrant separate ratings for compensable motion loss in different planes or the 20 percent rating criteria in either flexion or extension for the right knee. Thompson, 815 F.3d at 785 ("[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 [or 4.73] criteria."). The Veteran complains about functional impairment as limitations in prolonged standing, sitting and walking and in January 2019, incapacitating episodes of pain. However, he denied right knee flare-ups at the May 2016 VA examination. The clinical right knee ROM showed that flexion was to 110 degrees, at worst and extension was to 0 degrees, at worst. For separate compensable ratings, the Veteran would have to demonstrate flexion motion loss more nearly approximating 45 degrees, in addition to extension motion loss more nearly approximating 10 degrees. The Veteran does not provide any specific reports about motion loss from functional impairment as limitations in prolonged standing, sitting and walking. At best, he refers to incapacitating episodes of right knee pain in January 2019 without any details. Nonetheless, the Board must rely on the observed ROM studies as a baseline for rating right knee motion loss. The discrepancy from observed flexion motion loss is too great to infer that functional loss more nearly approximates limitation of flexion to 45 degrees and extension was to 10 degrees for separate compensable motion loss ratings. In other words, the demonstrated ROM studies are too great to infer motion loss more nearly approximating the 10 percent rating criteria for either plane. Id. For the foregoing reasons, prior to December 18, 2018, a right knee disability rating in excess of 10 percent or separate ratings for compensable motion loss in the flexion and extension planes is not warranted. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. 38 U.S.C. §§ 5107(b); 38 C.F.R. § § 4.3. (b) Limitation of motion from December 18, 2018 It cannot be stated with certainty as to precisely when the Veteran's right knee limitation of extension increased. 38 U.S.C. § 5110(b)(3) ("The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability occurred[.]"); 38 C.F.R. § § 3.400(o)(2) (awarding an increased evaluation for disability compensation as of the "[e]arliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred"). However, December 18, 2018 is the date of a private ROM study confirming right knee extension to 10 degrees. Taken together, all of the evidence including the lay evidence reflects that this is the earliest date on which it is factually ascertainable that the Veteran's right knee extension more nearly approximated the 20 percent rating criteria, but no higher, with consideration to functional impairment as explained below. Swain v. McDonald, 27 Vet. App. 219, 224 (2015) (an "effective date should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that [the veteran's disability] first manifested"). On December 18, 2018, a treating primary care physician (Dr. H) completed a right knee ROM assessment. He reported that right knee extension was to 10 degrees. As relevant, DC 5261 provides a 20 percent rating when leg extension is limited to 15 degrees and a 30 percent rating when limited to 20 degrees. Id. The December 18, 2018 ROM study report showed right knee extension was limited to 10 degrees. This report facially meets the 10 percent rating criteria under DC 5261 for leg, limitation in extension. Id. Then, the Veteran's competent and credible reports of functional impairment from repetitive use must also be considered. English, supra. The Board observes that the 20 percent rating criteria under DC 5261 contemplate 15 degrees limitation of extension, which is only 5 degrees more than the 10 degrees contemplated by the currently assigned rating criteria. Thompson, 815 F.3d at 785 ("[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 [or 4.73] criteria."); Id. The Veteran's right knee functional loss reports concern restricted activities due to significant increases in pain with prolonged activity, as opposed to specific right leg extension motion loss. The Board notes the January 2019 reference to incapacitating right knee pain episodes. However, the report is vague without details for the frequency, severity and duration. It is reasonable to infer that the Veteran experiences some degree of additional right leg extension motion loss during flare-ups and repetitive use. Although estimated functional loss cannot be stated with certainty, it is feasible to estimate that the right leg extension motion loss more nearly approximated 15 degrees during repetitive use over time or flare-up episodes. Id.; English, supra. Given the December 18, 2018 right knee extension ROM study and Veteran's reports of functional impairment during prolonged activity, the evidence is at least evenly balanced that estimated right leg extension motion loss during functional impairments more nearly approximates 15 degrees from December 18, 2018. Id. Thus, from December 18, 2018, a 20 percent rating for right leg, limitation of extension is more nearly approximated with consideration to functional impairment. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5242; Mitchell, 25 Vet. App. at 44; Correia, 28 Vet. App. at 169-170; Sharp, 29 Vet. App. at 33. The criteria for a rating in excess of 20 percent based upon right knee extension motion loss or a separate 10 percent rating for flexion motion loss is not more nearly approximated during this period. 38 C.F.R. § 4.71a, DC 5261. Again, the December 2018 ROM study showed right knee extension motion loss to 10 degrees. The Board has accounted for estimated extension motion loss due to functional impairment by assigning the next higher 20 percent rating. Id. Although the precise limitation of extension is not clear during flare-ups and repeated use over time, the baseline ROM studies show significantly greater right leg extension than 20 degrees. The preponderance of the evidence weighs against a finding that estimated right leg extension motion loss more nearly approximate 20 degrees for the 30 percent rating criteria. Id.; Thompson, supra. There is no evidence suggesting right knee flexion more nearly approximated 45 degrees even with consideration to functional impairment. Accordingly, the evidence from this period weighs against a rating award in excess of 20 percent for right knee limitation of extension or separate 10 percent award for right knee limitation of flexion, even with consideration to functional impairment. Id. For the foregoing reasons, the Board resolves reasonable doubt in the Veteran's favor to find from December 18, 2018, a 20 percent rating is warranted for service-connected right knee disability based upon limitation of extension. As the preponderance of the evidence is against a right knee strain rating based upon motion loss in excess of 20 percent, the benefit of the doubt doctrine is not for application and this portion of the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Lumbosacral strain with degenerative changes The Veteran has a 20 percent rating prior to June 5, 2021 and 40 percent rating thereafter for service-connected lumbosacral strain with degenerative changes under DC 5242-5237. DC 5242 provides ratings under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Id. Under the General Rating Formula for lumbar spine disability, such disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. As relevant, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 evaluation is warranted where forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. The only higher schedular evaluations under the General Rating Formula are 50 percent for unfavorable ankylosis of the entire thoracolumbar spine and 100 percent for ankylosis of the entire spine. Id. Any associated neurological abnormalities are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula, 38 C.F.R. § 4.71a. The Board notes the alternative Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, DC 5243. The Veteran referred to bed rest as part of his back pain treatment at the February 2019 Board hearing. However, there is no medical evidence concerning physician directed bed rest for IVDS treatment and incapacitating episodes of back pain. The VA and VA-contract examination report stated that IVDS was not found and make no reference to physician directed bed rest treatment. Thus, the alternative rating criteria for IVDS will not be considered further. See Robinson, supra. The Board also notes the recent amendment to the rating schedule. 85 Fed. Reg. 76453 (November 30, 2020); 85 Fed. Reg. 85523 (Dec. 29, 2020). However, these amendments do not raise any reasonable possibility of substantiating higher ratings than those awarded herein, and they will not be considered further. See Robinson, supra. The Veteran filed an increased rating claim for his lumbosacral strain disability on March 2, 2016. The rating period under consideration dates to March 2, 2015 to include the one year look back period for increased rating claims. 38 C.F.R. § 3.400(o). In April 2016, the Veteran had a VA lumbar spine examination with a NP. The Veteran reported persistent low back pain radiating to his left leg. He denied any epidural or surgical treatment. He took pain relief medication and reported having neuropathy secondary to diabetes. Functional loss was described as difficulty getting out of bed, bending, and lifting objects greater than 10 pounds. Lumbar spine flexion was to 60 degrees. Extension was to 20 degrees. Right and left lateral flexion and lateral rotation were all to 20 degrees. Pain was noted in all planes of motion, but not found to result in functional loss. Guarding and muscle spasm were not indicated. Muscle strength testing was complete for the knee and slightly diminished 4/5 for the ankle and great toe bilaterally. Reflex and sensory examinations were normal. Radiculopathy and IVDS were not indicated. The Veteran used a cane on a constant basis for ambulation. Functional impact was difficulty getting out of bed, bending, and lifting objects greater than 10 pounds. For flare-ups, the NP declined to assess additional functional impairment due to her inability to observe the Veteran. November 2016 private medical records included complaints about severe low back pain that made it difficult to walk. It had lasted two days. May 2018 private medical records reported complaints about low back pain with radicular symptoms. Lumbar spine imaging study showed L4-5 abnormalities. Surgery was not indicated, but steroid injections were. The clinician assessed radiculopathy, lumbar region. December 2018 private medical records included a ROM questionnaire. Lumbar spine flexion was reported as 50 degrees, extension as 5 degrees and right/ left lateral bending and right/left lateral rotation were all to 10 degrees. Functional impairment was inability to walk or stand long periods without rest breaks. In January 2019, the Veteran reported that his lumbar spine disability had worsened since the April 2016 VA spine examination. At the February 2019 Board hearing, the Veteran stated that he had limited flexibility in his back. His back pain radiated into his leg, and he had had left leg numbness for the past 10 or 12 years. Treating clinicians related these symptoms to his back. His only current treatment options were medication, heat pads, and a TENS unit. At night, he would wake up and be unable to move from a side leaning position without his wife's help. His wife also helped him put on his socks and arise from a seated position. The Veteran again reported that pain radiated down both legs. He used a back brace, TENS unit and cane. During flare-ups, he estimated that he lost 85 percent of his ROM. Sometimes heat pad and TENS machine helped, but generally he was unable to move his back very much during flare-ups. He also stated his physicians advised him to rest in bed for a few days as part of his back pain management. In February 2021, the Veteran had a VA-contract lumbar spine examination with a NP. The NP diagnosed degenerative disc disease, other than IVDS and lumbosacral strain. The Veteran currently experienced back pain with functional impairment of limited bending, limited twisting and inability to stand for long periods. Back pain flare-ups occurred daily and were severe with days long duration. They were precipitated by turning, particularly when arising from bed. Functional impairment was described as difficulty with bending over, picking up objects and walking. Active lumbar spine ROM was flexion to 50 degrees, extension to 15 degrees and right/ left lateral bending and right/left lateral rotation were all to 20 degrees. Pain was noted with planes of motion, weight-bearing activities and caused functional loss of pain with lifting over 15 pounds and prolonged weight bearing. For repeated use over time and flare-ups, the NP estimated lumbar flexion would be to 45 degrees. Guarding and muscle spasm was not indicated. Muscle strength testing was complete. Reflexes were normal. Straight leg raise (SLR) testing was negative. Radiculopathy, ankylosis and IVDS was not indicated. The Veteran used a cane on a regular basis for assistance. Functional impact was reported as pain with lifting objects over 15 pounds. In June 2021, the Veteran had a VA-contract lumbar spine examination with a physician. The physician diagnosed lumbosacral strain with degenerative changes. Following separation, the Veteran reported receiving primary care treatment for back pain since separation. He also referenced pain, radiation, tingling, weakness and numbness affecting his right lower extremity. Currently, he had 8/10 constant low back pain with pain, radiating, weakness and numbness affecting his left lower extremity only. He reported flare-ups occurring 3 to 4 days per year and lasting a few days. During flare-ups, he remained in bed for several days. Functional impairment was reported as difficulty with walking, prolonged standing, lifting, pushing, pulling, prolonged sitting, climbing and bending. Active lumbar spine ROM was flexion to 30 degrees, extension to 20 degrees and right/ left lateral bending and right/left lateral rotation were all to 20 degrees. Pain was observed with all planes of motion, weight-bearing activities and caused functional loss with difficulty walking and standing. For repeated use over time, the physician estimated lumbar flexion would be to 20 degrees. With flare-ups, the physician estimated lumbar flexion would be to 10 degrees. Localized tenderness was reported to cause an abnormal gait. Muscle strength testing was complete. Reflexes were normal. SLR testing was negative. Radiculopathy, ankylosis and IVDS was not indicated. The Veteran used a brace on an occasional basis and a cane on a regular basis for assistance. Functional impact was reported as limitations with walking, prolonged standing, lifting, pushing, pulling, prolonged sitting, climbing and bending. For the following reasons, the Board finds that an increased disability rating of 40 percent, but no higher, from March 2, 2016, but no earlier, is warranted for the service-connected lumbar spine disability. The Veteran has provided competent and credible reports about lumbar spine motion loss during flare-ups and repetitive use over time. English, 30 Vet. App. at 355 (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups). Crucially, at the February 2019 Board hearing, the Veteran estimated that he lost 85 percent of lumbar spine ROM during flare-ups. This would equate to lumbar spine flexion of about 14 degrees and clearly meets the 40 percent motion loss criteria under the General Rating Formula. 38 C.F.R. § 4.71a, DC 5237-5242. Although it is unclear how long he experienced this degree of lumbar spine motion loss, the evidence indicates that such motion loss had been present for some time. The Board observes that the April 2016 VA NP did not fully assess motion loss from functional impairment since she did not assess it in terms of degrees. Sharp, 29 Vet. App. 26. With this background, the evidence is at least evenly balanced as to whether lumbar spine flexion was to 30 degrees or less when considering functional impairment during flare-ups. As to the possibility of a lumbar spine rating in excess of 40 percent, it is limited to unfavorable ankylosis of the thoracolumbar spine or the entire spine. The evidence does not indicate that the Veteran's entire thoracolumbar spine has ever been fixed in flexion or extension in an unfavorable position. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). The Board notes that the Court held in Chavis v. McDonough, 34 Vet. App. 1, 23 (2021) that flare-ups resulting in symptoms more nearly approximating ankylosis can warrant a higher rating under the general rating formula. However, the evidence, with specific consideration to the Veteran's reports, private medical records, and February 2021 and June 2021 VA-contract examination reports, does not in any way suggest that unfavorable ankylosis of the entire thoracolumbar spine is present to include functional loss during periods of flare-ups or repeated use over time. Thompson, 815 F.3d at 785. Again, the Veteran's functional impairment reports concern severe low back pain, limited motion, and self-directed rest periods. His reports, nor does any additional evidence, suggest that his spine becomes fixed in an unusual or unfavorable position during periods of repeated use over time or flare-ups. Id. The evidence does not suggest a material increase in lumbar spine disability within the one year look back period to warrant an effective date prior to the March 2, 2016 increased rating claim. 38 C.F.R. § 3.400(o). For the foregoing reasons, an increased rating of 40 percent, but no higher, from March 2, 2016, for lumbar spine disability is warranted. The preponderance of the evidence reflects the symptoms of the Veteran's lumbar spine disability do not more nearly approximate the criteria for a rating higher than 40 percent at any time during the appeal period. Thus, the benefit of the doubt doctrine is not for application, and a lumbar spine disability rating greater than 40 percent is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Lower extremity radiculopathy This issue is raised as part of the increased rating claim for the lumbar spine disability. See Chavis, supra.; 38 C.F.R. § 4.71a, DC 5237-5242, Note 1. The lumbar spine disability factual background is incorporated into this analysis by reference. Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. The Board will rate by analogy to sciatic nerve based upon anatomic location. 38 C.F.R. § 4.20. Paralysis of the sciatic nerve, such as that caused by sciatica, is rated under DC 8520. Under DC 8520, a maximum schedular rating of 80 percent is awarded for complete paralysis of the sciatic nerve. With complete paralysis, the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. When there is incomplete paralysis, a 60 percent rating is in order for severe disability with marked muscular atrophy. Moderately severe incomplete paralysis warrants a 40 percent evaluation. Moderate incomplete paralysis warrants a 20 percent rating. Mild incomplete paralysis warrants a 20 percent rating. See 38 C.F.R. § 4.124a, DC 8520. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. For the following reasons, the Board finds that a separate 10 percent rating, but no higher, from May 3, 2018, but no earlier, for left lower extremity radiculopathy is warranted. The Veteran has a complex medical history with overlapping symptoms from non service-connected diabetic neuropathy. See July 2015 private medical records (noting sensory disturbances in both feet); February 2019 private medical records (assessing diabetes with neurological manifestations). The April 2016 VA NP, February 2021 VA-contract NP and June 2021 VA-contract physician did not find evidence of radiculopathy from clinical evaluations. However, the Veteran is competent to report lower extremity neurological type symptoms since they are readily observable, but he is not competent to report the cause of it because of his complex medical history. Jandreau, 492 F.3d at 1377 n.4. The Board finds his reports credible. At the February 2019 Board hearing, he reported left lower extremity sensory disturbances. Although he did not refer to lower extremity neurological disturbances at the April 2016 VA examination or February 2021 VA-contract examination, he did so at the June 2021 VA-contract examination. There he appears to report a prior history of right lower extremity radiculopathy but that the current radiculopathy symptoms affected his left lower extremity only. The earliest medical reference to lumbar radiculopathy is from May 9, 2018 private medical records based upon interpretation of May 3, 2018 lumbar spine imaging study. The clinician did not specific which was the affected extremity or whether both were affected. From the above reports, the Board finds that a separate 10 percent rating for left lower extremity radiculopathy from May 3, 2018 is warranted. The weight of the evidence does not indicate that the Veteran has had right lower extremity radiculopathy during the claims period. The February 2019 Board hearing and June 2021 VA-contract examination report refer to the left lower extremity as the affected extremity. Although the May 2018 clinician does not specify an extremity, it is reasonable to infer from the additional evidence that it is the left lower extremity from the Veteran's subsequent reports. A rating of 10 percent from May 3, 2018 for mild sciatic left lower extremity radiculopathy is supported by the same dated private clinical report assessing radiculopathy. The left lower extremity radiculopathy symptoms later described by the Veteran are primarily sensory in nature. (See February 2019 Board hearing and June 2021 VA-contract examination report); 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note. A rating in excess of 10 percent from May 3, 2018 for left lower extremity radiculopathy is not warranted. Both the April 2016 VA NP and February 2021 VA-contract NP did not find evidence of lumbar radiculopathy. The May 2018 private medical records do not provide any indication that the neurological disturbances attributable to lumbar radiculopathy were a substantial factor in any loss of motor strength, reflex impairment, or severe sensory disturbance for the left lower extremity. Given the limited findings for neurological disturbances specifically attributable to lumbar radiculopathy compared to other causes, the Veteran's left lower extremity lumbar radiculopathy has been manifested by at most mild incomplete paralysis. 38 C.F.R. § 3.100(a) (delegating the Secretary's authority "to make findings and decisions... as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination... so that the current rating may accurately reflect the elements of disability present"). In sum, a separate 10 percent rating, but no higher, is warranted for left lower extremity radiculopathy of the sciatic nerve, from May 3, 2018, but no earlier. In all other respects the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Entitlement to a TDIU exclusively due to service-connected lumbosacral strain with degenerative changes The July 2020 JMPR found that a TDIU based on a single service-disability from March 2, 2016 was reasonably raised by the record from the evidence suggesting unemployability due to service-connected back disability. The Board will now consider whether entitlement to a TDIU exclusively due to service-connected lumbosacral strain is warranted. TDIU may be assigned when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran is now service-connected for lumbosacral strain with a 40 percent rating from March 2, 2016. He has not met the percentage requirements under 38 C.F.R. § 4.16(a) based exclusively on his service-connected lumbosacral strain at any time. When the percentage requirements for a schedular TDIU rating under 38 C.F.R. § 4.16(a) are not met, a TDIU on an extraschedular basis, may nonetheless be granted when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability or disabilities. See 38 C.F.R. § 4.16(b). In April 2021, the Director issued an advisory opinion regarding extraschedular consideration for TDIU under 38 C.F.R. § 4.16(b). Although the Board is required to obtain the Director's decision before awarding extraschedular TDIU benefits in the first instance, the Board is not bound by the Director's decision or otherwise limited in its scope of review of that determination. Wages v. McDonald, 27 Vet. App. 233, 236-38 (2015) (citing 38 U.S.C. §§ 511(a), 7104(a); 38 C.F.R. § 4.16(b)). In this case, the issue of entitlement to an extraschedular TDIU pursuant to 38 C.F.R. § 4.16(b) has already been remanded and referred to the Director. Therefore, the extraschedular TDIU issue is now before the Board and can be addressed on the merits. In analyzing TDIU claims, the central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" as having two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: The Veteran's history, education, skill, and training; whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. In February 2019, the Veteran filed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. He identified his back disability as one of several disabilities. He stated that he last worked full time in March 2001 as a self-employed television repairman. He last worked part time from January 2013 to December 2017 as driver with marginal wages. He reports two years of college as his highest educational achievement. The above discussion concerning the evidence and analysis for the lumbosacral strain claim above is incorporated by reference. In addition, as noted in the July 2020 JMPR, there are several reports about the service-connected back disability interfering with employment. A SSA report from January 2018 included statements from the Veteran that as television repairman he had to frequently lift more than 50 pounds. A March 2007 report from the Veteran included reports that he could not work in his usual occupation in television repair since he was unable to lift televisions. As to the non-economic TDIU component of physical capability in Ray, supra., the functional impairment from March 2, 2016 from the service-connected lumbosacral strain shows occupational impairment affecting most physical occupational tasks. Functional impairment due to back pain significantly limited the Veteran's ability to bend, lift and walk. He was limited to lifting objects weighing no more than 10 or 15 pounds. These limitations due to service-connected lumbosacral strain would impair the Veteran's ability to perform a wide variety of physical tasks in his usual occupation of television and similar jobs in which he would otherwise be qualified. Ray, 31 Vet. App. at 73. Given the above, the Board finds that from March 2, 2016, the Veteran has significant physical limitations due to service-connected lumbosacral strain. As to the non-economic mental capability in Ray, supra., the Veteran's lumbosacral strain causes severe pain that would affect his ability to concentrate and pose mental impairment in completing occupational tasks associated with general labor or administrative work. The VA examination reports and February 2019 Board hearing testimony include reports of chronic back pain with limited response to treatment. The Board finds that the Veteran has some mental limitations due to pain associated with service-connected lumbosacral symptoms that impair his ability to secure work consistent with his education and occupational experience. These mental limitations include or are analogous to those outlined by the Court in Ray in determining whether the Veteran can secure and follow a substantially gainful occupation. Ray, 31 Vet. App. at 73. When considering the Veteran's work and education history and physical and mental impairments due exclusively to service-connected lumbosacral strain, the evidence is at least in a state of relative equipoise as to whether the Veteran is unable to secure and follow a substantially gainful occupation within the meaning of the applicable regulation. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"); 38 C.F.R. § 4.16. There is no indication that the Veteran is readily qualified to pursue an alternative occupation that might accommodate his physical limitations due to service-connected lumbosacral strain. See Withers v. Wilkie, 30 Vet. App. 139, 148 (2018). In other words, the physical limitations noted above from service-connected disabilities preclude a substantially gainful occupation for which the Veteran would otherwise be qualified. For the foregoing reasons, the evidence is thus at least evenly balanced as to whether the Veteran's service-connected lumbosacral strain, alone, has precluded him from securing or following a substantially gainful occupation. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU due exclusively to lumbosacral strain from March 2, 2016 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Entitlement to SMC(s)(1) SMC(s)(1) is payable at a specified rate if the Veteran, as the result of service-connected disability, has a single service-connected disability rated as total and has additional service-connected disability or disabilities independently ratable at 60 percent or more. 38 U.S.C. § 1114(s)(1). The regulations further state that such additional service-connected disability or disabilities be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily functions. 38 C.F.R. § 3.350(i)(1). Although the Veteran does not have a 100 percent rating for any single disability, he now has a TDIU due exclusively to lumbosacral strain. This rating satisfies the requirement for a single service-connected disability rated as 100 percent. Bradley v. Peake, 22 Vet. App. 280, 290 (2008); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). However, the Board finds that under 38 C.F.R. § 3.350(i)(1) the additional ratings for right ankle disability, left ankle disability, and right knee strain do not qualify as separate and distinct from the TDIU due exclusively to lumbosacral strain. The bilateral ankle and right knee disabilities pertain to the orthopedic system. Because of their orthopedic nature, they do not meet the separate and distinct requirement from the service-connected lumbosacral strain which is the basis of the single disability TDIU award. 38 C.F.R. § 3.350(i)(1); see also Brownlee v. McDonough, No. 19-7970 (Vet. App. July 13, 2021) (noting 38 C.F.R. § 3.350(i)(1) separate and distinct requirement); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). These disabilities cannot be considered in calculating additional service-connected disability or disabilities independently ratable at 60 percent. Id. The remaining compensable rated service-connected disabilities not involving the orthopedic system are the service-connected scar and tinnitus. They do not generate a combined rating of 60 percent. Gazelle v. McDonald, 27 Vet. App. 461 (2016); 38 C.F.R. §§ 3.350(i)(1), 4.25. For the reasons set forth above, the Veteran does not meet the statutory criteria for SMC pursuant to 38 U.S.C. § 1114(s)(1) from March 2, 2016. Entitlement to SMC pursuant to 38 U.S.C. § 1114(s)(1) is not warranted. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. D. Simpson, Counsel 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.