Citation Nr: 21064866 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 13-07 073 DATE: October 21, 2021 ORDER Entitlement to a disability rating in excess of 60 percent for lumbar intervertebral disc syndrome (IVDS), status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy, prior to February 2, 2018, is denied. Entitlement to a disability rating in excess of 20 percent for lumbar IVDS, status post decompression, laminectomy and fusion from February 2, 2018, forward is denied. Entitlement to a 40 percent disability rating, but not higher for radiculopathy, right lower extremity, sciatic nerve is granted. Entitlement to a 40 percent disability rating, but not higher for radiculopathy, left lower extremity, sciatic nerve is granted. Entitlement to a 30 percent disability rating, but not higher for radiculopathy, right lower extremity, anterior crural nerve is granted. Entitlement to a 30 percent disability rating, but not higher for radiculopathy, left lower extremity, anterior crural nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, external cutaneous nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, external cutaneous nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, ilioinguinal nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, ilioinguinal nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, obturator nerve is granted. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, obturator nerve is granted. FINDINGS OF FACT 1. Prior to February 2, 2018, the Veteran's lumbar IVDS, status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy, was evaluated as 60 percent disabling, the highest schedular evaluation under Diagnostic Code 5243. 2. From February 2, 2018, forward, the Veteran's or lumbar IVDS, status post decompression, laminectomy and fusion manifested as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; and guarding severe enough to result in an abnormal gait or abnormal spinal contour. 3. The Veteran's radiculopathy, right lower extremity, sciatic nerve manifested as moderately severe incomplete paralysis. 4. The Veteran's radiculopathy, left lower extremity, sciatic nerve manifested as moderately severe incomplete paralysis. 5. The Veteran's radiculopathy, right lower extremity, anterior crural nerve manifested as severe incomplete paralysis. 6. The Veteran's radiculopathy, left lower extremity, anterior crural nerve manifested as severe incomplete paralysis. 7. The Veteran's radiculopathy, right lower extremity, external cutaneous nerve manifested as severe to complete paralysis. 8. The Veteran's radiculopathy, left lower extremity, external cutaneous nerve manifested as severe to complete paralysis. 9. The Veteran's radiculopathy, right lower extremity, ilioinguinal nerve manifested as severe to complete paralysis. 10. The Veteran's radiculopathy, left lower extremity, ilioinguinal nerve manifested as severe to complete paralysis. 11. The Veteran's radiculopathy, right lower extremity, obturator nerve manifested as severe to complete paralysis. 12. The Veteran's radiculopathy, left lower extremity, obturator nerve manifested as severe to complete paralysis. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 60 percent prior to February 2, 2018, for the Veteran's lumbar IVDS, status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5243-5242. 2. The criteria for entitlement to a disability rating in excess of 20 percent for the Veteran's lumbar IVDS, status post decompression, laminectomy and fusion February 2, 2018, forward, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5243-5242. 3. The criteria for entitlement to 40 percent disability rating, but not higher for radiculopathy, right lower extremity, sciatic nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8620. 4. The criteria for entitlement to a 40 percent disability rating, but not higher for radiculopathy, left lower extremity, sciatic nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8620. 5. The criteria for entitlement to a 30 percent disability rating, but not higher for radiculopathy, right lower extremity, anterior crural nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8626. 6. The criteria for entitlement to a 30 percent disability rating, but not higher for radiculopathy, left lower extremity, anterior crural nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8626. 7. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, external cutaneous nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8629. 8. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, external cutaneous nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8629. 9. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, ilioinguinal nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8630. 10. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, ilioinguinal nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8630. 11. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, obturator nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8628. 12. The criteria for entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, obturator nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8628. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1984 to March 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision. In July 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Veteran's claim was remanded by the Board in October 2019 and April 2021 for further development. 1. Entitlement to a disability rating in excess of 60 percent for lumbar intervertebral disc syndrome (IVDS), status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy, prior to February 2, 2018. is denied. 2. Entitlement to a disability rating in excess of 20 percent for lumbar IVDS, status post decompression, laminectomy and fusion from February 2, 2018, forward is denied. Prior to February 2, 2018, the Veteran's IVDS, status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy was rated as 60 percent disabling under Diagnostic Code 5243. From February 2, 2018, forward, his IVDS is rated as 20 percent disabling under DC 5242, with separate ratings assigned for neurologic abnormalities of the lower extremities which will be addressed below. The Board notes that a disability of the spine may be evaluated under either the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Here, as of February 2, 2018, the RO determined that it was more beneficial to rate the Veteran's low back disability under the General Rating Formula with separate ratings assigned for neurologic abnormalities of the lower extremities, for a combined disability rating of 80 percent. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App.at 126. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107;38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 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 to38 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."). The provisions of sections 4.40 and 4.45 thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca, 8Vet. App.at 206-07(holding that the provisions of 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). Moreover, the intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See 38C.F.R. §4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. See 38C.F.R. § 4.59; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Additionally, the United States Court of Appeals for Veterans Claims (the Court) recently held that the plain language of § 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under diagnostic codes predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Court held that § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is being evaluated is predicated on range of motion measurements. Id. at 354. 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." 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 rating schedule provides for the evaluation of all disabilities of the spine under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (DC 5243). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The evaluation of IVDS will be discussed below. Under the General Rating Formula, evaluations are assigned as follows: A 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned where unfavorable ankylosis of the entire spine is demonstrated. Id. The above evaluations apply 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. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from 0 to 90 degrees, extension is from 0 to 30 degrees, left and right lateral flexion are from 0 to 30 degrees, and left and right lateral rotation are from 0 to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (2). Unfavorable ankylosis is defined, in pertinent part, as "a condition in which the entire thoracolumbar spine is fixed in flexion or extension." Id., Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Associated objective neurologic abnormalities, including but not limited to bowel or bladder impairment, are to be separately evaluated under an appropriate diagnostic code. Id. Note (1). Under Diagnostic Code 5243, IVDS may be evaluated under the General Rating Formula, as set forth above, or the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the Formula for Rating IVDS, a 10 percent rating is assigned if incapacitating episodes have a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent evaluation is assigned if incapacitating episodes have a total duration of at least two weeks but less than four weeks; a 40 percent rating is assigned if the total duration is at least four weeks but less than six weeks; and a 60 percent rating is assigned if the total duration is at least six weeks. Id. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. Id., Note (1). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The revised schedule, in effect as of February 7, 2021, contemplating IVDS under Diagnostic Code 5243, provides that such criteria shall be used only when there is disc herniation with compression and/or irritation of the adjacent nerve root; in all other cases, Diagnostic Code 5242 should be used for all other disc diagnoses. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5243). IVDS shall be evaluated, preoperatively or postoperatively, either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Id. Of note, the August 2020 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire states that the Veteran's lumbar disc herniation caused compression of the exiting lumbar nerve roots. Therefore, consideration of Diagnostic Code 5243 is appropriate from February 7, 2021, forward. The revisions to the General Rating Formula for Diseases and Injuries of the Spine do not include changes to Diagnostic Code 5242, contemplating degenerative arthritis, save for its inclusion of degenerative disc disease other than IVDS. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5242). In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. To evaluate the severity of the Veteran's back disability, she was afforded several examinations. Of note, the Veteran was provided with a September 2010 examination that states that she has severe low back pain and missed approximately 50 days of work in the past six months. She occasionally has a severe burning sensation in the toes of her right foot when she stands for 15 to 20 minutes. She also has flares of back pain with no radiation. Her pain reaches a 7 out of 10 in terms of severity. She has constant low back pain, which is made worse if she lies on her side, rotates, or bends laterally. She can lift and carry up to 20 pounds with no increased back pain if she does not rotate her trunk. She reports she has functional limitation when walking due to back pain and she has not fallen because of her back. The September 2010 examination report states that she takes Methadone, Gabapentin, and Hydrocodone daily. She is being evaluated for a revision of an earlier back surgery because of her back symptomatology and broken surgical hardware. The Veteran reported experiencing back stiffness, fatigue, spasms, decreased motion, and paresthesia. She does not have numbness, weakness, bowel problems in relation to her back, or bladder problems in relation to her back. On physical examination, the September 2010 examination report states that the Veteran's posture is within normal limits and her gait is somewhat antalgic due to her back pain. Her walk is steady, and she does not require any assistive device for ambulation. The examination revealed no evidence of radiating pain on movement. Muscle spasm was absent. There was tenderness noted on the examination described as severe tenderness in the midline at L4-5-S1, and paraspinous tenderness at the same level. The Veteran's spinal contour was not preserved due to tenderness and there was guarding of movement. The Veteran's guarding produced an abnormal gait. The examination did not reveal any weakness. Her muscle tone and musculature were normal. There was negative straight leg raising bilaterally, Lasègue's sign was negative, and there was no atrophy present in the limbs. There was no ankylosis of the thoracolumbar spine. The September 2010 examination report states that initial range of motion was 85 degrees of flexion, 10 degrees of flexion, 30 degrees at right lateral flexion, 10 degrees at left lateral flexion, 20 degrees of right rotation, and 20 degrees of left rotation with pain at the endpoints. On repetitive range of motion testing, the Veteran did not have any additional degrees of limitation. The joint function of the spine is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The inspection of the spine reveals normal head position with symmetry in appearance. There is symmetry of spinal motion with abnormal curves of the spine, reversed lordosis. The September 2010 examination report states that the Veteran's lumbar spine revealed no sensory deficits from L1-L5, and the sacral spine revealed no sensory deficits of S1. There was no lumbosacral motor weakness. The bilateral lower extremity reflexes revealed knee jerk 2+ and ankle jerk 2+. The lower extremities showed no signs of pathologic reflexes and normal cutaneous reflexes. There were no signs of lumbar IVDS with chronic and permanent nerve root involvement. Diagnostic testing demonstrated status posts fusion L5-S1; grade II anterior spondylolisthesis L4-L5; and degenerative joint disease throughout. The Veteran was also provided a September 2013 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The Veteran reported flare-ups of her back that consist of trouble bending, twisting, and lifting and carrying heavy objects. She has decreased range of motion and pain with movement. On initial range of motion testing, the Veteran had flexion to 40 degrees, extension to 10 degrees, bilateral lateral flexion to 10 degrees, and bilateral lateral rotation to 15 degrees, with painful motion at the endpoints. On repetitive-use testing, the Veteran had flexion to 40 degrees, extension, and bilateral lateral flexion to 10 degrees, and bilateral lateral rotation to 15 degrees. The Veteran does not have additional limitation in range of motion following repetitive-use testing. She has functional impairment described as less movement than normal and pain on movement. On flare-ups and repeated use over time, the Veteran has an additional loss of 10 degrees of range of motion of flexion and 5 degrees of extension. The September 2013 examination report states that the Veteran does not have localized tenderness or pain to palpation for joints and/or soft tissue. She has guarding and/or muscle spasm but her guarding and/or muscle spasm does not result in abnormal gait or spinal contour. The Veteran's muscle strength testing and reflex examination were normal, and she does not have muscle atrophy. On sensory examination, she had decreased sensation on the left upper anterior thigh and left thigh/knee. The sensory examination was otherwise normal. The Veteran's straight leg raising test was positive bilaterally. The September 2013 examination report indicates that the Veteran had moderate left lower extremity constant pain and severe left lower extremity numbness at L4/L5/S1/S2/S3, which was described as moderate in severity. The Veteran has IVDS without any incapacitating episodes over the past 12 months due to IVDS. She occasionally uses a walker. She can only sleep in the supine position because of her back disability. She is limited in bending to 30 degrees, cannot kneel, has lifting restrictions, has limitations regarding walking, and cannot run. Diagnostic testing from September 2013 showed extensive surgery at L2-S1, lateral fusion at L2-L5, posterior fusion at L4 through S1 with separate screw at L5-S1. There was narrowing at disc heights severely at L2-S1, laminectomy defect present extensively, and lateral bone graft at L4-S1. The Veteran's alignment was unremarkable, and her SI joints appeared normal. The Veteran was provided with a December 2017 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The examination report states that her back pain has worsened, and the pain cannot be controlled for multiple hours at a time. She has decreased range of motion and pain with movement. She did not report flare-ups. Concerning functional impairment, the Veteran reported uncontrollable back pain over multiple hours. On initial range of motion testing, the Veteran had flexion to 30 degrees, extension to 5 degrees, bilateral lateral flexion to 5 degrees, and bilateral lateral rotation to 5 degrees per the December 2017 examination report. Pain was noted on examination that causes functional loss on all planes of range of motion and there was evidence of pain with weightbearing. The Veteran's range of motion contributes to functional loss with lifting and bending, and there was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. On repetitive use, there was no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability, and incoordination does not significantly limit functional ability with repeated use over time. The December 2017 examination report states that the Veteran has muscle spasm and guarding that results in abnormal gait or abnormal spine contour. Muscle strength testing was normal, and the Veteran does not have muscle atrophy. The Veteran had a normal reflex examination at her bilateral knee and ankle. The sensory examination was normal bilaterally at the upper anterior thigh and decreased bilaterally at the thigh/knee, lower leg/ankle, and foot/toes. She had positive straight leg testing results. The December 2017 examination report indicates that the Veteran has signs or symptoms due to radiculopathy with severe constant pain of her bilateral lower extremities and moderate paresthesias and/or dysesthesias and numbness of her bilateral lower extremities. The nerve roots involved were noted as L4/L5/S1/S2/S3 and the severity of her radiculopathy was described as severe bilaterally. There was no ankylosis of the spine. She has IVDS with episodes of bed rest having a total duration of at least 6 weeks during the past 12 months, which was supported by information provided by the Veteran as self-limitation of activity due to spasm and pain. She does not use an assistive device. The December 2017 examination report states that the functional impact of the Veteran's back disability as limitations regarding bending and lifting and carrying an object. She last worked five years ago, and she retired because of her back disability. Her radicular pain used to be concentrated on her left leg, but it has progressed to her right leg one month ago. During her previous employment, she was limited with lifting, sitting, and standing, but retired because unable to meet physical demands. She avoids stairs, is unable to sit for more than 30 minutes, and she cannot drive a motor vehicle. She gets little sleep because of pain and is unable to concentrate and think clearly due to sleep deprivation. The Veteran was also afforded an August 2020 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The Veteran advised that her back disability has progressed or worsened, and she has a tingling needle-like sensation in her lower back and stabbing pains in her back when she lays down. She reported flare-ups of a sharp, shooting pain that occurs when she gets up from her couch. She advised of functional limitations of limited walking and the use of a walker. The August 2020 examination report states that on initial range of motion testing, the Veteran had flexion to 52 degrees, extension to 4 degrees, bilateral lateral flexion to 14 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 9 degrees. The Veteran does not have the range of motion to complete tasks that require bending. The Veteran has pain on examination that causes functional loss on all planes of range of motion. There is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue over her lumbar spine that is mild in severity and is related to lumbar IVDS and radiculopathy. There is pain on weightbearing. The Veteran has additional loss of function or range of motion due to pain on repetitive-use testing as she had flexion to 48 degrees, extension to 4 degrees, bilateral lateral flexion to 8 degrees, right lateral rotation to 6 degrees, and left lateral rotation to7 degrees. The August 2020 examination report states that the Veteran has pain that significantly limits functional ability with repeated use over a period of time and is described in terms of range of motion as flexion to 52 degrees, extension to 4 degrees, bilateral lateral flexion to 14 degrees, and right lateral rotation to 10 degrees, and left lateral rotation to 9 degrees. The Veteran has pain that significantly limits functional ability on flare-ups and is described in terms of range of motion as flexion to 48 degrees, extension to 4 degrees, bilateral lateral flexion to 8 degrees, right lateral rotation to 6 degrees, and left lateral rotation to7 degrees. The Veteran has guarding that results in an abnormal gait or abnormal spine contour. She has a bent at the waist when walking and cannot straighten her back well. She has disturbance of locomotion, interference with sitting, and interference with standing, and increased back pain with prolonged sitting, standing, and walking as additional contributing factors of her disability. The August 2020 examination report described the Veteran's muscle strength as active movement against some resistance bilaterally with hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. She does not have muscle atrophy. The reflex examination states that the Veteran's deep tendon reflexes were hyperactive without clonus bilaterally at her knee and ankle. The sensory examination was decreased bilaterally at the thigh/knee, absent at the lower leg, and decreased at the foot/toes. The Veteran's straight leg raising test was negative. The August 2020 examination report indicates that the Veteran has radiculopathy that manifests as moderate bilateral intermittent pain, severe bilateral paresthesias and/or dysesthesias, and severe bilateral numbness at L2/L3/L4 nerve roots and L4/L5/S1/S2/S3. The severity of the Veteran's radiculopathy was described as moderate bilaterally. She does not have ankylosis of the spine. She has IVDS but has not had any acute signs or symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician in the past 12 months. She uses a walker constantly. Concerning functional impairment, the Veteran cannot perform tasks that require quick movements or prolonged walking or standing. She walks slowly and she has lost proprioception in her legs and feet that impact her balance. There is objective evidence of pain on non-weightbearing, and passive range of motion could not be performed or was not medically appropriate. Washing dishes and cleaning performing other household chores takes longer to accomplish, and some tasks, such as vacuuming and mopping, are not possible for the Veteran perform on her own. Bathing and dressing also takes more time than normal to accomplish as well. The Veteran's private treatment records describe the severity of her back disability and related treatment. Generally, her treatment records reveal that she received steroid injections, was prescribed pain medication, and underwent several surgeries and physical therapy. An April 2010 private lumbar spine magnetic resonance imaging (MRI) reveals an impression of excessive metallic artifact related to posterior fusion hardware at L5-S1, mild spinal stenosis at L3-L4, broad-based small disc osteophyte complex or disc protrusion far right posterolateral L2-L3x, and foraminal narrowing. Private physical therapy records from 2010 state that the Veteran has low back pain that radiates down her leg when laying on her side and left leg nerve pain. She also reported restless leg syndrome. She does not have pain during activities but has severe pain in the evenings after activity. She rated her pain as 4 out of 10. She is unable to run on a treadmill due to burning in her left foot and cannot sit for long periods of time. A May 2010 private treatment record states that the Veteran has pain on the left side with numbness and tingling that goes down to her buttock and outer thigh. She has constant difficulty with sitting and walking. She has pain that is 9 out of 10 and specifically aggravated by sitting, putting socks and shoes on her feet, walking, standing, ascending and descending stairs, squatting, and kneeling. A June 2010 private physical therapy record notes that on objective examination, the Veteran has normal range of motion without pain. She had low back soreness with combined movement testing. Light PA pressure to the L4-L5 segment elicited increased low back pain and tenderness. Palpation over the greater trochanter was remarkable for eliciting lateral hip and lateral leg pain bilaterally. Tenderness was also shown over the gluteus medius muscle. Her single-leg raise was limited to 75 degrees on the left with burning on her lower left back and limited to 50 degrees on the right eliciting low back pain that is relieved with plantar flexing on her right ankle. October 2010 private treatment records reveal that the Veteran had L4-L5 T-lift with removal of hardware, and exploration of fusion, L5-S1, and physical therapy consultation. In particular, the procedure included posterolateral fusion L4-L5, interbody fusion L4-L5; application of intervertebral device L4-L5; transforaminal decompression L4-L5; exploration of fusion L5-S1; removal of hardware L5-S1; instrumentation L4, L5, S1; autologous local bone graft; application of recombinant human bone morphogenic protein-2; interpretation of intraoperative fluoroscopy. The Veteran was neurologically intact following the surgery and she began working with physical therapy. The Veteran's postoperative diagnosis was adjacent segment with prior instrumented fusion with spondylolisthesis and foraminal stenosis. Private treatment records from 2012 and 2013 demonstrate that the Veteran experienced back and leg pain following lumbar lateral arthrodesis for adjacent segment disease. She reported that her back pain can be 10 out of 10 that radiates down her legs. The Veteran's back pain is worsened with standing and walking. Concerning functional impairment, the Veteran's symptoms are worsened with bending, twisting, lifting, and standing for long periods of time. The Veteran's VA treatment records also describe the severity of her back disability. VA treatment records from 2010 indicate that the Veteran has chronic low back pain that is flaring and radiating to her hips and that she is taking Methadone for treatment. A September 2010 VA treatment record states that the Veteran fell recently after tripping on her feet, and she tends to drag her feet and fall. An April 2011 VA treatment record states that she describes her pain as a "right-sided buzzing shock" that is 8 out of 10 in severity and occurs when walking occasionally. She has flare-ups when walking that can last for several hours if she continues walking. Her flare-ups reside with sitting, elevating her feet, and changing positions. She does not have lower extremity pain, numbness, or weakness. On physical examination, the Veteran has negative straight leg raise bilaterally, negative figure-of-four bilaterally, and 5/5 strength in the iliopsoas, quadriceps, hamstrings, tibialis anterior, extensor hallucis longus, and gastroc soleus bilaterally. Her light touch is intact and equal L2 to S1, reflexes are +1 at the knees, ankles, and downgoing toes bilaterally. She does not have edema in her legs and her distal skin is well perfused. Diagnostic imaging showed grade I spondylolisthesis at L3-L4 above her prior fusion and a broken screw at the right S1. The Veteran's pain depends on activity and she has increased burning and sharp pain, which radiates down left leg according to a January 2012 VA treatment record. Diagnostic imaging from September 2013 show that there has been extensive surgery at L2-S1, lateral fusion present at L2-L5, posterior fusion at L4 through S1, separate screw noted over L5-S1 area. The Veteran has narrowing of disc heights severely at L2-S1, laminectomy defect present extensively, lateral bone graft present at L4-S1. Her alignment was unremarkable and her S1 joints appeared normal. The Veteran's claims folder contains lay statements describing the severity of her back disability. In December 2010, the Veteran advised that she recently underwent back surgery and that she is currently not working. She also stated that she takes prescribed medication, utilizes a walker, and is unable to bend, lift, reach over her head, or walk for prolonged distances without pain in her back, legs, and right foot. In April 2011, the Veteran provided that she underwent a second spinal fusion surgery in October 2010 and that she was hospitalized for three days. She stated that upon release from the hospital, she was unable to stand without a walker or other assistance. She could not bend, lift, or twist and she had severe pain in her back and sides. She was unable to sleep for periods longer than two hours. She fell twice and sustained injuries to her knees and left hand. She was unable to stand alone and continues to have pain in her low back and right side. She had difficulty completing work functions. In the Veteran's March 2013 VA Form 9, Appeal to the Board of Veterans' Appeals, she stated that she has increased back pain following her spinal surgeries. She stated that the spinal fusion surgeries have caused pain to her back, leg, numbness, and an additional surgery. She provided that the hardware used for her surgery has broken, leading to increased pain. She has undergone painful spinal injections. She also indicated that she has had problems with urination and sexual dysfunction following her third back surgery. She cannot control her bladder and sex is painful. During the July 2016 hearing, the Veteran provided that her back disability has made working more difficult as she could not ascend stairs, or carry her laptop, books, and pamphlets. She left her job because of her back disability. She advised that she has trouble bending, dressing herself, entering her bathtub, and cannot sleep without pain or ascend and descend stairs. She has trouble bending and showering. She has fallen several times as her legs give way. She wears shoes without laces, utilizes a higher toilet, and waddles when she walks. She has been put on bedrest because of her back disability. She has tingling, burning, and weakness in her legs. In a January 2018 written statement, the Veteran stated that she has constant pain, limited mobility, and is unable to get up at all on some days. She has pain when walking, bending, and cannot take a shower without supervision. She has pain in her lower back, hips, legs, and bottoms of her feet. She falls regularly, and has difficulty getting up by herself. She can barely drive a motor vehicle and must depend on others for help. She rarely sleeps, has restless leg syndrome, and cannot control her legs. She cannot touch her toes, bend over very far, or take a step without holding on to a railing. Because the Veteran is not shown to have a medical background or expertise, she is considered a layperson in the field of medicine. Lay testimony is competent as to matters capable of lay observation or within a person's first-hand experience and may be competent evidence with respect to both the diagnosis of a medical condition and its etiology or cause. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). However, lay testimony is not competent with respect to determinations that cannot be made based on lay observation alone due to their medical or scientific complexity. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). The Board must determine on a case-by-case basis whether lay testimony is competent on the matter at issue, or whether medical evidence is required. See Davidson, 581 F.3d at 1316 (holding that it was error to reject categorically lay statements on the issue of medical nexus, or to make a categorical finding that a medical opinion was required); Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without assessing its competence). Therefore, the Veteran's statements concerning her back symptomatology, including pain, numbness, weakness, tingling, burning, and their related functional impairments are competent concerning the severity of her back disability. The Board additionally finds these competent assertions concerning her symptomatology to be credible, as they are have remained generally consistent throughout the pendency of her claim. See Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table) (holding that, in determining whether statements submitted by or on behalf of a claimant are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). Thus, these statements weigh in her favor in determining whether a higher disability rating is warranted. In sum, prior to February 2, 2018, the Veteran's IVDS, status post decompression, laminectomy and fusion with bilateral S-1 radiculopathy was rated as 60 percent disabling. The December 2017 examination report demonstrates that the Veteran has IVDS with episodes of bed rest having a total duration of at least 6 weeks during the past 12 months, which was supported by information provided by her as self-limitation of activity due to spasm and pain. As a 60 percent disability rating is the highest possible rating assignable under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a higher disability rating based on these criteria is not possible. 38 C.F.R. § 4.71a, DC 5243. A 100 percent evaluation is warranted where unfavorable ankylosis of the entire spine is demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Because the Veteran does not have unfavorable ankylosis of the entire spine, or the functional equivalent of unfavorable ankylosis of the entire spine, a 100 percent rating is not warranted under the General Rating Formula. There is no involvement of the cervical spine. As the preponderance of the evidence weighs against a higher disability rating prior to February 2, 2018, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. The Veteran's lumbar IVDS, status post decompression, laminectomy and fusion has been rated as 20 percent disabling from February 2, 2018, forward under Diagnostic Code 5243-5242. 38 C.F.R. § 4.71a. At worst, during this time period, the August 2020 examination report shows that the Veteran had forward flexion to 52 degrees and a combined range of motion of the thoracolumbar spine of 89 degrees. The Veteran described flare-ups of a sharp, shooting pain that occurs when she gets up from her couch. She advised of functional limitations of limited walking and the use of a walker. The Veteran had pain that significantly limits functional ability on flare-ups and is described in terms of range of motion as flexion to 48 degrees, extension to 4 degrees, bilateral lateral flexion to 8 degrees, right lateral rotation to 6 degrees, and left lateral rotation to 7 degrees according to the examination report. The Veteran's range of motion on repetitive-use testing was the same as her estimated range of motion on flare-ups. She also had guarding that results in an abnormal gait or abnormal spine contour. Considering the above medical and lay evidence, with consideration of the factors of pain and functional loss as described above, the Board finds that a disability rating in excess of 20 percent for the Veteran's lumbar IVDS, status post decompression, laminectomy and fusion is not warranted under Diagnostic Code 5242 from February 2, 2018, forward. 38 C.F.R. §§ 4.40, 4.45; 4.59; 4.71a, Mitchell, 25 Vet. App. at 38; DeLuca, 8 Vet. App. at 206. At no point during time period was the Veteran's forward flexion limited to 30 degrees or less, including when considering the Veteran's reports of flare-ups or with repetitive-use testing. Nor was there evidence of favorable ankylosis, or unfavorable ankylosis, of the functional equivalent of such, of the entire thoracolumbar spine, or entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. As such, Diagnostic Code 5242 does not afford the Veteran a higher disability rating. 38 C.F.R. §4.71a. The benefit-of-the-doubt rule does not apply. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 3. Entitlement to a 40 percent disability rating, but not higher for radiculopathy, right lower extremity, sciatic nerve is granted. 4. Entitlement to a 40 percent disability rating, but not higher for radiculopathy, left lower extremity, sciatic nerve is granted. 5. Entitlement to a 30 percent disability rating, but not higher for radiculopathy, right lower extremity, anterior crural nerve is granted. 6. Entitlement to a 30 percent disability rating, but not higher for radiculopathy, left lower extremity, anterior crural nerve is granted. 7. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, external cutaneous nerve is granted. 8. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, external cutaneous nerve is granted. 9. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, ilioinguinal nerve is granted. 10. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, ilioinguinal nerve is granted. 11. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, right lower extremity, obturator nerve is granted. 12. Entitlement to a 10 percent disability rating, but not higher for radiculopathy, left lower extremity, obturator nerve is granted. The Veteran's radiculopathy, bilateral lower extremity, sciatic nerve is rated as 20 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8620 (neuritis of the sciatic nerve). Mild incomplete paralysis warrants a 10 percent rating. Moderate incomplete paralysis warrants a 20 percent rating. Moderately severe incomplete paralysis warrants a 40 percent rating. Severe incomplete paralysis with marked muscle atrophy warrants a 60 percent rating. Complete sciatic nerve paralysis warrants the assignment of an 80 percent rating and contemplates foot dangles and drops; no active movement possible of muscles below the knee; flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8620. Based on the below evidence, the Veteran's disabilities warrant 40 percent disability ratings. The Veteran's radiculopathy, bilateral lower extremity, anterior crural nerve is rated as 20 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8626 (neuritis of the anterior crural nerve). Mild incomplete paralysis warrants a 10 percent rating. Moderate incomplete paralysis warrants a 20 percent rating. Severe incomplete paralysis warrants a 30 percent rating. Complete paralysis with paralysis of the quadriceps extensor muscles warrants a 40 percent rating. Based on the below evidence, the Veteran's disabilities warrant 30 percent disability ratings. The Veteran's radiculopathy, bilateral lower extremity, external cutaneous nerve is rated as noncompensable under 38 C.F.R. § 4.124a, Diagnostic Code 8629 (neuritis of the external cutaneous nerve). The Veteran's radiculopathy, bilateral lower extremity, ilioinguinal nerve is rated as noncompensable under 38 C.F.R. § 4.124a, Diagnostic Code 8630 (neuritis of the ilioinguinal nerve). The Veteran's radiculopathy, bilateral lower extremity, obturator nerve is rated as noncompensable under 38 C.F.R. § 4.124a, Diagnostic Code 8628 (neuritis of the obturator nerve). Mild or moderate paralysis warrants a noncompensable rating and severe to complete paralysis warrants a 10 percent rating under these diagnostic codes. Based on the below evidence, the Veteran's disabilities warrant 10 percent disability ratings. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). Neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain (at times excruciating), is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in the regulation will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. See 38 C.F.R. § 4.123. Neuralgia, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See 38 C.F.R. § 4.124. The terms "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "mild" and "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding a rating. 38 C.F.R. §§ 4.2, 4.6. The VBA Adjudication Manual (M21-1) provides general guidelines for each level of incomplete paralysis of the upper and lower peripheral nerves. Mild incomplete paralysis can be described as a disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis. Moderate incomplete paralysis is the maximum evaluation reserved for the most significant cases of sensory-only impairment. Symptoms will likely be described as significantly disabling. Combinations of significant sensory changes and reflex or motor changes of a lower degree or motor and/or reflex impairment such as weakness or diminished hyperactive reflexes (with or without sensory impairment) are graded as medically moderate. Severe incomplete paralysis includes motor and/or reflex impairment such as atrophy, weakness, or diminished hyperactive reflexes at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. See M21-1, Part III, Subpart iv, Chapter 4, Section N, Topic 4, Assigning Level of Incomplete Paralysis, Neuritis, or Neuralgia. The Board acknowledges that when relying on any M21-1 provision, the Board must independently review the matter the M21-1 addresses. If after such review, the Board chooses to rely on the M21-1 as a factor in its analysis or as the rule of decision, it must provide adequate reasons or bases for doing so. The Board may not simply rely on the nonbinding M21-1 position without analysis. Overton v. Wilkie, 30 Vet. App. 257 (2018). The Veteran's examination reports describe the severity of her radiculopathy. The September 2010 examination report states that the Veteran occasionally has a severe burning sensation in the toes of her right foot when she stands for 15 to 20 minutes. The September 2013 examination report provides that on sensory examination, the Veteran had decreased sensation on the left upper anterior thigh and left thigh/knee and her straight leg raising test was positive bilaterally. The Veteran had moderate left lower extremity constant pain and severe left lower extremity numbness at L4/L5/S1/S2/S3, which was described as moderate in severity. The sensory examination contained in the December 2017 examination report was normal bilaterally at the upper anterior thigh and decreased bilaterally at the thigh/knee, lower leg/ankle, and foot/toes. She had positive straight leg testing results. The Veteran signs or symptoms due to radiculopathy with severe constant pain of her bilateral lower extremities and moderate paresthesias and/or dysesthesias and numbness of her bilateral lower extremities. The nerve roots involved were noted as L4/L5/S1/S2/S3 and the severity of her radiculopathy was described as severe bilaterally. Her radicular pain used to be concentrated on her left leg, but it has progressed to her right leg one month ago. The August 2020 examination report described the Veteran's muscle strength as active movement against some resistance bilaterally with hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. The reflex examination states that the Veteran' deep tendon reflexes were hyperactive without clonus bilaterally at her knee and ankle. The examination report indicates that the Veteran has radiculopathy that manifests as moderate bilateral intermittent pain, severe bilateral paresthesias and/or dysesthesias, and severe bilateral numbness at L2/L3/L4 nerve roots and L4/L5/S1/S2/S3. The severity of the Veteran's radiculopathy was described as moderate bilaterally. The August 2020 examination report states that when describing the Veteran's radiculopathy, she has sciatic nerve, incomplete paralysis, moderately severe, bilaterally; external popliteal nerve, incomplete paralysis, moderate, bilaterally; musculocutaneous nerve, incomplete paralysis, moderate, bilaterally; anterior tibial (deep peroneal) nerve, incomplete paralysis, moderate, bilateral; internal popliteal (tibial) nerve, incomplete paralysis, moderate, bilateral; posterior tibial nerve, incomplete paralysis, moderate, bilateral; anterior crural (femoral) nerve, incomplete paralysis, moderate, bilateral; internal saphenous nerve, incomplete paralysis, moderate, bilateral; obturator nerve, incomplete paralysis, moderate, bilateral; external cutaneous nerve of the thigh, incomplete paralysis, moderate, bilateral; ilioinguinal nerve, incomplete paralysis, moderate, bilateral. The August 2020 examination report states that the Veteran has difficulty walking and must use a walker due to loss of balance and weakness of the muscles in the legs. The required use of a walker resulted from the loss of nerve signals reaching the muscles of her legs. Her weakness and loss of balance in the legs and feet cause difficulty in standing or walking for prolonged periods of time. The Veteran was lastly afforded an August 2020 Peripheral Nerves Conditions (Not Including Diabetic SensoryMotor Peripheral Neuropathy) Disability Benefits Questionnaire. The examination report provides that the Veteran experienced shooting pains from her feet up her legs to her back that interrupt her sleep. Her numbness and tingling began in her feet and gradually worked its way proximally, until it is now up to her groin area bilaterally. As her radiating pain was progressing, she noted that the muscles in her legs grew increasingly weaker. One and a half years ago, she began to have tingling and numbness in her fingertips, which has gradually progressed to involve her hands and arms up to her elbows. She has lost grip strength. She has moderate bilateral lower extremity intermittent pain, paresthesias and/or dysesthesias, and numbness. The Veteran's muscle strength on elbow flexion, elbow extension, wrist flexion, wrist extension, grip, and pinch were normal, bilaterally. Her muscle strength was active against some resistance on knee extension, ankle plantar flexion, and ankle dorsiflexion, bilaterally. The August 2020 Peripheral Nerves examination states that she does not have muscle atrophy. The reflex examination showed that her upper and lower extremities were hypoactive without clonus. The sensory examination states that the Veteran has decreased sensation bilaterally at the thigh/knee, absent bilaterally at the lower leg/ankle, and decreased bilaterally at the foot/toes. She does not have any trophic changes. Her gait is abnormal as she walks very slowly, hunched over, and uses a walker for support. The Phalen's sign test and Tinel's sign test were negative bilaterally. The August 2020 Peripheral Nerves examination provides that for upper extremity nerves and radicular groups, for the radial nerve, median nerve, ulnar nerve, musculocutaneous nerve, and lower radicular group, she has bilateral, mild incomplete paralysis. For the ulnar nerve, she has left extremity mild incomplete paralysis. The Veteran's lower extremity nerves were described as normal. She does not use an assistive device. Concerning functional impairment, she cannot walk on uneven ground as she loses her balance. She utilizes a walker and walks slowly, which negatively impacts her efficiency. Her grip strength is weak, which causes difficulty performing tasks that involve gripping, such as using tools. The Veteran's private treatment records also describe the severity of her radiculopathy. Private physical therapy records from 2010 state that the Veteran has low back pain that radiates down her leg when laying on her side and left leg nerve pain. She is unable to run on a treadmill due to burning in her left foot and cannot sit for long periods of time. A May 2010 private treatment record states that the Veteran has pain on the left side with numbness and tingling that goes down to her buttock and outer thigh. A June 2010 private physical therapy record indicates that the Veteran had weakness on left ankle dorsiflexion and eversion consistent with L4 and S1 nerve roots. Reflex testing was unable to elicit dorsiflexion on the left. The Veteran had strength of 3/5 weakness with bilateral hip abduction. Private treatment records from 2012 and 2013 demonstrate that the Veteran reported weakness and that her back pain can be 10 out of 10 that radiates down her legs. She also complained of balance issues and burning pain on the right side of her hip, numbness in the anterior portion of her left thigh and lateral thigh and calf. The Veteran's VA treatment records also contain evidence of the severity of her radiculopathy. VA treatment records from 2010 indicate that she has chronic low back pain that is flaring and radiating to her hips. A February 2014 VA Internal Medicine Attending Note demonstrates that the Veteran has low back pain that radiates down her left leg up to her knee. She has left leg numbness and she sometimes experiences shooting pain. She also has swelling in her left lower extremity after prolonged standing. An April 2015 VA Physical Medicine Rehab Consult provides that the Veteran has lower back pain that is primarily left-sided with pain radiating down the lateral aspect of her left thigh to her knee. She does not describe any symptoms radiating below her knee and she does not have any change in bowel or bladder habits. She also does not have any progressive weakness or persistent numbness or tingling. An April 2015 VA treatment record indicates that the Veteran was assessed with chronic lower back pain status post three L5-S1 fusion surgeries. She currently reports that her pain is stable. She has some left lower extremity radicular symptoms not below her knee that are potentially related to radiculitis versus possible meralgia paresthetica. A June 2015 VA Electrodiagnostic Consult Report states that the Veteran advised of bilateral hand numbness and tingling. The left median motor study demonstrated mildly prolonged onset latency with normal amplitude and conduction velocity. The Veteran had a normal right median motor nerve study and normal bilateral ulnar motor nerve studies. Lastly, she had prolonged bilateral median sensory nerve peak latency as compared with ulnar and radial sensory nerve peak latencies. There was evidence of bilateral carpal tunnel syndrome, but no evidence of upper extremity peripheral neuropathy. A November 2017 VA treatment record states that the Veteran has burning pain in her feet that is episodic and has worsened progressively over the past year. This pain typically occurs at night, prevents her from laying down, and feels like an all-body pain. This pain will occasionally last for hours. A December 2017 VA treatment record provides that the Veteran has peripheral neuropathy of unknown etiology. She advised that the local creams provided to her are working well for her and that she is fairly asymptomatic. The Veteran also described the severity of her radiculopathy. In her March 2013 VA Form 9, she stated that the spinal fusion surgeries have caused pain to her back, leg, numbness, and an additional surgery. She also indicated that she has had problems with urination and sexual dysfunction following her third back surgery. She cannot control her bladder and sex is painful. The Veteran also advised of numbness radiating down her back to both legs. She cannot tolerate being touched and she has a burning sensation in her lower right side in her March 2013 VA Form 9. She advised of pain, numbness, muscle weakness, and bladder issues. She has numbness in her hands, and she is unable to sew, hold a book while reading, or perform other tasks with her hands. She awakens with numbness in her hands and has difficulty brushing her teeth and dressing herself. She has weakness while standing and has fallen several times and sustained serious injuries. She utilizes a walker when walking prolonged distances. Her legs are swollen, and her skin has turned reddish and purple since her most recent surgery. She has burning in her lower back and left side that comes after standing. She also believes that she has restless leg syndrome because of her back disability. During the July 2016 hearing, the Veteran provided that she has fallen several times as her legs give way. She also advised of tingling, burning, and weakness in her legs. In a January 2018 written statement, the Veteran stated that she has pain in her lower back, hips, legs, and bottoms of her feet. She falls regularly, and has difficulty getting up by herself. In an October 2020 written statement, the Veteran provided that she has constant pain, numbness, and pin-like tingling throughout her body. She has difficulty bending, sitting, and standing. She utilizes a walker or uses walls for balance when walking. She has problems with grip strength and her reflexes are poor. She bruises easily and has difficulty walking. She is unable to drive a motor vehicle due to a loss of sensation in her feet and hands. The Board finds that the Veteran's statements concerning her radiculopathy symptoms and associated functional impairment are competent and credible and thus weigh in her favor in determining whether higher disability ratings are warranted. However, the cause or etiology of her bladder issues and sexual dysfunction is a determination that is too complex to be made based on lay observation alone. Therefore, medical evidence is required to make such a determination. Accordingly, the above-cited unsupported lay opinions are not competent evidence on the areas of her bladder issues and sexual dysfunction, and therefore are not competent or probative. See Layno, 6 Vet. App. at 470-71 (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). In sum, the evidence demonstrates that the Veteran's radiculopathy, bilateral lower extremity, sciatic nerve warrants a 40 percent disability rating, but not higher, under 38 C.F.R. § 4.124a, Diagnostic Code 8620 for moderately severe incomplete paralysis. The evidence indicates that the Veteran has severe constant pain, decreased or absent sensation, tingling, burning, severe, numbness, swelling, severe paresthesias and/or dysesthesias, and weakness. The August 2020 examination report shows that her deep tendon reflexes were hyperactive without clonus bilaterally at her knee and ankle. She has also demonstrated reduced muscle strength. She has described a very high level of functional limitation, including loss of grip strength, difficulty walking, and in inability to drive a motor vehicle. There is no evidence that the Veteran has had severe incomplete paralysis with marked muscular atrophy. Therefore, a 60 percent disability rating is not warranted under Diagnostic Code 8620 and the benefit-of-the-doubt rule does not apply. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. For the reasons listed above, the Veteran's radiculopathy, bilateral lower extremity, anterior crural nerve warrants a 30 percent disability rating under 38 C.F.R. § 4.124a, Diagnostic Code 8626 for severe incomplete paralysis. There is no evidence that the Veteran's bilateral lower extremity, anterior crural nerve has manifested as severe incomplete paralysis or complete paralysis; paralysis of quadriceps extensor muscles. As such, the benefit-of-the-doubt rule does not apply, and a higher disability is not warranted is not warranted under Diagnostic Code 8626. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Again, for the reasons listed above, the Veteran's radiculopathy, bilateral lower extremity, external cutaneous nerve, rated under 38 C.F.R. § 4.124a, Diagnostic Code 8629; radiculopathy, bilateral lower extremity, ilioinguinal nerve rated under 38 C.F.R. § 4.124a, Diagnostic Code 8630; and radiculopathy, bilateral lower extremity, obturator nerve rated under 38 C.F.R. § 4.124a, Diagnostic Code 8628 warrant separate 10 percent disability ratings for severe paralysis. As the Veteran is in receipt of the highest schedular disability ratings under Diagnostic Codes 8628, 8629, and 8630, there is no basis for higher disability ratings. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.