Citation Nr: 21066452 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-48 806 DATE: November 1, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. An initial rating higher than 10 percent for the right knee disability is denied. An initial rating higher than 20 percent for the right shoulder disability is denied. Prior to October 15, 2020, an initial rating higher than 10 percent for the lumbar spine disability is denied. Beginning October 15, 2020, an initial rating higher than 20 percent for the lumbar spine disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a hearing loss disability in either ear pursuant to 38 C.F.R. § 3.385. 2. The right knee disability did not more nearly manifest as flexion as 60 degrees or less, recurrent subluxation, lateral instability, or persistent instability. 3. The right shoulder manifested no worse than flexion and abduction to 90 degrees. 4. Prior to October 15, 2020, the lumbar spine degenerative arthritis did not more nearly manifest as forward flexion of the thoracolumbar spine 60 degrees or less, manifest as a combined range of motion of 120 degrees or less, or manifest as muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 5. Beginning October 15, 2020, the thoracolumbar spine did not more nearly manifest as forward flexion of the thoracolumbar spine of 30 degrees or less or manifest as favorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. The criteria to establish service connection for bilateral hearing loss disability are not met. 38 U.S.C. § 1131, 5107; 38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.385. 2. The criteria for an initial rating higher than 10 percent for right knee degenerative arthritis with painful motion are not met. 38 U.S.C. §§ 1131, 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260. 3. The criteria for an initial rating higher than 20 percent for the right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, Diagnostic Code 5201. 4. Prior to October 15, 2020, the criteria for a rating higher than 10 percent for the lumbar spine degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 5. Beginning October 15, 2020, the criteria for a rating higher than 20 percent for the lumbar spine degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2002 to July 2003, June 2006 to January 2008, and July 2012 to September 2013. He also served on for an unverified period of active duty for training from June 1988 to October 1998. He retired from the National Guard in December 2014. This matter comes on appeal before the Board of Veterans' Appeals (Board) from February and April 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran received notice of the April 2017 rating decision in May 2017. This matter was previously before the Board in February 2020. The Board denied a compensable rating for a right knee scar and remanded the remaining claims for further development. While on remand, the RO granted service connection for posttraumatic stress disorder (PTSD). As this was a grant of the full benefit sought on appeal, this issue is no longer before the Board. The remaining claims have been returned to the Board for further appellate consideration. The Veteran waived a hearing before the Board in his September 2017 substantive appeal, via a VA Form 9. A claim for a total rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes, however, that the most recent medical evidence demonstrates that the Veteran is currently employed as a Drug Enforcement Agency (DEA) agent. See October 2020 VA examination. There is no indication that employment with the federal government is less than substantial or gainful or that it is in a protected environment. Furthermore, the Veteran has not asserted he is unable to work due to his service-connected right knee, right shoulder, or low back disabilities. As such, the issue of TDIU is not raised by the record. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 1. Entitlement to service connection for bilateral hearing loss is denied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). For the purposes of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Sensorineural hearing loss, as other disease of the nervous system, is considered by VA to be a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestation in service will permit service connection. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served ninety days or more of active service, and certain chronic diseases, such as tinnitus (as an organic disease of the nervous system), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. A layperson is competent to report the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran asserts that he currently experiences hearing loss that was caused by or is otherwise related to service. Upon review of all the evidence of record, the Board finds that the Veteran does not have a hearing loss disability for VA compensation purposes. The Veteran was afforded a VA audiological examination for hearing loss in October 2016. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 20 30 30 LEFT 25 35 30 40 45 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The right ear did not meet the criteria for a hearing loss disability for VA purposes, but the left ear did at this examination. In the March 2017 VA audiological examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 20 25 25 LEFT 20 20 20 25 25 Speech audiometry revealed speech recognition ability of 100 percent in each ear. Neither the right nor left ear met the criteria for a hearing loss disability for VA purposes under 38 C.F.R. § 3.385 at this examination. In the September 2020 VA audiological examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 20 30 35 LEFT 20 30 20 25 25 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and 100 percent in the left ear. Neither the right nor left ear met the criteria for a hearing loss disability for VA purposes under 38 C.F.R. § 3.385 at this examination. An addendum opinion was requested regarding whether the Veteran had hearing loss for VA purposes, which was obtained in September 2020. After reviewing the claims file and examining the Veteran, the examiner, an audiologist, concluded it was less likely than not that the Veteran had a current hearing loss disability for VA purposes in either ear. The examiner noted that although the Veteran had mild hearing loss from 2012-2013, prior to the appellate period, and on the September 2020 VA examination, the Veteran did not have hearing loss for VA purposes at either point in time. After reviewing the evidence, both lay and medical, the Board finds the preponderance of the evidence is against a finding that the Veteran has a hearing loss disability for VA purposes under 38 C.F.R. § 3.385 in either ear. The Board notes the July 2013 service audiogram, referenced by the September 2020 VA examiner, also does not show a hearing loss disability for VA purposes in either ear. The Board also considered the October 2016 VA audiogram which reported pure tone thresholds that suggest the Veteran had left ear hearing loss for VA purposes; however, when considered in the context of the two subsequent VA audiograms in March 2017 and September 2020, which do not show hearing loss for VA purposes in either ear, the Board finds that the October 2016 audiogram to be less reliable. Therefore, the Board assigns the October 2016 audiogram less probative weight than the subsequent March 2017 and September 2020 VA audiograms. The remaining evidence of record, to include post-service treatment records, do not demonstrate evidence that supports a finding of a current bilateral hearing loss disability as required by 38 C.F.R. § 3.385. Additionally, in an October 2015 TBI evaluation, the Veteran reported experiencing severe hearing loss, but on physical examination, his hearing was found to be intact. The Veteran is competent to report symptoms he can observe through his senses, such as reduced hearing acuity. However, the Veteran is not competent to diagnose a hearing loss disability or conduct an audiogram to meet the criteria of 38 C.F.R. § 3.385. See Layno, 6 Vet. App. at 470. Because the evidence does not show that the Veteran's hearing loss is to a disabling degree according to 38 C.F.R. § 3.385, the weight of the evidence demonstrates that the Veteran's bilateral hearing loss has not met the threshold to establish a current hearing loss "disability," and the claim must be denied. Brammer, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Pertinent Regulations for Increased Rating Claims Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria."). The U.S. Court of Appeals for Veterans Claims (Court) recently held in Chavis v. McDonough, No. 18-2928 (U.S. Vet. App., April 16, 2021) that application of §§ 4.40 and 4.45 permits consideration under the General Rating Formula for Diseases and Injuries of the Spine of an evaluation based on ankylosis if a claimant's functional loss is consistent with that contemplated by ankylosis. In other words, if the demonstrated functional loss is the functional equivalent of ankylosis then a higher rating may be warranted. In Chavis, the Court noted that the rating criteria define ankylosis in terms of limitation of motion. See 38 C.F.R. § 4.71a, General Rating Formula, Note (5) (ankylosis is a condition in which the spine or a spinal segment is fixed in flexion or extension). Essentially, ankylosis contemplates "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012); see also Villareal v. Principi, 18 Vet. App. 13 (2001) (defining ankylosis to mean that "a joint is fixed, or 'frozen' in one position."). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes through the senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. A rating higher than 10 percent for the right knee disability is denied. The right knee disability is currently assigned an initial 10 percent rating under Diagnostic Code 5260. The Veteran contends that he is entitled to a higher rating because it takes him extra time to get out of bed or extra time to stand after sitting for prolonged periods. Occasionally, the pain was severe, and he had to take pain medications. See February 2017 notice of disagreement. The Veteran later reported there were days his right knee was so painful he was unable to walk. He required support when he got up during the night. He did not have full range of motion in the right knee, and he had difficulty climbing stairs. See September 2017 VA Form 9. In addition, he had pain along his meniscus, and he did not believe the that the pain was all attributable to the right knee arthritis. He also asserted that he should be awarded a 75 percent disability rating overall for the right knee to adequately compensable him for his overall condition. See October 2017 VA Form 9. Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg; however, Diagnostic Code 5260 were unchanged. Effective February 7, 2021, Diagnostic Code 5003 and 5257 were amended. Pre-amended Diagnostic Code 5003 provides degenerative arthritis (hypertrophic or osteoarthritis) established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned for painful range of motion with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent rating is assigned for painful range of motion with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The February 7, 2021 amendments to Diagnostic Code 5003 only clarified that Diagnostic Code 5003 would now specifically apply to degenerative arthritis, other than posttraumatic arthritis. The Veteran's right knee disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Pre-amended Diagnostic Code 5257 assigned a 10 percent rating for slight recurrent subluxation or lateral instability of the knee. A 20 percent rating was assigned for moderate recurrent subluxation or lateral instability of the knee, and a 30 percent rating was assigned for severe recurrent subluxation or lateral instability of the knee. Effective February 7, 2021, the amended Diagnostic Code 5257 awards a 10 percent disability rating for recurrent subluxation or instability with a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent disability rating is warranted for recurrent subluxation or instability with either a (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for recurrent subluxation or instability, and an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Amended Diagnostic Code 5257 also provides ratings for patellar instability in the patellofemoral complex, which consists of the quadriceps tendon, the patella, and the patellar tendon. Here, there is no evidence of patellar instability. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." Sellers v. Wilkie, 30 Vet. App. 157 (2018). Rather than applying a mechanical formula, the Board must instead evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). As an initial matter, the currently assigned Diagnostic Code 5260 suggests that the right knee arthritis is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the right knee disability has manifested as arthritis and been rated based on painful noncompensable limitation of motion, and that the right knee disability has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period. Therefore, the Diagnostic Code assigned should have been Diagnostic Code 5003-5260, to show that the right knee disability with arthritis is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board is changing the Diagnostic Code for the right knee arthritis to 5003-5260 to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. The Board finds that the preponderance of the evidence is against a rating higher than 10 percent for the right knee disability. Post-service VA treatment records show the Veteran had pain in his right knee. He tore his ACL 10 years earlier and had an ACL repair two years after the tear. He used a knee brace. The Veteran felt he had right knee instability. Most of his pain was in the anterior of the right knee. On physical examination, his gait was normal; with normal stance, cadence, and arm swing using a right knee brace. There was no erythema or atrophy. There was a mild amount of palpable fluid, and a well healed surgical scar. His right knee was non-tender to palpation. He had full flexion and extension in the right knee. April 2016 x-ray studies showed right knee arthralgia. No range of motion measurements were provided. During the October 2016 VA knee examination, the examiner, a physician, noted the right knee had painful, normal flexion to 140 degrees and full extension to 0 degrees. No pain was noted on examination. There was no objective evidence of tenderness to palpation of the right knee, and no evidence of crepitus. The Veteran was able to perform repetitive motion testing with three repetitions without any additional loss of range of motion in the right knee. The Veteran was not examined after repeated use over time or during a flare up, and the physical examination was neither consistent nor inconsistent with the Veteran's reports of functional loss during these circumstances. Pain, weakness, fatigability, and incoordination did not contribute to the Veteran's functional loss with repeated use over time or during a flare up. No additional contributing factors, muscle atrophy, ankylosis, history of subluxation, history of lateral instability, or history of recurrent effusion were found. Muscle strength was normal in the right knee on flexion and extension. Joint stability testing was performed, and no instability was found on Lachman, posterior drawer, medial instability, or lateral instability testing. The Veteran did not currently have, or ever had, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran had never had, and did not have on examination, a meniscal condition. The Veteran had right knee surgery in 2007 with residuals of pain and a scar. No other pertinent physical findings, complications, conditions, signs, or symptoms related to the right knee disability. The Veteran occasionally used a knee brace to assist his normal locomotion. The functional loss due to the right knee disability was not so severe that he would be equally well served with an amputation and prosthetic. Imaging studies were performed and documented degenerative arthritis in the right knee. The Veteran was afforded another VA examination in October 2020. The examiner, a nurse practitioner, noted the Veteran had been diagnosed with a right knee strain and right knee arthritis status post-surgery. The Veteran reported he tore his ACL in 2005 while playing basketball. He felt a pop and experienced pain. He sought medical attention and had surgery to repair the ACL in 2007. In 2013, he had a hard fall from a vehicle in Afghanistan while wearing heavy gear and hit his right knee. Since onset, the Veteran had worsening, intermittent, sharp right knee pain. Due to his right knee, the Veteran's left knee had been overcompensating. The Veteran's pain was a 6 out of 10 on the 10 point pain scale in the right knee. Early morning, prolonged walking, and standing made the pain worse. Stretching and Tylenol helped the pain. The Veteran reported flare-ups in the right knee, described as being unable to get out of bed or walk for hours due to the severe pain until the pain medications took effect. He indicated flare-ups occurred twice a week, were moderate in severity, and lasted 20 minutes. The Veteran also described his functional loss due to the impairment of the right knee as difficulty with running, kneeling, crawling, and squatting. On physical examination, the Veteran had abnormal flexion to 95 degrees and normal extension to 0 degrees. Pain was noted on examination in active and passive motion testing, and the pain on flexion caused functional loss. There was no objective evidence of tenderness or pain to palpation of the joint or associated soft tissue. There was pain on weight bearing, but not in non-weight bearing. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with three repetitions, and no additional functional loss was reported. Pain, fatigue, weakness, lack of endurance, and incoordination did not cause additional functional loss on repetitive use testing. The Veteran was not immediately examined after repeated use over time or during a flare up. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing his functional loss during these circumstances. With repeated use over time and during flare-ups, pain caused additional functional loss estimated to be limited flexion to 85 degrees with normal extension to 0 degrees. No additional contributing factors were noted. Right knee muscle strength was reduced, measured described as active movement against some resistance in flexion and extension (4/5). There was a reduction in strength solely attributable to the right knee disability. No muscle atrophy, ankylosis, history of recurrent subluxation, history of lateral instability, or history of effusion were found. Joint stability testing was performed, and no instability was found on anterior instability, posterior instability, medical instability, or lateral instability testing. The Veteran did not have, nor ever had, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairments. He had never had, nor had on examination, a meniscal condition. The Veteran had a right ACL repair surgery in 2007 with residuals of pain and a scar. He occasionally used a right knee brace. The Veteran's right knee disability was not so severe that he would be equally well served with an amputation and prosthetic. Right knee imaging studies had been previously performed and documented arthritis. The Board acknowledges the Veteran's lay reports of symptoms and functional loss due to pain, difficulty walking up the stairs, difficulty with balance, and difficulty standing after sitting for a significant period of time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. At worst, the Veteran's estimated range of motion during a flare up and with repeated use over time was flexion to 85 degrees. No additional functional loss has been noted in any circumstances for the right knee extension. See October 2016 and October 2020 VA examinations. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). As discussed above, the Veteran is currently receiving a 10 percent rating under the preamble of Diagnostic Codes 5003-5260, applicable for when a compensable rating is not otherwise available under Diagnostic Code 5260 for loss of range of motion. Nevertheless, a 20 percent rating is only available under Diagnostic Code 5003 "[i]n the absence of limitation of motion..." Here, although the loss of range of motion is noncompensable under Diagnostic Code 5260, the Veteran exhibited reduced range of motion. As there is no absence of loss of range of motion in the right knee, the remaining diagnostic criteria under Diagnostic Code 5003 are not for application, and a rating higher than 10 percent is not warranted. As to instability, the preponderance of the evidence is against the finding that the Veteran has recurrent subluxation or lateral instability under the pre-amended Diagnostic Code 5257 or recurrent subluxation or persistent instability under the amended Diagnostic Code 5257. The Veteran mentioned instability one time in October 2015. No objective signs of instability were found in either the October 2015 VA treatment record or the October 2016 or October 2020 VA examinations. No instability was noted in the treatment records. Furthermore, the Veteran did not report subjective instability as a symptom of his right knee in either VA examination. Thus, the evidence is against a finding that any subjective instability experienced by the Veteran was recurrent or persistent, and a separate rating is not warranted under either the pre-amended or amended Diagnostic Code 5257. In addition, although the Veteran has indicated he has pain "along the meniscus," there is no evidence he has experienced a meniscal condition to warrant consideration of a separate rating under Diagnostic Codes 5258 or 5259. The Veteran is already being compensated for right knee pain by the 10 percent rating assigned under Diagnostic Code 5003 (previously rated under 5260). Without additional symptoms related to a dislocation or removal of the meniscus, to assign a separate rating for pain alone would be impermissible pyramiding. 38 C.F.R. § 4.14. There is no evidence of ankylosis, dislocated semilunar cartilage with frequent periods of locking pain and joint effusion, removal of the semilunar cartilage, limited extension, impairment of the tibia of fibula, or genu recurvatum. Therefore, Diagnostic Codes 5256, 5258, 5259, 5261, 5252, and 5263 under the pre-amended regulations prior to February 7, 2021 and the amended regulations effective February 7, 2021 do not apply. Finally, the Board also considered the possibility of awarding a higher rating with consideration of 38 C.F.R. §§ 4.40 and 4.45. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App., April 16, 2021); Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012); see also Villareal v. Principi, 18 Vet. App. 13 (2001). In this case, the Board acknowledges the Veteran's lay reports of symptoms of difficulty standing after sitting for a prolonged period and the inability to get out of bed until the pain medications were effective for the right knee; however, the Board concludes that such alleged functional loss is not consistent with that contemplated by ankylosis. Notably, there is no suggestion of any limited motion of the right knee comparable to immobility; he was still able to perform right knee flexion to 85 degrees, at worst, and right knee extension was normal. Also, to the extent that the Veteran experienced functional loss due pain on movement, he has not alleged functional impairment comparable to that experienced by an individual with immobility of the right knee. His symptoms are fully contemplated by the assigned schedular rating. The DeLuca concepts are still used to apply the rating criteria found in the diagnostic codes. Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016) and Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011). The Thompson court explained that "[s]ection 4.40 also makes clear that functional loss may be due to pain and that pain may render a part seriously disabled. When evaluating a disability, § 4.40 provides a broad canvas. However, whatever the background, an applicant for disability benefits is rated based on the criteria set forth in § 4.71a." Thompson, 815 F.3d at 786. Indeed, pain alone without resulting functional loss is not enough to warrant an increased rating. The Veteran was also able to perform after repetitive use testing without any additional limitation of range of motion, and the estimated range of motion during flare-ups and with repeated use over time were not functionally equivalent to the right knee being immobile. As such, the current rating adequately compensates him for the right knee pain with limited motion, and a higher rating is not warranted, nor is his disability the equivalent of ankylosis. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent for the right knee disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. A rating higher than 20 percent for the right shoulder disability is denied. The Veteran contends that he is entitled to a rating higher than 20 percent for the right shoulder disability because he has limited motion in his right shoulder, and there were days he was unable to raise his arm above his head due to pain. He also asserted he could not raise his right arm to turn the steering wheel of his vehicle. See February 2017 notice of disagreement and September 2017 VA Form 9. The Veteran's right shoulder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Effective February 7, 2021, VA amended the rating criteria for disabilities of the shoulder. Diagnostic Code 5201 was amended. Under the pre-amended Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warranted a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warranted a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Under the amended Diagnostic Code 5201, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. There is no dispute that the Veteran's right arm is his major extremity. See October 2016 and October 2020 VA examinations. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran was afforded an October 2016 VA shoulder examination. The examiner, a physician, noted the Veteran had been diagnosed with right shoulder degenerative arthritis. The Veteran had right shoulder popping and constant pain. He had right shoulder flare-ups described as increased pain if he sat for a long period on time. The Veteran had to roll his shoulders for a few minutes before he could raise his arm. The Veteran described his functional impairment as being unable to fully raise his right arm. Active range of motion in the right shoulder was normal in all planes. Pain was noted on examination in flexion but did not cause functional loss. There was no evidence of pain on weight bearing, crepitus, or localized tenderness to palpation of the joint or associated soft tissue. He was able to perform repetitive use testing with at least three repetitions without additional functional loss. The Veteran was not examined after repeated use over time or during a flare-up. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing his functional loss in these circumstances. Pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability during repeated use over time or during a flare-up. There were no additional factors contributing to the right shoulder functional loss. Muscle strength was normal (5 out of 5) in forward flexion and abduction in the right shoulder. No muscle atrophy or ankylosis were noted. A right rotator cuff condition was suspected, but Hawkins' Impingement Test, Empty can Test, External Rotation/Infraspinatus strength test, and lift-off subscapularis test were negative. There was no shoulder instability, dislocation, or labral pathology suspected. Clavicle, scapular, acromioclavicular (AC) joint, or sternoclavicular joint conditions were not suspected. The Veteran did not have loss of head, nonunion, or fibrous union of the humorous. He did not have malunion of the humorous with moderate or marked deformity. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. The right shoulder disability was not so severe that an amputation of the right arm and prosthetic would equally well serve the Veteran. Imaging studies documented right shoulder arthritis. The Veteran was afforded another VA examination in October 2020. The examiner, a nurse practitioner, noted the Veteran had right shoulder degenerative joint disease. The Veteran had right shoulder pain. Lifting and a change of weather made it worse. Stretching and Ibuprofen made the pain better. His pain was dull and rated at 4 out of 10 on a 10 point pain scale with 10 being the most severe pain. He had moderate right shoulder flare-ups twice a week that lasted thirty minutes each. He would stretch the right shoulder during a flare up until the pain medication took effect. The Veteran's reported functional loss included difficulty reaching backwards, carrying, pushing, pulling, and lifting. Initial range of motion measurements showed right shoulder flexion to 100 degrees, abduction to 100 degrees, external rotation to 45 degrees, and internal rotation to 40 degrees. The range of motion itself contributing to the functional loss. Pain was noted on active and passive motion and caused functional loss in active motion. There was no objective evidence of localized tenderness or pain on palpation of the joint and associated soft tissue. There was evidence of pain on weight bearing, but no evidence in non-weight bearing. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of range of motion. Pain, fatigue, weakness, lack of endurance, and incoordination did not cause additional functional loss. The Veteran was not examined after repetitive use over time or during a flare-up. The examination was neither medically consistent nor inconsistent with the Veteran's statements regarding functional loss with repeated use over time. Pain and weakness caused additional functional loss during repeated use over time. Pain, weakness, fatigability, or incoordination did not significantly limit his functional ability during flare ups. The examiner estimated the range of motion during repeated use over time and during a flare-up to be flexion to 90 degrees, abduction to 90 degrees, external rotation to 35 degrees, and internal rotation to 30 degrees. No additional contributing factors were found. Muscle strength was measured as active movement against some resistance (4/5) in forward flexion and abduction. No muscle atrophy or ankylosis was found. A right rotator condition was suspected, but the Hawkins' impingement test, empty-can test, external rotation/infraspinatus strength testing, and lift-off subscapularis test were negative. No shoulder instability, dislocation, labral pathology, clavicle, scapula, AC joint, sternoclavicular joint condition, loss of head, nonunion, or fibrous union of the humerus conditions were suspected. No additional pertinent findings, complications, signs, or symptoms were noted. He did not use a right shoulder assistive device. The right shoulder functional impairment was not so severe that amputation and prosthetic would equally well-serve the Veteran. Prior x-ray studies showed degenerative joint disease in the right shoulder. The examiner noted the impact of the right shoulder disability was that he was limited in reaching backward, carrying, pushing, pulling, and lifting moderate objects overhead and has difficulty lifting his arm past his shoulder height causing limitations with dressing and grooming. The examiner remarked that the slight decrease in range of motion did not contribute to functional loss. The Board acknowledges that the October 2016 VA examination did not comport with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016) in providing estimated range of motion in passive motion and non-weight bearing. Nevertheless, active range of motion testing generally produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. Similarly, testing on weight bearing would generally produce more restrictive results than testing done without weight bearing. Therefore, there is no prejudice to the Veteran in relying on the VA examinations that involved active range of motion testing or weight-bearing for the lumbar spine because such results tend to produce the "worst case scenario" of impairment and tend to support the highest possible rating. After a review of the evidence, both lay and medical, the Board finds that the preponderance of the evidence is against a rating higher than 20 percent for the right shoulder disability. The Board acknowledges the Veteran's lay reports of symptoms and acknowledges that there is functional loss due to painful motion of the right shoulder and arm. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in symptoms more nearly approximating limitation of right arm motion to midway between side and shoulder level or limitation of motion of the arm to 25 degrees from the side. During the appellate period, at worst, the Veteran's flexion and abduction were limited to 90 degrees during a flare-up and after repeated use over time. See October 2020 VA examination. These estimated findings are consistent with the Veteran's lay reports of functional loss, which included difficulty reaching backwards, carrying, pushing, pulling, and lifting. The Board also considered the Veteran's reports that he was unable to lift his arm to turn the steering wheel, but the evidence does not show that the Veteran's right arm motion was limited to midway between his side and shoulder level (45 degrees or less), and the October 2020 VA physical examination findings clearly show that his right arm motion was not limited to 45 degrees or less. See September 2017 VA Form 9. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating higher than 20 percent for the right shoulder disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Increased rating claim for the lumbar spine disability a) Pertinent regulations applicable to rating the lumbar spine The Veteran's lumbar spine degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. b) Prior to October 15, 2020, a rating higher than 10 percent for the lumbar spine disability is denied. Turning to the evidence, the Board notes that an October 2015 VA traumatic brain injury evaluation reported that the Veteran "might" get some numbness in his right lower extremity "maybe" to the calf. His bowel and bladder were continent; and his gait was normal in his stance, cadence, and arm swing without assistive device, other than a right knee brace. On physical examination, there was tenderness to palpation in the lumbar spine and interspinous ligament. He was positive for pain on palpation in the right lumbar paravertebral muscle. L3 to S1 were intact to light touch sensation testing bilaterally. The clinician noted that active range of motion was decreased in flexion, extension, right lateral flexion and left lateral flexion but did not report the range of motion in degrees. Straight leg raise testing and sitting slumped root testing were positive bilaterally. Patricks' test was unable to be conducted as the Veteran was unable to get into the proper position to complete testing, and facet load testing with lateral rotation and extension was negative. December 2015 VA treatment records show the Veteran sought treatment for increased back pain, rated as a 4 out of 10 on a 10 point pain scale. He had difficulty with his stairs at home. His pain was an 8 out of 10 on a 10 point pain scale in the morning and after prolonged sitting. He took pain medications and used a heating pad for relief. Rest and leaning back relieved the pain more than leaning forward. Active range of motion for the lumbar spine was within normal limits. Bilateral lower extremity strength testing was 4 out of 5. Tenderness to palpation was noted at L5 to S1. Sensation testing was intact on neurological examination. The Veteran was afforded a VA lumbar spine examination in October 2016. The examiner, a physician, noted the Veteran had degenerative arthritis of the lumbar spine. The Veteran had constant low back pain. He had not had surgery or steroid injections. The Veteran reported flare-ups described as increased pain after driving or standing for fifteen minutes or more. Occasionally the pain radiated into his left leg. The Veteran reported the functional loss attributed to his low back he had to "step or lay flat" after driving or sitting. Active range of motion in the lumbar spine was normal, including 90 degrees of forward flexion, 30 degrees extension, 30 degrees right lateral flexion, 30 degrees left lateral flexion, 30 degrees right lateral rotation, and 30 degrees left lateral rotation. Pain was noted in forward flexion on examination but did not cause functional loss. There was no evidence of pain on weight bearing. There was no evidence of localized pain to palpation of the joint or associated soft tissue. The Veteran was able to perform observed repetitive use testing with at least three repetitions without any additional functional loss. The Veteran was not examined with repeated use over time or during a flare-up. The examination was neither medically consistent nor inconsistent with the Veteran's description of functional loss in these circumstances. Pain, weakness, fatigability, or incoordination did not limit his functional ability with repeated use over time or during a flare-up. The Veteran did not have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine. No additional contributing factors were noted. Muscle strength was normal (5/5) in all areas. The Veteran did not have muscle atrophy, ankylosis, or intervertebral disc syndrome (IVDS). Deep tendon reflexes were normal (5/5) bilaterally. Sensory examination was normal bilaterally in all areas. Strait leg raising test was negative bilaterally. The Veteran did not have radicular pain or signs or symptoms of radiculopathy. No other neurological abnormalities were noted. The functional impairment due to the back disability was not so severe that he would be equally well served by amputation and prosthetic. Imaging studies had been performed and documented arthritis. In October 2017, the Veteran underwent a chiropractic evaluation for low back pain. The pain was sharp and worse in morning than at night. At times, the pain radiated to the right knee. Standing and stretching made it better and sitting made it worse. The pain was rated as a 7 in the morning and a 5 throughout the day. No reports or evidence of bowel or bladder issues. His gait was normal. No pain in squat was noted. He had a dull ache at L5 in lunge. Bechterew's sitting test showed no pain. The seated strait and supine strait leg raises were negative, bilaterally. Deep tendon reflexes in the achilles and patellar were +2 (normal) and symmetrical, bilaterally. Light touch sensory testing was intact at L4-S1 bilaterally. He was able to walk on heels and toes without pain. Extension produced dull ache at L5. The Veteran was afforded additional chiropractic treatment at VA. Upon review of the evidence, both lay and medical, the preponderance of the evidence is against assigning a rating higher than 10 percent for the low back disability prior to October 15, 2015. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements did not more nearly approximate forward flexion of the thoracolumbar spine to 60 degrees or less or more nearly manifest as combined range of motion of the thoracolumbar spine of 120 degrees or less. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. The Board also considered the possibility of awarding a higher rating with consideration of 38 C.F.R. §§ 4.40 and 4.45. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App., April 16, 2021); Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012); see also Villareal v. Principi, 18 Vet. App. 13 (2001). In this case, although the Board acknowledges the Veteran's lay reports of symptoms of difficulty standing, walking, bending, lifting, and squatting, the Board concludes that such alleged functional loss is not consistent with that contemplated by ankylosis. Notably, there is no suggestion of any limited motion of the spine comparable to any type of immobility. He was still able to perform forward flexion to 60 degrees, at worst. Also, to the extent that the Veteran experienced functional loss due pain on movement, he has not alleged functional impairment comparable to that experienced by an individual with immobility of part of the spine. His symptoms are fully contemplated by the assigned schedular rating. The DeLuca concepts are still used to apply the rating criteria found in the diagnostic codes. Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016) and Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011). The Thompson court explained that "[s]ection 4.40 also makes clear that functional loss may be due to pain and that pain may render a part seriously disabled. When evaluating a disability, § 4.40 provides a broad canvas. However, whatever the background, an applicant for disability benefits is rated based on the criteria set forth in § 4.71a." Thompson, 815 F.3d at 786. Indeed, pain alone without resulting functional loss is not enough to warrant an increased rating. The Veteran was also able to perform repetitive use testing without any additional limitation of range of motion. As such, the current rating adequately compensates him for his pain with limited motion, and a higher rating is not warranted under DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995), nor is his disability the equivalent of ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Board finds that the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. While the Veteran has occasionally and vaguely reported that his low back pain radiates down either leg, there is no evidence that the Veteran consistently experiences these symptoms. Furthermore, there have been no physical findings either on examination or in the treatment records that indicate the Veteran has radiculopathy or neuropathy. There is also no evidence of record of bowel or bladder incontinence or any other neurological diagnosis, signs, or symptoms attributed to the low back disability. Indeed, the Veteran has not asserted that he has a neurological disability related to the lumbar spine. While the Veteran is competent to report symptomatology that he experiences, such as occasional radiating pain into one leg or the other, he has not shown that he has the medical experience or training to diagnose a neurological condition or relate the condition to his lumbar spine disability, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent for the lumbar spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). c) Beginning October 15, 2020. a rating higher than 20 percent for the lumbar spine disability is denied. The Veteran contends that he is entitled to a rating higher than 20 percent for the low back disability because he had increased pain, decreased ability to stand, and reduced range of motion without medications. The Veteran was afforded a VA examination in October 2020. The examiner, a nurse practitioner, diagnosed the Veteran with degenerative arthritis of the lumbar spine. The Veteran denied undergoing surgery or injections. He had been treated by a chiropractor, but the treatment was not helping. His pain was worsening. The Veteran rated it as a 7 out of 10 on a 10 point pain scale. Prolonged sitting made it worse. Lying flat on the floor and taking ibuprofen provided some relief. The Veteran had flare-ups if he drove or sat too long. His flare-ups occurred three times a week, were moderate, and lasted 20 minutes each. The Veteran described his functional loss as difficulty with prolonged sitting, driving, walking, and bending. The Veteran's initial active range of motion was flexion to 70 degrees, extension to 25 degrees, right lateral flexion to 25 degrees, left lateral flexion to 30 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 30 degrees. Passive range of motion was not assessed as the examiner did not feel it was feasible to do in a safe and reasonable manner. The abnormal range of motion itself contributed to the Veteran's functional loss. Pain was noted on examination and caused functional loss in forward flexion and extension. There was pain on weight bearing. According to the examiner, non-weight bearing range of motion was not applicable to the spine, and there is no opposing joint to the back to assess. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional functional loss. Pain, fatigue, weakness, lack of endurance, and incoordination did not cause functional loss. The Veteran was not examined after repeated use over time or during a flare-up. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing his functional loss in these circumstances. Pain caused additional functional loss with repeated use over time and during flare-ups. The examiner estimated the Veteran would have additional loss of motion to 60 degrees of flexion, 15 degrees of extension, 15 degrees of right lateral flexion, 20 degrees of left lateral flexion, 15 degrees of right lateral rotation, and 20 degrees of left lateral rotation with repeated use over time and during a flare-up. The Veteran did not have guarding or muscle spasms of the thoracolumbar spine. No additional contributing factors were noted. The Veteran had reduced muscle strength, described as active movement against resistance (4/5) in right hip flexion, knee extension, ankle plantar flexion, and ankle dorsiflexion. Muscle strength was normal (5/5) in the right great toe extension and left hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. No muscle atrophy, ankylosis, or IVDS were noted. Deep tendon reflexes were normal in all aspects. Straight leg raise testing was negative bilaterally. The examiner determined the Veteran did not have radicular pain or any other signs and symptoms of radiculopathy. No other neurological abnormalities or findings related to the thoracolumbar spine were noted. He regularly used a back brace. The thoracolumbar spine disability was not so severe that amputation and prosthetic would equally well serve the Veteran. Imaging studies had been conducted and arthritis had been documented. The Veteran did not have thoracic vertebral fracture with loss of 50 percent or more of height. The Veteran worked as a DEA agent, and the low back disability caused difficulty with prolonged walking, standing, bending, pushing, pulling, carrying, and lifting moderate objects related to degenerative arthritis of the spine. After reviewing the evidence, both lay and medical, the Board finds that the preponderance of the evidence is against a rating higher than 20 percent for the lumbar spine disability. The Board acknowledges the Veteran's lay reports of symptoms and functional loss due to pain and reduced range of motion with repeated use over time and during the flare-ups. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Although the Board acknowledges the Veteran's lay reports of symptoms of difficulty standing, walking, bending, lifting, and squatting, the Board concludes that such alleged functional loss is not consistent with that contemplated by ankylosis. Notably, there is no suggestion of any limited motion of the spine comparable to any type of immobility; he was still able to perform forward flexion to 60 degrees, at worst. Also, to the extent that the Veteran has experienced functional loss due pain on movement, he has not alleged functional impairment comparable to that experienced by an individual with immobility of part of the spine. His symptoms are fully contemplated by the assigned schedular rating. The DeLuca concepts are still used to apply the rating criteria found in the diagnostic codes. Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016) and Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011). Pain alone without resulting functional loss is not enough to warrant an increased rating. As such, the current rating adequately compensates him for his pain with limited motion, and a higher rating is not warranted. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Furthermore, his lumbar spine disability is not the equivalent of ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS, and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Board notes that the Veteran has not asserted that he has experienced radiating back pain into his legs during this period on appeal, and there have been no physical findings or diagnoses of neurological disability during this period on appeal. The Board also considered whether the 20 percent rating could be awarded effective earlier than October 15, 2020, the date of the most recent VA examination, during the appellate period. While the Board acknowledges that it is less likely that the Veteran's lumbar spine disability suddenly worsened on the date of the October 15, 2020 VA examination, the Veteran's increase in disability is not factually ascertainable before this date. As discussed above, there is no evidence prior to October 15, 2020 to support a rating higher than 10 percent for the lumbar spine disability. (Continued on the next page) Based on the foregoing, the preponderance of the evidence is against the Veteran's claim for a rating higher than 20 percent for the lumbar spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. Chu Veterans Law Judge Board of Veterans' Appeals Representative for the Board T. Harper, 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.