Citation Nr: 21066574 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 14-09 951 DATE: November 1, 2021 ORDER Entitlement to a rating in excess of 10 percent for right knee retropatellar femoral syndrome (RPS), to include on an extraschedular basis is denied. Entitlement to a rating in excess of 10 percent for left knee RPS, to include on an extraschedular basis is denied. Entitlement to a separate 10 percent rating, but no higher, for slight instability of the right knee is granted. Entitlement to a separate 10 percent rating, but no higher, for slight instability of the left knee is granted. Prior to April 4, 2016, entitlement to a rating in excess of 10 percent for a low back strain, to include on an extraschedular basis is denied. Beginning April 4, 2016, entitlement to a rating in excess of 20 percent for a low back strain, to include on an extraschedular basis is denied. FINDINGS OF FACT 1. The Veteran's right knee disability is manifested by painful motion and locking, but not limitation of flexion to 30 degrees or less, limitation of extension to 15 degrees or more, with no cartilage impairment, effusion, tibia or fibula impairment, ankylosis, or genu recurvatum; functional loss included pain on use and with prolonged sitting, standing, and walking. 2. The Veteran's left knee disability is manifested by painful motion and locking, but not limitation of flexion to 30 degrees or less, limitation of extension to 15 degrees or more, with no cartilage impairment, effusion, tibia or fibula impairment, ankylosis, or genu recurvatum; functional loss included pain on use and with prolonged sitting, standing, and walking. 3. The Veteran's right knee was shown to have slight instability with giving way, but not moderate lateral instability, recurrent subluxation, or persistent and recurrent instability. 4. The Veteran's left knee was shown to have slight instability with giving way, but not moderate lateral instability, recurrent subluxation, or persistent and recurrent instability. 5. Prior to April 4, 2016, the Veteran's lumbar spine disability manifested with pain on movement and forward flexion limited to 80 degrees, at its worst; with no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. 6. Beginning April 4, 2016, the Veteran's lumbar spine disability manifested with pain on movement, forward flexion limited to 50 degrees, with functional loss to 45 degrees of forward flexion due to flareups, but no incapacitating episodes or ankylosis (or its functional equivalent). CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee RPS have not been met. 38 U.S.C. §§ 1110, 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5299-5260. 2. The criteria for a rating in excess of 10 percent for left knee RPS have not been met. 38 U.S.C. §§ 1110, 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5299-5260. 3. The criteria for a 10 percent rating, but no higher, for slight instability of the right knee have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. The criteria for a 10 percent rating, but no higher, for slight instability of the left knee have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. Prior to April 4, 2016, the criteria for a rating in excess of 10 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107, 5107 (b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71(a), DC 5237. 6. Beginning April 4, 2016, the criteria for a rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107, 5107 (b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71(a), DC 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1992 to November 1995. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a June 1996 rating decision, the RO granted service connection for a low back disability and assigned a 10 percent rating, effective November 16, 1995. In a September 1998 rating decision, the RO granted service connection for retropatellar pain syndrome of the bilateral knees and assigned 10 percent ratings, effective November 16, 1995. The Board previously remanded the Veteran's claims in February 2016, October 2018, October 2020, and May 2021. In May 2021, the appeal was remanded to obtain additional VA treatment records and to obtain adequate medical opinions. Additional CAPRI records were associated with the claims file in May 2021. Also, new medical opinions were associated with the claims file in June 2021. The Board finds that the June 2021 medical examinations issued in connection with the Veteran's claims for increased ratings of the low back and bilateral knees are adequate. Thus, the Board determines that there has been substantial compliance with the May 2021 remand directives as to the claims, and further remand is not required. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that remand not required where there was substantial compliance with remand directives). In a March 2020 rating decision, a 20 percent rating was assigned for lumbosacral strain, effective September 4, 2019. In a July 2021 rating decision, a 20 percent rating was assigned for lumbosacral strain from April 4, 2016. However, the claim remains on appeal as this does not represent a full grant of the benefit sought. AB v. Brown, 6 Vet. App. 35 (1993). Increased Rating The Veteran's entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). At the time of an initial rating, consideration of the appropriateness of a staged rating is also required. Fenderson v. West, 12 Vet. App. 119 (1999). Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular DC, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different DCs, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2017); see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Musculoskeletal Disabilities When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509- 10 (2007); Fenderson, 12 Vet. App. at 126-27. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See 85 Fed. Reg. 230 (Nov. 30, 2020). When the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question, unless the regulatory change specifically permits retroactive application. 38 U.S.C. § 5110 (g); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Therefore, the Board will review the Veteran's appeal 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. 1. Entitlement to a rating in excess of 10 percent for right knee RPS, to include on an extraschedular basis 2. Entitlement to a rating in excess of 10 percent for left knee RPS, to include on an extraschedular basis The Veteran contends that he is entitled to higher ratings for his service-connected bilateral knee disabilities. Again, the Veteran is currently in receipt of 10 percent ratings for both knees under Diagnostic Code 5299-5260, for painful motion of the knee. 38 C.F.R. § 4.59. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 5260 provides that flexion of the leg limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a 0 percent (noncompensable) rating. 38 C.F.R. § 4.71a. This diagnostic code was not revised in the new rating schedule. DC 5261 provides that a noncompensable rating is warranted for extension limited to 5 degrees; a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 50 degrees. 38 C.F.R. § 4.71a. This code was also not revised in the new rating schedule. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. The rating schedule also provides that dislocation of semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint, warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides for the assignment of a maximum 10 percent rating based on symptomatic removal of the semilunar cartilage. These codes were not affected by the new revisions. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if it is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, DC 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this diagnostic code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As of February 7, 2021, under the amended criteria, DC 5257 still applies to other impairment of the knee but is now separated into impairments of recurrent subluxation or instability or patellar instability. For recurrent subluxation or instability of the knee, a 10 percent rating is now warranted where there is 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 is warranted if either: (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, is present. A 30 percent is warranted for unrepaired or failed repair of complete ligament tear of the knee causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability of the knee, a 10 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Separate ratings can be assigned for knee disabilities (e.g. DCs 5257, 5258, 5259, 5260, and 5261) when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). In March 2006 correspondence, the Veteran claimed that his knee condition worsened. Specifically, the Veteran stated that his knees have accelerated to "excruciating pain." After a thorough review of the evidence, however, the Board finds that the preponderance of the evidence is against ratings in excess of 10 percent for each knee disability under either the prior or revised rating criteria. In a May 2006 buddy statement, the Veteran's friend (P.B.) stated that the Veteran's knees were so bad that he has to use Theragesic, ice packs, Icy Hot, Ibuprofen, Tylenol, Bengay, BioFreeze, and a heating pad for relief. The Veteran's friend also stated that because of his knee problems, he cannot engage in everyday activities, such as grocery shopping, going to dinner, or going to the park, or having a picnic. The Veteran was afforded a VA examination in June 2006, at which time the Veteran reported having bilateral knee pain and stated that he was unable to participate in an exercise program due to his knees. There was no effusion or instability. The Veteran did not have knee braces. Examination found both knees to be tender in the retropatellar area and around the articular margins. Range of motion testing was 0 to 125 degrees with crepitus, bilaterally, but with no pain. There was no additional limitation with repetitive movement. Gait was normal and there was no ankylosis. During an October 2009 VA examination, the Veteran reported constant moderate aching pain with intermittent weakness, instability, or giving way and locking with tenderness and swelling. Physical examination revealed tenderness on palpation of both knees. As to both knees, the Veteran had a normal gait with no objective evidence of abnormal weight bearing and no ankylosis. Flexion was 0 to 135 degrees with pain, bilaterally. There was no evidence of instability with normal medial and lateral collateral ligament testing, anterior and posterior cruciate ligaments testing, and medial lateral meniscal testing. The Veteran was afforded a VA Knee and Lower Leg Conditions DBQ in April 2016. The examiner noted that the Veteran had knee pain. The Veteran further reported that his pain was sharp and radiated around the patella. Pain was present intermittently, flared for no reason and sometimes with increased activity. The Veteran also stated that he has flare-ups about twice a week (which last for one hour) and were alleviated using topical rub. The Veteran reported having functional loss or functional impairment which limited prolonged standing and walking and difficulty with squatting, bending, kneeling, stair climbing, and walking up inclines. Range of motion testing of both knees revealed flexion to 120 degrees and extension to 0 degrees. There was no evidence of pain with weight bearing; objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue; or crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. While the examiner noted that there was additional functional loss or range of motion after three repetitions, range of motion after three repetitions resulted in 120 degrees of flexion and extension to 0 degrees, bilaterally. As to both knees, the examiner noted that he was unable to determine without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability or with repeated use over a period of time or significantly limited functional ability with flare-ups because the Veteran was not examined after repetitive use over time or during a flare-up. There were no additional factors contributing to disability. Muscle strength testing was normal. The Veteran did not have muscle atrophy or ankylosis. There was no history of recurrent subluxation or recurrent effusion or lateral instability. Joint stability testing was performed, but there was no joint instability, bilaterally. The examiner noted that the Veteran had bilateral "shin splints" (medial tibial stress syndrome), which did not affect range of motion of the knee or ankle. The Veteran did not have meniscus (semilunar cartilage) condition. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed. The Veteran did not use any assistive device as a normal mode of locomotion. Imaging studies were performed, but they did not reveal degenerative or traumatic arthritis. As to functional impact, the examiner noted that the Veteran's conditions impacted his ability to perform any type of occupational task, to specifically include that his knee pain required him to change positions frequently. The Veteran was afforded another Knee and Lower Leg Conditions DBQ in September 2019. The examiner noted diagnoses of retropatellar pain syndrome of the bilateral knees. The Veteran reported that his symptoms included sharp, throbbing knee pain. The Veteran also stated that his condition has worsened over the years and impacts daily life making it difficult to walk long distances, climb up/down stairs, and do any type of bending during flare-ups. Treatment included rest, limited activities, and medication. The Veteran reported daily flare-ups of the bilateral knees which were moderate in severity and which lasted several hours. The bilateral knee flare-ups were precipitated by prolonged walking and standing and alleviated by rest. The Veteran also reported that functional loss or functional impact, to specifically include difficulty bending, squatting, lifting 20 or more pounds, kneeling, and prolonged driving. Range of motion testing, bilaterally, revealed flexion to 110 degrees and extension to 0 degrees, with pain on both flexion and extension. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight bearing or objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, bilaterally, with no additional loss of functional range of motion after three repetitions. Pain and lack of endurance, bilaterally, significantly limited functional ability with repeated use over a period of time, which resulted in 90 degrees of flexion, bilaterally and extension to 0 degrees, bilaterally. The examination was not conducted during a flare-up. Pain and lack of endurance, bilaterally, significantly limited functional ability with flare-ups, which resulted in 90 degrees of flexion, bilaterally and extension to 0 degrees, bilaterally. There were no additional factors contributing to disability. Muscle strength testing was normal, with no evidence of muscle atrophy. The Veteran did not have ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion, bilaterally. Joint stability testing was performed, but no joint instability was noted. The examiner noted that the Veteran did not have or had in the past recurrent patellar dislocation or a meniscus condition. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to any condition. The Veteran did not have any scars. The Veteran did not use an assistive device. Imaging studies were not performed. As to functional impact, the examiner noted that the Veteran's condition did not impact any occupational task. In the Remarks section of the report, the examiner noted that there was objective evidence of pain on passive range of motion testing of both knees and objective evidence of pain on non-weight bearing testing of both knees. A November 2020 Knee and Lower Leg Conditions DBQ revealed a diagnosis of retropatellar pain syndrome of the bilateral knees. The Veteran reported that he had limitations in walking and standing, as well as climbing. He also stated that he cannot run any longer. The Veteran did not report flare-ups of the knee and/or lower leg. The Veteran, however, reported having functional loss or functional impairment, including but not limited to repeated use over time, to include limitations in walking and standing and difficulty with climbing. As to the right knee, range of motion testing revealed flexion to 120 degrees and extension to 0 degrees, which contributed to a decrease in flexion and extension of the knees which interfered with walking and climbing abilities. Pain was noted on flexion and extension. There was evidence of pain with weight bearing, as well as objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, to include reports of lateral and medial pain when the knee is palpated. There was no objective evidence of crepitus. As to the left knee, range of motion testing revealed flexion to 110 degrees and extension to 0 degrees, the decrease in flexion and extension of the knees interferes with walking and climbing abilities. Pain was noted on examination in flexion and extension and that caused functional loss. There was objective evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, to include reports of lateral and medial pain when the knee is palpated. There was objective evidence of crepitus. Bilaterally, the Veteran was able to perform repetitive use testing with at least three repetitions, without additional functional loss or range of motion after three repetitions. Bilaterally, pain and lack of endurance significantly limited functional ability with repeated use over a period of time, described as flexion to 100 degrees and extension to 0 degrees. There were no additional contributing factors of disability. Muscle strength testing was normal in the right knee and there was active movement against some resistance in the left knee. The Veteran did not have muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed, but no joint instability was discovered, bilaterally. The Veteran did not have and never had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran did not have and never had a meniscus condition. There were no other pertinent physical findings, complications, conditions, signs, or symptoms or any scars. The Veteran did not use an assistive device to ambulate. Imaging studies were performed, but degenerative or traumatic arthritis was not documented. As to other significant diagnostic test findings, impressions revealed no definite acute fracture, but there was a finding of mild arthritic changes with medial knee joint space narrowing, bilaterally. As to functional impact, the Veteran was limited in walking, standing, and climbing, and he was unable to run any more due to pain. In the Remarks section of the report, the examiner noted that there was evidence of pain on passive range of motion testing, but there was no evidence of pain when the joint was used in nonweight bearing. The examiner also stated that he had no basis to deny additional losses of function or range of motion when it comes to repetitive use over time during flare-ups. The Veteran underwent a Knee and Lower Leg DBQ in June 2021, at which time the examiner noted diagnoses of retropatellar pain syndrome of the bilateral knees, as well as bilateral degenerative arthritis. The Veteran reported that his knee pain had gotten progressively worse since his last examination. The Veteran specifically reported constant bilateral knee pain, sharp in nature with associated popping, stiffness, swelling, grinding, locking, and giving way. The Veteran noted that his pain was located around the knee, which was alleviated by muscle rubs, heat, ice, and exercises. Further, the Veteran reported that he tried knee braces but he did not notice any difference in pain, so he no longer uses them. The Veteran reported bilateral knee flare-ups with prolonged periods of weightbearing and prolonged sitting, which lasted about two hours and which occur two to three times per week. The Veteran also noted that his mobility was limited and that he had difficulty walking, bending, standing, and sitting. The Veteran also reported having functional loss or functional impairment in that he was unable to stand, walk, and sit for long periods of time. The Veteran denied a history of instability, recurrent subluxation, and effusion of the knee. As to the right knee, active range of motion testing revealed flexion to 80 degrees and extension to 0 degrees, with pain beginning at 10 degrees in flexion and 70 degrees in extension. Passive range of motion testing revealed flexion to 90 degrees and extension to 0 degrees, with pain beginning at 10 degrees in flexion and 70 degrees in extension. There was evidence of pain with weight-bearing, active motion, passive motion, and that caused functional loss, to include an impairment of weightbearing activities, bending, climbing, and prolonged sitting. There was objective evidence of crepitus, localized tenderness or pain on palpation of the joint or associated soft tissue, with audible popping noted. The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional functional loss or range of motion after three repetitions. The Veteran was not being examined immediately after repeated use over time. Procured evidence suggested that pain significantly limited functional ability with repeated use over time. Repeated use over time testing revealed flexion ending at 80 degrees and extension ending at 0 degrees. Here, the Veteran reported increased knee pain and decreased tolerance for weight bearing activities. The examination was not conducted during a flare-up. Procured evidence suggested that pain significantly limited functional ability with flare-ups. Range of motion testing during flare-ups revealed flexion ending at 70 degrees and extension ending at 0 degrees. There were no additional factors contributing to disability. As to the left knee, active range of motion testing revealed flexion to 75 degrees and extension to 0 degrees, with pain beginning at 5 degrees in flexion and 70 degrees in extension. Passive range of motion testing revealed flexion to 90 degrees and extension to 0 degrees, with pain beginning at 5 degrees in flexion and 70 degrees in extension. There was evidence of pain with weight-bearing, active motion, passive motion, and that caused functional loss, to include an impairment of weightbearing activities, bending, climbing, and prolonged sitting. There was objective evidence of crepitus, localized tenderness or pain on palpation of the joint or associated soft tissue, with audible popping noted. The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional functional loss or range of motion after three repetitions. The Veteran was not being examined immediately after repeated use over time. Procured evidence suggested that pain significantly limited functional ability with repeated use over time. Repeated use over time testing revealed flexion ending at 75 degrees and extension ending at 0 degrees. Here, the Veteran reported increased knee ain and decreased tolerance for weight bearing activities. The examination was not conducted during a flare-up. Procured evidence suggested that pain significantly limited functional ability with flare-ups. Range of motion testing during flare-ups revealed flexion ending at 70 degrees and extension ending at 0 degrees. There were no additional factors contributing to disability. Bilaterally, the Veteran did not have muscle atrophy; ankylosis; recurrent subluxation or persistent instability; a ligament tear; surgical repair of the knee for patellar instability. Bilaterally, the Veteran had not been diagnosed with a recurrent patellar dislocation, shin splints, stress fracture, or other tibial or fibular impairment. Bilaterally, the Veteran never had a surgical procedure. The Veteran had other persistent physical findings, to include pain elicited by toe and heel walk, but the Veteran's gait was normal. The Veteran did not have any scars or other disfigurement. The Veteran did not use an assistive device to ambulate. There was not functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies had not been performed. Other diagnostic test findings, dated November 2020, revealed mild arthritis changes with medial knee joint space narrowing and no definite acute fracture, bilaterally. Functional impact included an impairment of prolonged standing, walking, running/jogging, squatting, bending, prolonged sitting, and climbing. In the Remarks section of the report, the examiner noted that there was evidence of pain on passive range of motion testing, but there was no evidence of pain when the joint was used in non-weight bearing. Degenerative arthritis was noted to be directly due to or related to the service-connected diagnosis. It was also noted that the Veteran was unable to perform weightbearing passive and active range of motion, contraindicated due to risk of falling as both knees were injured. With respect to increased ratings under Diagnostic Codes 5260 and 5261, a rating in excess of 10 percent is not warranted because the evidence does not demonstrate that the Veteran's right or left knee flexion is limited to 30 degrees or less, or that his extension is limited to 15 degrees or more. Likewise, a 20 percent evaluation under Diagnostic Code 5003 is not warranted for either knee as each knee is a single major joint. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261. However, separate compensable ratings of 10 percent under Diagnostic Code 5257 for slight instability of the right and left knees are warranted. While all the VA examiners concluded that there was no evidence of instability in the Veteran's right and left knee, the Veteran has reported having instability of both knees. More specifically, the Veteran reported that his knees were "giving away" at the June 2021 VA examination. Here, the Board notes that medical evidence is not categorically more probative than lay evidence under Diagnostic Code 5257. See English v. Wilkie, 30 Vet. App. 347, 352-54 (2018). Furthermore, there is no reason to doubt the credibility of the Veteran's lay statements, as they were made during the course of treatment. Notably, a November 2010 VA treatment record shows that the Veteran was given a prosthetics referral for bilateral knee braces. Furthermore, at the June 2021 VA examination, the Veteran acknowledged trying knee braces, but noted that they did not work for him. However, a rating in excess of 10 percent for instability of the right or left knee under Diagnostic Code 5257 is not warranted, because there is no objective evidence of moderate recurrent subluxation or lateral instability of the right knee. The Board also finds that separate ratings under Diagnostic Code 5258 and 5259 are not warranted. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Veteran has not been diagnosed with cartilage damage at any time during the appeal period, nor has there been frequent episodes of effusion. Furthermore, the Veteran's symptoms of pain and locking are being compensated under the assigned ratings for painful limitation of motion and instability under Diagnostic Codes 5260 and 5257. Compensating the same symptom under two separate diagnostic codes is prohibited pyramiding. 38 C.F.R. §§ 4.14, 4.71a, Diagnostic Code 5258 and 5259. Finally, as the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5262 or 5263, respectively. With regard to additional compensation for functional loss, as noted above, the Board finds that the Veteran's functional loss consisted of painful motion, which increases during flare-ups, and is compensated in the assigned 10 percent rating under section 4.59. The Board acknowledges that the Veteran experienced additional symptoms contributing to functional loss, in the form of giving way, limitations with prolonged standing and walking, the need for a brace, and lack of endurance; however, such have been compensated for in the current rating assigned and additional 10 percent rating assigned under Diagnostic Code 5257. Accordingly, there is no additional compensation for functional loss warranted at any time during the appeal period. 38 C.F.R. §§ 4.40, 4.45, 4.59. New Regulations Effective February 7, 2021 The Board has considered the new regulatory changes and finds that the new criteria respecting evaluations of knee disabilities are not as advantageous to the Veteran in this case, and that the Veteran does not meet the criteria for a higher evaluation. Specifically, the significant changes related to knee disabilities were to add Diagnostic Code 5002 for active arthritic process, which the Veteran does not have. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5002). Additionally, changes were made to the rating provisions for tibia and fibula impairment with an addition of ratings for shin splints. While the Board acknowledges that only the April 2016 VA examiner noted that the Veteran had a history of bilateral shin splints in the military, the condition did not affect range of motion of the knee. The Board further notes that the September 2019, November 2020, and June 2021 VA examiners noted that the Veteran did not have any tibia or fibula impairment. Thus, these new regulations are not applicable. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38C.F.R. §4.71a, Diagnostic Code 5262). Further, changes were made to Diagnostic Code 5257 governing instability, which added the requirement of either (1) sprain of or tear (either complete or incomplete) of a knee ligament causing persistent instability, or (2) a diagnosed condition of the patellofemoral complex with recurrent instability (with or without surgical repair); and (3) assistive devices or bracing (either by prescription or not) to the criteria, which were not present in the old pre-February 7, 2021 criteria. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38C.F.R. §4.71a, Diagnostic Code 5257). Because the new criteria under Diagnostic Code 5257 require more specific criteria than the old criteria, they are less advantageous to the Veteran. The Veteran is already in receipt of a 10 percent rating for instability of the bilateral knees under prior version of rating schedule. A higher rating under the new criteria is not warranted because the Veteran is not shown to have any ligament injury or any surgical repair for any patellar instability throughout the appeal period. In sum, the Board finds that, a rating in excess of 10 percent for limitation of motion of the bilateral knees is denied, but a separate rating of 10 percent for slight instability of the bilateral knees under Diagnostic Code 5257 is granted. The Board further notes that the Veteran's representative raised the issue of extraschedular consideration. See April 2021 Appellate Brief. In this regard, the Veteran's representative stated that during the November 2020 VA examination, the Veteran reported that he had "very limited walking, standing, difficulty with climbing, cannot run at all." As to extraschedular consideration, the Board notes that the Veteran's right and left knee disabilities are manifested by reports of pain, locking, instability, reduced ROM, and flare-ups (as outlined above). Such manifestations and related impairment are fully contemplated by the regular schedular criteria. Those criteria provide for higher ratings, but the criteria for such ratings are not met. Furthermore, there is nothing exceptional or unusual about the Veteran's right or left knee disability. See Long v. Wilkie, No. 16-1537 (Vet. App. December 30, 2020). Accordingly, referral for extraschedular consideration is not warranted. In sum, the Board finds that, a rating in excess of 10 percent for limitation of motion of the bilateral knees is denied as the preponderance of the evidence is against this increased rating claim. Yet, as noted above, a separate rating of 10 percent for slight instability of the bilateral knees under Diagnostic Code 5257 is granted. 3. Entitlement to a rating in excess of 10 percent prior to April 4, 2016, and in excess of 20 percent thereafter, for a low back strain, to include on an extraschedular basis. The Veteran contends that he is entitled to a higher rating for his service-connected low back strain. The Veteran is currently in receipt of a 10 percent rating prior to April 4, 2016 and a 20 percent rating thereafter, rated under Diagnostic Code 5237. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula, 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 body 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 combined range of motion of the thoracolumbar spine greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. And, a 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. Associated objective neurologic abnormalities are evaluated separately. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Diagnostic Codes 5237, 5242, Note 1. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Intervertebral disc syndrome permits evaluation under either 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 results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5242, 5243. Diagnostic Code 5243 provides for rating intervertebral disc syndrome (IVDS) under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating IVDS based on Incapacitating Episodes provides ratings for incapacitating episodes as follows: having a total duration of at least 6 weeks during the past 12 months (60 percent); having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent); having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); and having a total duration of at least one week but less than 2 weeks during the past 12 months (10 percent). 38 C.F.R. § 4.71a. Note 1 states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. VA regulations also instruct that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board notes that the criteria for rating musculoskeletal disabilities, including disabilities of the spine, have changed once during the period covered by this appeal, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. Effective February 7, 2021, Diagnostic Code 5242 was amended to include degenerative disc disease other than IVDS. Diagnostic Code 5244 was also added to add paraplegia and quadriplegia; and, Diagnostic Code 5237 was not changed. The Board notes that the spine regulations were also amended to state that Diagnostic Code 5243 governing IVDS should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). This change does not impact the evaluation in this case as the Veteran does not have any evidence of incapacitating episodes that would warrant a compensable rating under Diagnostic Code 5243. Period Prior to April 4, 2016 In March 2006 correspondence, the Veteran claimed that his back condition worsened. Specifically, the Veteran stated that his knees have accelerated to "excruciating pain." After a thorough review of the evidence, however, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's back disability under either the prior or revised rating criteria. In a May 2006 buddy statement, the Veteran's friend (P.B.) stated that the Veteran's back is so bad that he can barely stand up. The Veteran's friend also stated that because of his back problems, he cannot engage in everyday activities, such as grocery shopping, going to dinner, or going to the park, or having a picnic. The Veteran was afforded a VA Spine examination in July 2006, at which time the Veteran reported having back pain and stiffness, without paresthesias. The Veteran reported having flare-ups, which occurred with continued lifting activities. Range of motion testing revealed flexion to 80 degrees; extension to 30 degrees; right and left lateral flexion to 30 degrees; and right and left lateral rotation to 30 degrees. There was no additional pain or limitation with repetitive motion. There were no muscle spasms. There was diffuse tenderness, but there was no point tenderness. There was no effusions or instability. No incapacitating episodes were noted. Imaging studies revealed chronic mechanical low back pain. During an October 2009 VA examination, the Veteran reported constant moderate aching pain with intermittent weakness, instability, or giving way and locking with tenderness and swelling. Physical examination revealed tenderness on palpation of both knees. As to both knees, the Veteran had a normal gait with no objective evidence of abnormal weight bearing and no ankylosis. Flexion was 0 to 135 degrees with pain, bilaterally. There was no evidence of instability with normal medial and lateral collateral ligament testing, anterior and posterior cruciate ligaments testing, and medial lateral meniscal testing. As noted above, the Veteran is in receipt of a 10 percent rating prior to April 4, 2016. The Board notes that the 10 percent rating was granted based on painful motion under 38 C.F.R. § 4.59 as his lumbar spine range of motion did not meet the criteria for a compensable evaluation. Based on the above and remaining evidence, the Board finds the Veteran's 10 percent rating has been appropriately staged and higher ratings are not warranted. In this regard, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. Here, although the Veteran complained of pain in his July 2006 and October 2009 examinations, pain did not cause further limitation of motion. In addition, in his June 2006 examination, there was no evidence of pain following repetitive motion or additional limitations in motion. During this period, the Veteran had a normal gait, and there was no evidence of guarding or spasm severe enough to result in an abnormal gait or abnormal contour such as scoliosis, atrophy, ankylosis or incapacitating episodes. The Board has also considered the Veteran's available VA treatment records; however, these records do not indicate that a higher rating is warranted. Thus, for this period on appeal, a rating in excess of 10 percent is not warranted. The preponderance of the evidence is against this claim. Therefore, the benefit of the doubt rule does not apply; the appeal in this matter must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Period Beginning April 4, 2016 The Veteran underwent a Back (Thoracolumbar Spine) Conditions DBQ in April 2016. The examiner noted that the Veteran had lumbosacral strain and lumbar spondylosis. The Veteran reported that his symptoms included radiating back pain on both sides and occasional left buttock pain with walking. The Veteran described the pain as sharp, stabbing and occurs with standing and with activity. The Veteran reported flare-ups occurred on a daily basis and lasted a few minutes to a few hours. The Veteran also reported having functional loss or functional impairment of the back, which interfered with lifting, walking, exercise, prolonged sitting, standing, and walking. The Veteran also noted that he must change positions frequently to avoid pain. Range of motion testing revealed forward flexion to 80 degrees; extension to 30 degrees; right and left lateral flexion to 30 degrees; and right and left lateral rotation to 30 degrees. Range of motion itself contributed to functional loss in that decreased range of motion inhibited normal use of the back. Pain was noted on all planes of motion. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with at least three repetitions. Range of motion after three repetitions resulted in forward flexion to 80 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 25 degrees, and right and left lateral rotation to 30 degrees. The Veteran was not being examined immediately after repetitive use over time, and the examiner could not determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. The examination was not conducted during a flare-up, and the examiner could not determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. The Veteran did not have guarding or muscle spasm. There were no additional factors contributing to disability. Muscle strength testing was normal, and the Veteran did not have muscle atrophy. Reflex examination showed hypoactive reflexes in the bilateral knees, otherwise reflex testing was normal. Sensory examination was normal. Straight leg raising test was negative. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine or any other neurologic abnormalities or findings related to a thoracolumbar spine condition. The Veteran did not have IVDS. The Veteran did not use an assistive device. Imaging studies were performed, and arthritis was documented. The examiner also noted that an October 2010 x-ray showed hypertrophic changes of the facet joints at the lower levels. The examiner noted that the Veteran's back condition impacted his ability to work in that his back pain makes it difficult to sit for a long time in one position in his office job. The Veteran underwent a Back (Thoracolumbar Spine) Conditions DBQ in September 2019. The examiner noted that the Veteran had lumbosacral strain. The Veteran reported that his symptoms since onset included moderate back pain and tightness and treatment included rest, back stretches, and ibuprofen. The Veteran also reported that his condition worsened over the years and impacted daily activities. The Veteran reported flare-ups that occurred three to four times per month and which were mild in severity and lasted several hours. The Veteran noted that such flare-ups are precipitated by walking, standing, and sitting for prolonged periods and they are not alleviated by anything. Range of motion testing revealed forward flexion to 60 degrees; extension to 20 degrees; right and left lateral flexion to 20 degrees; and right and left lateral rotation to 25 degrees. Range of motion itself did not contribute to functional loss. Pain was noted on all planes of motion. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with at least three repetitions. Range of motion after three repetitions resulted in forward flexion to 55 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 20 degrees. Pain and lack of endurance caused this functional loss. The Veteran was not being examined immediately after repetitive use over time. Pain and lack of endurance caused functional loss, resulting in forward flexion to 50 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 15 degrees. The examination was not conducted during a flare-up. Pain and lack of endurance significantly limited functional ability with flare-ups, and which resulted in forward flexion to 45 degrees; extension to 10 degrees; right and left lateral flexion to 10 degrees; and right and left lateral rotation to 10 degrees. The Veteran had muscle spasms but they did not result in abnormal gait or abnormal spinal contour. The Veteran did not have guarding. There were no additional factors contributing to disability. Muscle strength testing was normal, and the Veteran did not have muscle atrophy. Sensory examination was normal. Straight leg raising test was negative. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine or any other neurologic abnormalities or findings related to a thoracolumbar spine condition. The Veteran did not have IVDS. The Veteran did not use an assistive device. Imaging studies were not performed. The examiner noted that the Veteran's back condition impacted his ability to work in that he had difficulty bending, lifting 20 pounds, squatting, kneeling, and prolonged driving. In the Remarks section of the report, the examiner noted that there was objective evidence of pain on passive range of motion testing of the back and there was also objective evidence of pain on non-weight bearing testing of the back. The Veteran was afforded a Back (Thoracolumbar Spine) Conditions DBQ in November 2020. The examiner provided diagnoses of degenerative arthritis of the spine, as well as lumbar strain with fusion of L5 to S1. At the time of the examination, the Veteran stated that he continued to have persistent pain which had worsened over the years and which radiated from his mid to lower back. The Veteran did not report flare-ups. The Veteran reported functional loss or functional impairment, noting that he could not sit, walk, or stand for long periods of distance. Range of motion testing revealed forward flexion to 75 degrees, extension to 20 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. Range of motion contributed to functional loss, to include decreased forward flexion and backward extension limited by pain. There was evidence of pain with weight bearing. There was not objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions, but there was no additional loss of function or range of motion after three repetitions. The Veteran was not immediately examined after repetitive use over time. Pain and lack of endurance significantly limited functional ability with repeated use over a period of time, resulting in forward flexion to 65 degrees; extension to 20 degrees; right and left lateral flexion to 30 degrees; and right and left lateral rotation to 30 degrees. The Veteran had guarding that did not result in abnormal gait or abnormal spinal contour. The Veteran did not have muscle spasms. Muscle strength testing was normal, and the Veteran did not have muscle atrophy. Reflex examination was normal. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine or other neurologic abnormality. The Veteran did not have IVDS and episodes requiring bed rest. The Veteran did not use an assistive device. There were no other persistent physical findings, complications, conditions, signs or symptoms related to any conditions. Imaging studies were performed, and arthritis was documented. The Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of height. Other significant diagnostic test findings and/or results included impressions of prominent transverse processes of L1 and arthritis changes with disc space narrowing at L4-5 and L5-S1 levels, but no evidence of compression fracture of the lumbar vertebra. As to functional impact, the examiner noted that the Veteran's thoracolumbar spine impacted his ability to work in that it limited walking, standing, bending, lifting, pushing and pulling, and stair climbing. In the Remarks section of the report, the examiner noted that there was evidence of pain on passive range of motion testing, but there was no evidence of pain when the joint is used in non-weight bearing. The examiner also noted that given the Veteran's history and current subjective complaints, there was no basis to deny additional losses of function or range of motion when it comes to repetitive use over time or during a flare-up. The Veteran underwent a Back (Thoracolumbar Spine) Conditions DBQ in June 2021, at which time the examiner noted a diagnosis of a lumbosacral strain, as well as lumbar degenerative disc disease and degenerative arthritis. At the time of the examination, the Veteran reported that his lower back pain worsened since the last examination. Specifically, the Veteran reported constant low back pain, stabbing and aching, with associated muscle soreness and stiffness. The Veteran stated that his pain is located across the lower back and up and down his lumbar spine. He does self-care for his low back, to include natural muscle rubs, heat, ice, and stretching exercises. The Veteran reported flare-ups of the thoracolumbar spine which occur with prolonged periods of sitting and with excessive walking/weight bearing. He states that the flare-ups last for two to three days and that the severity was beyond a "10" on the pain scale. During these times, the Veteran cannot do anything and that nothing relieves the pain. He also stated that his mobility was limited and that he has difficulty with walking, bending, standing, and sitting. The Veteran reported having functional loss or functional impairment, which again impaired prolonged walking, sitting, and standing; bending; running/jogging; squatting; lifting more than 20 pounds; and twisting motions. Initial range of motion testing revealed forward flexion to 50 degrees; extension to 0 degrees; right and left lateral flexion to 20 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 10 degrees; pain was noted on all planes of motion. Painful motion began at 15 degrees in forward flexion; 5 degrees in extension; 10 degrees in right and left lateral flexion; 10 degrees in left lateral rotation; 5 degrees in right and left lateral rotation. Passive range of motion testing was not performed, as the examiner noted that it was medically contraindicated as it was "not medically appropriate." There was evidence of pain with weight-bearing, nonweight-bearing, active motion, and it caused functional loss in that it impaired bending, weightbearing activities, lifting, and twisting motions. There was no objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue in L3-S1. The Veteran was able to perform repetitive use testing with at least three repetitions. There was not additional loss of function or range of motion after three repetitions. The Veteran was not being examined immediately after repeated use over time, but procured evidence suggested that pain significantly limited functional ability with repeated use over time. Range of motion immediately after repeated use over time testing revealed forward flexion to 50 degrees; extension to 20 degrees; bilateral lateral flexion to 20 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 10 degrees. Here, the Veteran reported increased back pain and decreased tolerance for weight bearing activities, bending, twisting motions, lifting, and prolonged sitting. The Veteran did not report additional loss of motion, but there was loss of range of motion during repeated use over time, without additional loss of range of motion beyond what was reflected in the current objective ranges of motion documented on examination. The Veteran was not being examined during a flare-up, but procured evidence suggested that pain significantly limited functional ability with flare-ups. Range of motion during flare-ups resulted in forward flexion to 45 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees, right lateral rotation to 15 degrees, and left lateral rotation to 10 degrees. Here, the Veteran reported increased back pain and decreased tolerance for weight-bearing activities and prolonged sitting, and there was loss of range of motion during flare-ups. The Veteran had localized tenderness, but it did not result in an abnormal gait or abnormal spinal contour. The Veteran did not have muscle spasms or guarding. There were no additional factors contributing to disability. Muscle strength testing was normal. The Veteran did not have muscle atrophy. Reflex examination and sensory examination was normal. Straight leg raising test revealed negative findings. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine or any other neurologic abnormalities. The Veteran did not have IVDS. The Veteran did not use an assistive device. The Veteran's gait was normal, but there was pain elicited with toe and heel walk. Imaging studies were not performed. Other significant diagnostic test findings/results, dated November 2020, showed prominent transverse processes of L1; no evidence of compression fracture of the lumbar vertebra; arthritic changes with disc space narrowing at L4-5 and L5-S1 levels. As to functional impact, the Veteran showed impairment with prolonged walking, sitting, and standing, as well as with bending, running/jogging, lifting greater than 20 pounds, squatting, and with twisting motions. In the Remarks section of the report, the examiner noted that passive range of motion testing was not medically appropriate. There was evidence of pain when the joint was used in non-weight bearing. The lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of a 20 percent disability rating for this period. The evidence shows that the Veteran experiences forward flexion of the thoracolumbar spine which is better than 30 degrees, even during flare-ups, which is required for a higher rating based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Here, the lay evidence has been considered; however, that evidence when accepted as correct does not establish that he is functionally limited to 30 degrees or less forward flexion. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. Additionally, the Veteran does not experience incontinence or bowel complaints as a result of his lumbar spine disability. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. However, the evidence shows no atrophy or decrease in strength. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion and impairment, as well as estimated limitation of motion during a flare-up. The Board observes that the Veteran's projected limitation of motion was based on the Veteran's reports of symptomatology and reports of functional loss and by examination. Here, no examiner found that range of motion warranted a higher rating due to functional loss, to include during a flare-up or on repeated use. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). See also Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Moreover, the available medical findings do not show that painful motion, limitation of motion on repetitive use testing, or pain or limitation of motion on active motion/passive motion/in weight-bearing/nonweight-bearing resulted in functional loss warranting the assignment of any higher evaluation for the lumbar spine during the entire appeal period. See Correia v. McDonald, 28 Vet. App. 158 (2016). To the extent that the Veteran reports flare-ups, the Board finds that the Veteran's flare-ups, especially in light of their frequency, do not show that the evidence more nearly approximates a disability picture with forward flexion of the spine limited to 30 degrees or less. 38 C.F.R. §§ 4.7, 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of a 20 percent disability rating. With respect to a higher evaluation based on incapacitating episodes under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, as noted earlier, the Veteran does not have intervertebral disc syndrome which is productive of incapacitating episodes requiring physician prescribed best rest having a total duration of at least 4 weeks during a 12-month period as contemplated by a higher evaluation. Review of the Veteran's treatments record also do not reveal any periods of physician prescribed bed rest as a result of his lumbar spine disability. Furthermore, there was no evidence of a diagnosis of intervertebral disc syndrome. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Veteran's VA examination reports reflect that the Veteran does not experience any lower extremity neurological deficits, it is not for consideration here. As such, the Board finds that the evidence of record reveals manifestations consistent with the currently assigned 20 percent evaluation for the entire rating period on appeal for his lumbar spine disability. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The Board further notes that the Veteran's representative raised the issue of extraschedular consideration. See April 2021 Appellate Brief. In this regard, the Veteran's representative stated that during the November 2020 VA examination, the Veteran reported that he "cannot sit, stand, or walk for prolonged periods of time." As to extraschedular consideration, the Board notes that the Veteran's low back disability is manifested by reports of pain, stiffness, reduced ROM, and flare-ups (as outlined above). Such manifestations and related impairment are fully contemplated by the regular schedular criteria. Those criteria provide for higher ratings, but the criteria for such ratings are not met. Furthermore, there is nothing exceptional or unusual about the Veteran's low back disability. See Long v. Wilkie, No. 16-1537 (Vet. App. December 30, 2020); see also Thun v. Peake, 22 Vet. App. 111 (2008). Accordingly, referral for extraschedular consideration is not warranted for any period on appeal. Based on the foregoing, a rating in excess of 20 percent for the Veteran's low back disability, for the period beginning April 6, 2016, is not warranted. The preponderance of the evidence is against this claim. Therefore, the benefit of the doubt rule does not apply; the appeal in this matter must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hanson 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.