Citation Nr: 21067194 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 13-18 364 DATE: November 3, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to an increased rating higher than 40 percent for lumbar spine spondylolisthesis (lumbar spine disability) is denied. Entitlement to an initial rating higher than 20 percent for right lower extremity radiculopathy is denied. Entitlement to an initial 20 percent rating, but not higher, from October 7, 2015 for left lower extremity radiculopathy is granted subject to the laws and regulations controlling the award of monetary benefits. REMANDED Entitlement to service connection for bilateral hip disabilities is remanded. Entitlement to service connection for bilateral knee disabilities is remanded. FINDINGS OF FACT 1. The Veteran's diagnosed PTSD was caused by an in-service stressor related to his fear of hostile, military, or terrorist activity. 2. The Veteran's lumbar spine disability symptoms do not more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. 3. The Veteran's right lower extremity radiculopathy symptomatology does not more nearly approximate moderately severe incomplete paralysis. 4. The Veteran's left lower extremity radiculopathy symptomatology more nearly approximates moderate incomplete paralysis for the entire period on appeal from October 7, 2015, but it does not more nearly approximate moderately severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304 (f). 2. The criteria for a disability rating higher than 40 percent for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71a, Diagnostic Code (DC) 5237. 3. The criteria for an initial 40 percent rating for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, DC 8520. 4. The criteria for an initial 20 percent rating, but not higher, for left lower extremity radiculopathy have been met for the entire period on appeal from October 7, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1976 to September 1979. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts which, inter alia, denied reopening the Veteran's claim for service connection for a psychiatric disorder, and continued a 40 percent rating for lumbar spine disability. In May 2010, the Veteran filed his notice of disagreement with, among other things, the 40 percent rating for a lumbar spine disability, and the denial of reopening the claim for service connection for a psychiatric disability, was issued a statement of the case in May 2013, and in June 2013 perfected his appeal to the Board. In a December 2015 Decision Review Officer (DRO) decision, the DRO granted a 10 percent rating for left lower extremity radiculopathy, a 20 percent rating for right lower extremity radiculopathy, and reduced the rating for a lumbar spine disability from 40 percent to 20 percent, effective October 7, 2015. In a February 2016 supplemental statement of the case, the RO notified the Veteran that his claim for service connection for a psychiatric disability was not reopened, and notified the Veteran regarding the previously noted ratings for lumbar spine disability, and right and left lower extremity radiculopathy. In April 2016, the Veteran filed his notice of disagreement with the evaluations assigned for his right and left lower extremity radiculopathy, was issued a statement of the case in November 2016, and in December 2016 perfected that appeal to the Board. In June 2017, the Veteran appeared before the undersigned Veterans Law Judge at a videoconference Board hearing. A copy of the transcript is of record. In a September 2017 decision, the Board, among other things, found the reduction in the disability rating for lumbar spine disability from 40 to 20 percent improper, reopened the claim for service connection for a psychiatric disability, and remanded the claims for service connection for a psychiatric disability, a higher rating for right and left lower extremity radiculopathy, and a higher rating for a lumbar spine disability. In a December 2017 rating decision, the RO granted a rating increase for the Veteran's lumbar spine disability, evaluating it as 40 percent disabling from October 7, 2015, and in a September 2019 rating decision, granted a rating increase for left lower extremity radiculopathy, evaluating it as 20 percent disabling from May 31, 2018, creating a staged rating. As these constitute a partial grant of the benefits sought on appeal, these issues remain on appeal before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). In August 2021, the RO, among one other thing, continued a 40 percent rating for lumbar spine disability, a 20 percent rating for right lower extremity radiculopathy, a 10 percent rating for left lower extremity radiculopathy prior to May 31, 2018, and 20 percent thereafter, and denied service connection for a psychiatric disability, notifying the Veteran in a supplemental statement of the case. The Board notes that the Veteran's claim for a total disability rating due to individual unemployability (TDIU) from May 31, 2018 was granted in the September 2019 rating decision with the Veteran filing a 10182 Notice of Disagreement with the effective date in September 2020, electing the Hearing docket. The Board will thus adjudicate that claim in a separate decision once the hearing has been conducted in accordance with the Appeals Modernization Act. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Psychiatric Disability The record contains psychiatric diagnoses for PTSD and major depressive disorder. Therefore, the Board has expanded the issue on appeal to include all psychiatric disorders, to include PTSD and major depressive disorder consistent with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM 5) criteria, in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that a claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304 (f). The Board notes that the DSM-IV has been updated with a Fifth Edition (DSM-5). VA has amended 38 C.F.R. § 4.125(a) to require the diagnosis to conform to DSM-5. The amendment applies to cases such as this one that were certified to the Board after August 4, 2014. See Schedule for Rating DisabilitiesMental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). Under 38 C.F.R. § 3.304 (f)(3), if a stressor claimed by a veteran is related to the veteran's fear of hostile, military, or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The Veteran testified that he was informed by his doctors that there was a connection between his depression and back pain. The Veteran's service treatment records do not reflect treatment for, or complaints of a psychiatric disability, or for symptoms which are attributable to a psychiatric disability, and his September 1979 medical examination report upon discharge is normal. In a November 2009 letter, the Veteran stated that his back pain is causing him to go into a deep depression to the point that he does not want to do anything. In an October 2013 VA mental therapy note, the psychologist diagnosed persistent depressive disorder and PTSD, stating that the Veteran's chronic depression and anxiety likely stemmed from early childhood experiences, and that the Veteran struggles with PTSD symptoms related to the death of his sergeant by suicide. In a January 2014 statement, the Veteran reported witnessing his platoon sergeant commit suicide while he was stationed at Camp Schwab. November 2019 VA records reflect that the Veteran has a diagnosis of major depressive disorder. In a November 2019 VA examination report, the examining psychologist reported that the Veteran had a diagnosis of PTSD that conforms to the DSM-5 criteria, and that all his symptoms were related to PTSD as his substance abuse disorders are in sustained remission. The Veteran reported that he was depressed all of the time, and that he experiences anxiety. He also stated that he often thinks of the event that occurred when his sergeant shot himself while the Veteran was in service. The psychologist noted that the Veteran's reported stressor met the criteria to support the diagnosis of PTSD, and opined that it is at least as likely as not (at least a 50 percent probability) that the Veteran meets the DSM-5 criteria for PTSD, and that it is related to events that occurred while the Veteran was on active duty. In an undated records research response, it was reported that a professional researcher from the Veterans Benefits Administration, Compensation Service, Military Records Research Center was unable to locate evidence to support documentation of the Veteran's claimed stressor. The evidence of record, specifically the November 2019 VA treatment records and examination report reflect that the Veteran has current diagnoses of major depressive disorder and PTSD which meets the diagnostic criteria under DSM-5 according to a licensed psychologist with whom VA has contracted. While VA has been unable to corroborate the stressful in-service events, the Veteran has provided competent and credible evidence of witnessing the death of fellow servicemember. The stressor as described by the Veteran is related to the Veteran's fear of hostile, military, or terrorist activity, as the Veteran witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others. Therefore, the first 2 criteria for establishing service connection for PTSD have been met, and the remaining issue is whether the Veteran's PTSD is related to the in-service stressor. 38 C.F.R. § 3.304 (f). Here, the November 2019 psychologist opined that the Veteran's PTSD is at least as likely as not (at least a 50 percent probability) related to his in-service stressor, and provided a thorough rationale based on an accurate characterization of the evidence of record. Therefore, the November 2019 psychologist's opinion is afforded significant probative value. See Nieves-Rodriguez, 22 Vet. App. at 304. There is no negative nexus opinion of record regarding the etiology of the Veteran's PTSD, and the November 2019 medical opinion is consistent with the additional record, specifically the October 2013 VA mental therapy note which indicated that the Veteran struggled with PTSD related to the death of his sergeant by suicide. As indicated above, the Veteran has been diagnosed with major depressive disorder in addition to PTSD. Notably, the VA examiner did not differentiate between symptomatology associated with the Veteran's PTSD and his other psychiatric disability, and in fact attributed all of the Veteran's psychiatric disability symptoms to his PTSD. As the Veteran will therefore be compensated for all of his psychiatric symptoms, the Board will not separately adjudicate a claim for service connection for any other psychiatric disorder. Mittleider v. West, 11 Vet. App. 181 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). Therefore, the weight of the evidence supports a nexus between the Veteran's diagnosed PTSD and his in-service stressor. As any reasonable doubt must be resolved in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. Lumbar Spine Disability, Left and Right Lower Extremity Radiculopathy The Veteran's lumbar spine disability is currently rated 40 percent disabling under DC 5237. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Under the General Rating Formula for Diseases and Injuries of the Spine applied by DC 5237, the disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A 20 percent rating requires thoracolumbar spine forward flexion 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 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the thoracolumbar spine warrants a 50 percent evaluation, and unfavorable ankylosis of the entire spine is rated 100 percent disabling. 38 C.F.R. § 4.71a. Following the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, in relevant parts, note (1) instructs to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2) provides that 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. Note (5) provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The IVDS Rating Formula provides for ratings based on incapacitating episodes, and provides a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. The Veteran testified that the bottoms of his feet are numb, and that every step he takes causes a shooting pain down his right leg. He also reported sharp back pain, stating that the degree of pain varies on a day to day basis. He stated that he gets a sharp pain if he bends forward and that sudden movements cause pain. The Veteran stated that the radiculopathy in his legs has worsened, but that the severity is the same in both the left and right legs. He reported that his chronic pain affects his depression as he cannot do what he likes to do anymore, like play hockey or roller blade. The Veteran also explained that sometimes his back will lock in place and he cannot move "for a second", and once that time has passed, he has limited ability to bend or move. In a November 2009 letter, the Veteran reported that his back is so stiff it is impossible to bend over to do everyday things such as get dressed or put on shoes. He stated that if he turns to the side to pick something up, the pain is unbearable for hours. A March 2010 examination report reflects that there was no radiating pain on movement, but muscle spasm was present which did not produce an abnormal gait, or guarding of movement. Forward flexion was to 15 degrees, extension to 15 degrees, right and left lateral flexion to 10 degrees, and right and left rotation to 15 degrees with no additional limitation with repetitive testing. The examining physician noted that the Veteran has no signs of lumbar IVDS, but the x-ray report showed degenerative arthritis of the lumbar spine. An April 2013 VA examination report reflects that the Veteran reported flare-ups of the lumbar spine, stating that his most recent flare-ups require 4 to 5 days of bed rest, and that he fell in the shower 3 months prior, requiring 4 to 5 days of recouperation. Forward flexion was to 40 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 10 degrees. The Veteran was unable to perform repetitive use testing, and the examination indicated that the Veteran had less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. The Veteran reported localized pain with guarding which did not result in abnormal gait or spinal contour. There was no muscle atrophy present, there was decreased sensation to light touch, and the examining physician reported radicular pain, or other signs or symptoms due to radiculopathy. The examination report reflects moderate constant pain and paresthesias and/or dysesthesias of the right and left lower extremities, severe intermittent pain in the right and left lower extremities, moderate numbness of the right lower extremity, and mild numbness of the left lower extremity. The Veteran reported recent involuntary movements of the legs. The physician noted involvement of the femoral and sciatic nerves, moderate radiculopathy of the right side, and mild radiculopathy of the left side. The examination report indicates that the Veteran does not have any other neurologic abnormalities or findings related to his lumbar spine disability, but the Veteran reported constant use of a brace and cane for ambulation. An October 2015 VA examination report reflects that the Veteran suffered flare-ups of his lumbar spine disability, and reported constant pain. He stated that if he sits still, his sciatica comes on, but if he walks, the pain improves. Forward flexion was to 55 degrees, extension to 10 degrees, right lateral flexion to 15 degrees, left lateral flexion to 10 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 15 degrees. Pain was noted upon examination on rest and non-movement, as well as with each range of motion. There was evidence of pain with weight-bearing, and the low back was tender to direct touch. The examination report indicated that there was no additional loss of range of motion with repetitive use testing. The examiner reported that pain, fatigue, and lack of endurance limited the Veteran's functional ability with repeated use over a period of time and with flare-ups, but was unable to describe the limitations in terms of range of motion, as the Veteran was not experiencing a flare-up at the time of the examination. The examiner noted muscle spasms resulting in abnormal gait or abnormal spinal contour, and localized tenderness not resulting in abnormal gait or spinal contour. The examination report indicated that the Veteran had muscle atrophy in the thigh and calf on the right, which was notably reduced in volume compared to the left thigh and calf. The examiner also noted radicular pain, with moderate constant pain in the right lower extremity, and mild constant pain in the left lower extremity, severe intermittent pain in the right lower extremity, mild intermittent pain in the left lower extremity, paresthesias and/or dysesthesias which was moderate in the right lower extremity, and mild in the left lower extremity, and mild numbness in the left lower extremity. The examiner reported that the Veteran has numbness in his anterior thigh probably related to his left hip degenerative disease rather than his back condition. The examination report indicated that the sciatic nerve was involved with moderate radiculopathy on the right side, and mild radiculopathy on the left side. No ankylosis was noted, and the Veteran did not have IVDS of the thoracolumbar spine. The Veteran reported constant use of a brace, and regular use of a cane. The examiner reported that the Veteran has hip and knee problems with limited active motion related to his lumbar spine disability. A May 2018 VA examination report reflects that the Veteran reported flare-ups, describing intermittent episodes of increased back pain. He stated that he suffers from constant back pain exacerbated by activities involving trunk range of motion and weight bearing. He reported that his decreased range of motion affected ambulation and activities requiring the use of his back. Forward flexion was to 20 degrees, extension to 10 degrees, right and left lateral flexion and rotation each to 20 degrees, with pain noted with each range of motion. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no additional loss of function or range of motion with repetitive use testing. The examiner noted that the examination was not conducted during a flare-up, and that he was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination limited functional ability with flare-ups, or with repeated use over a period of time. The Veteran had guarding resulting in abnormal gait or spinal contour, and the examiner indicated that passive range of motion, and non-weight bearing testing could not be performed, or was not medically appropriate. The examination report indicated that the Veteran did not have muscle atrophy, but did have radicular pain reported as moderate constant pain in the right and left lower extremities, moderate numbness, and moderate paresthesias and/or dysesthesias in the right and left lower extremities. The examiner noted that both sciatic nerves were involved, and indicated that there was moderate severity of radiculopathy in both lower extremities. There was no ankylosis of the spine, but the Veteran did have IVDS. The Veteran had not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran reported regular use of a brace, and constant use of a cane for his lumbar spine disability. A November 2019 VA examination report reflects that the Veteran reported flare-ups of his lumbar spine disability which occur once a week and last 2 to 3 days. The examiner indicated that there does not appear to be additional loss of range of motion, weakened movement, fatigability, or incoordination during flare-ups, but there was increased pain. Flexion was to 15 degrees, extension to 10 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 10 degrees. The Veteran reported difficulty twisting and bending over to pick up items, and pain was noted with each range of motion. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine, with moderate tenderness, and mild right paraspinal spasming, and right paraspinal point tenderness. There was no additional loss of function or range of motion after three repetitions, and the examiner indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups, or with repeated use over time. The Veteran did report muscle spasms not resulting in abnormal gait or abnormal spinal contour, and guarding which did result in abnormal gait or abnormal spinal contour. The Veteran also reported difficulty with activities that involve torsion and flexion of the spine. The Veteran did not have muscle atrophy. The examination report indicated that the Veteran had radicular pain, described as moderate constant pain, paresthesias and/or dysesthesias, and numbness of the right and left lower extremities, but no other signs or symptoms of radiculopathy. The examiner noted involvement of the sciatic nerve, and indicated that the Veteran's radiculopathy was moderate in both the right and left lower extremities. There was no ankylosis of the spine noted, and while the Veteran had IVDS of the lumbar spine, he did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran reported regular use of a brace, and constant use of a cane. The examination report indicated that the Veteran's passive range of motion was similar to weight bearing active flexion testing, and the examiner stated that non-weight bearing testing was not medically appropriate as there is no safe way to feasibly test on the lumbar spine in a non-weight bearing situation in this case. The examiner stated that the Veteran has some range of motion in his spine, thus would not fit the description of ankylosis, and although the Veteran has pain which is a limiting factor, he still has some mobility in his spine. The examiner also noted that while the Veteran reported more pain on flare-ups and with repetitive use over time, the estimated range of motion is the same as active motion measurements, and there did not seem to be any significant loss of functionality beyond his baseline due to weakness, incoordination, or fatigability. In a November 2019 VA examination addendum, the examiner stated that there did not appear to be any gross atrophy of the Veteran's legs due to his lumbar arthritis. He also stated that it does appear that pain is the limiting factor and not a physical inability to flex or extend the spine, thus the Veteran would not meet the definition of ankylosis. A July 2021 disability benefits questionnaire (DBQ) reflects that the Veteran suffered from mild constant pain and intermittent pain, and moderate numbness, and paresthesias and/or dysesthesias of the right and left lower extremities. The examiner noted that the Veteran did not have muscle atrophy, sensation testing for light touch was normal, but the Veteran did have trophic changes attributable to peripheral neuropathy, with the examiner noting shiny skin on the bilateral shins down to the ankles with hyperpigmentation as well as no hair growth. The DBQ reflected an abnormal gait, and the examiner reported moderate incomplete paralysis of the sciatic nerve, and mild incomplete paralysis of the common peroneal nerve in the right and left lower extremities. The Board finds that a rating higher than 40 percent is not warranted at any point during the appeal period. This is so because even though the Veteran's range of motion of the thoracolumbar spine is limited, the VA examination reports dated during the relevant time period do not demonstrate unfavorable ankylosis, as it is clear that the Veteran has motion in all relevant directions and his thoracolumbar spine is not fixed in flexion or extension. See 38 C.F.R. § 4.71a, DCs 5235-5243, Note (5). A review of the Veteran's October 2015, and November 2019 examination reports show that the Veteran's service-connected low back disability has not resulted in unfavorable ankylosis, with the November 2019 examiner specifically addressing that the Veteran's range of motion did not fit the description of ankylosis. Additionally, the Veteran has demonstrated an ability to perform range of motion testing with substantial motion in each direction, including with repetitive use. Therefore, the evidence of record indicates that the Veteran's lumbar spine disability symptomatology does not more nearly approximate unfavorable ankylosis of the thoracolumbar spine. Chavis v. McDonough, 34 Vet. App. 1, 23-24 (2021) (ankylosis in VA's General Rating Formula for Diseases and Injuries of the Spine can be met with evidence of the functional equivalent of ankylosis during a flare). Additionally, the March 2010 and October 2015 examination reports indicated that the Veteran did not have IVDS, and while the May 2018 and November 2019 examiners noted IVDS, they reported that the Veteran had not had any incapacitating episodes over the past 12 months requiring bedrest as prescribed by a physician or treatment by a physician in the past 12 months due to IVDS. Therefore, the evidence does not reflect, and the Veteran does not otherwise contend, that he has suffered from incapacitating episodes due to IVDS, and a higher disability rating based on incapacitating episodes is not warranted. For the foregoing reasons, the preponderance of the evidence reflects that the symptoms of the Veteran's lumbar spine disability do not more nearly approximate the criteria for a rating higher than 40 percent for the entire period on appeal. The benefit of the doubt doctrine is therefore not for application, and the claim for an initial rating higher than 40 percent for lumbar spine disability must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The Veteran's left lower extremity radiculopathy is currently rated 10 percent disabling under DC 8520 from October 7, 2015, and 20 percent from May 31, 2018, and his right lower extremity radiculopathy is rated 20 percent disabling from October 7, 2015. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or (very rarely), lost. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, note at "Diseases of the Peripheral Nerves." VA has generally considered that the mild level of evaluation would be more reasonably assigned when sensory symptoms are recurrent but not continuous assigned a lower medical grade reflecting less impairment and/or affecting a smaller area in the nerve distribution. The moderate level of evaluation would be reserved for the most significant and disabling cases of sensory-only involvement. These are cases where the sensory symptoms are continuously assigned a higher medical grade reflecting greater impairment and/or affecting a larger area in the nerve distribution. This provision does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength. The Board finds that an initial 20 percent rating is warranted for the Veteran's left lower extremity radiculopathy for the entire period on appeal from October 7, 2015. While the October 2015 examiner reported mild constant pain, mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the left lower extremity, the April 2013 examination report reflects moderate constant pain and paresthesias and/or dysesthesias, mild numbness, but severe intermittent pain in the left lower extremity. The Board thus finds that considering the Veteran's description of sciatic pain including while seated, coupled with the findings of the April 2013 and October 2015 examination reports, the Veteran's left lower extremity radiculopathy symptomatology more nearly approximates moderate incomplete paralysis of the sciatic nerve as contemplated by a 20 percent disability rating under DC 8520 for the entire period from October 7, 2015. However, a higher 40 percent disability rating is not warranted under DC 8520 for either the Veteran's right or left lower extremity radiculopathy symptomatology. The previously discussed examination reports do not indicate, and there is no evidence within the claims file which suggests, that the Veteran's right or left lower extremity radiculopathy symptomatology more nearly approximate moderately severe incomplete paralysis of the sciatic nerve to warrant a disability rating higher than 20 percent. The examiners primarily described the Veteran's pain, dysesthesias/paresthesias, and numbness as mild to moderate, with the May 2018, November 2019, and July 2021 examiners finding and reporting moderate incomplete paralysis of the sciatic nerve. While those characterizations are not binding on the Board, they are consistent with the above evidence. The evidence of record thus reflects that the Veteran's right and left lower extremity radiculopathy symptomatology does not more nearly approximate moderately severe symptomatology, therefore a higher 40 percent rating is not warranted for the Veteran's right and left lower extremity radiculopathy. As the preponderance of the evidence is against any higher ratings, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board has considered the Veteran's claims and decided entitlement based on the evidence. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). REASONS FOR REMAND As previously discussed, the October 2015 VA examination report indicated that the Veteran has hip and knee problems with limited active motion related to his lumbar spine disability. Thus, the issues of entitlement to service connection for bilateral hip and bilateral knee disabilities to include as secondary to his lumbar spine disability have been raised by the record. In Morgan v. Wilkie, 31 Vet. App. 162, 167 (2018), the Court held that, in the extraschedular context, the Board must use all schedular tools to maximize benefits, including secondary service connection. Additionally, in Bailey v. Wilkie, 33 Vet. App. 188 (2021), the Court held that 38 C.F.R. § 3.155(d)(2) requires that, when entitlement to secondary service connection is raised, a formal claim for secondary service connection need not be filed, rather, VA must consider those "complications" in connection with the claim on appeal. VA is therefore required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of an increased rating claim for the primary disability. See 38 C.F.R. § 3.160; Bailey, 33 Vet. App. at 188. Here, the October 2015 examiner reported that the Veteran has hip and knee problems related to the Veteran's lumbar spine disability, but did not specify the nature of the disabilities, i.e., whether the lumbar spine disability impacted both the left and right hip, and/or left and right knee. Therefore, a remand is necessary for a specific disability determination regarding the Veteran's hips and knees as they relate to his lumbar spine disability. The matters are thus REMANDED for the following actions: 1. Obtain an addendum medical opinion, from the October 2015 VA examiner if possible, to determine the nature of any right and/or left hip disabilities caused by the Veteran's lumbar spine disability. If an opinion cannot be provided without an examination, schedule the Veteran for an examination, to include via telehealth if feasible, to determine the nature of any right and/or left hip disabilities. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered when determining the nature of the Veteran's right and/or left hip disabilities. 2. Obtain an addendum medical opinion, from the October 2015 VA examiner if possible, to determine the nature of any right and/or left knee disabilities caused by the Veteran's lumbar spine disability. If an opinion cannot be provided without an examination, schedule the Veteran for an examination, to include via telehealth if feasible, to determine the nature of any right and/or left knee disabilities. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered when determining the nature of the Veteran's right and/or left knee disabilities. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.