Citation Nr: 21067630 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 14-26 398 DATE: November 4, 2021 ORDER Entitlement to service connection for right-ankle disorder is denied. Entitlement to an increased disability evaluation in excess of 20 percent prior to July 20, 2015 for thoracolumbar strain disorder is denied. Entitlement to an increased disability evaluation in excess of 40 percent from July 20, 2015 for thoracolumbar strain disorder is denied. FINDINGS OF FACT 1. The objective medical evidence shows right ankle disorder was not incurred during active service and it is not caused by an event, injury or illness occurring in active service. arthritis, as associated with right-ankle disorder, did not manifest to a compensable degree within 1 year of separation from active service. 2. The objective medical evidence shows at no time during the appeal period prior to July 20, 2015 did thoracolumbar strain more closely approximate forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. 3. The objective medical evidence shows at no time during the appeal period from July 20, 2015 did thoracolumbar strain more closely approximate unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. CONCLUSIONS OF LAW 1. The criteria for service connection for right-ankle disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 2. The criteria for an increased disability evaluation in excess of 20 percent prior to July 20, 2015 for the thoracolumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 3. The criteria for an increased disability evaluation in excess of 40 percent from July 20, 2015 for the thoracolumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 2003 to January 2007. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2020). Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). 1. Entitlement to service connection for right-ankle disorder. The service treatment records (STRs) show in an October 2003 lower-extremity musculoskeletal screening, the treatment provider found normal active and passive range of motion in both ankles. In the Veteran's June 2003 pre-screen and enlistment examinations and in an October 2004 routine physical examination, the examiners found normal lower extremities. Additionally, the Veteran reported he had no past or current foot trouble, swollen or painful joints or arthritis. In the pre-screen examination, he reported he had no past or current dislocated ankle joint, locking, giving way or loss of full flexion of any joint or surgery on a bone or joint. An April 2006 "sick slip" indicates there should be no running during duty for the Veteran, as he presented with right-foot pain. However, on examination, the treatment provider found the pain was in the right-foot sole with dorsiflexion, specifically in the arch area. Late October 2006 treatment notes show the Veteran's problems lists make no reference to a right-ankle disorder and the notes show findings of "[n]o musculoskeletal symptoms." The STRs overall do not show reports, complaints, treatment, or diagnoses pertaining to a right-ankle disorder or any possible related orthopedic disorder. The post-active-service record shows the Veteran reported in a visit to VA in December 2010 that he had pain in both ankles. The Veteran presented to VA in January 2011 with complaints of ankle pain, reporting a left-ankle injury when jumping from a truck, and he underwent x-rays and received treatment for the next several months. However, he reported nothing regarding his right ankle. The record reflects that treatment for left-ankle pain continued at VA intermittently for the next several years. An April 2013 telephone call from the Veteran to VA shows he reported regarding "right knee and ankle" that "it's killing me and when I stand to do anything like brush my teeth or wash my hands it hurts." A right-knee x-ray was scheduled. In May 2013, the Veteran reported to his VA treatment provider that he has throbbing pain in his "ankles." When updating the Veteran in June 2013 on his VA x-ray results, the treatment provider stated x-rays revealed he has flat feet and added "[t]his can sometimes cause ankle pain." In May 2014, a private treatment provider, Dr. D.B., based on the Veteran's report, noted "right knee pain and ankle pain [the Veteran] has had for years since an injury in the military." No further reference that day was made to "ankle pain" and the Veteran offered no further specific information as to which ankle hurt. In a visit to VA in October 2014, the Veteran reported "ankle swelling," but, once again, the treatment note does not indicate which ankle. A May 2015 VA primary care note shows the Veteran's presented with complaints of right-ankle pain, as well as back and knee pain. He reported the injury occurred in the military and he was wearing an ankle brace. The treatment provider prescribed medications and noted he would proceed with an x-ray. In February 2016, the Veteran requested an MRI for his "back and ankle pain." The treatment provider assessed the Veteran with "chronic back pain/ankle pain." In May 2016, the Veteran was updated on x-ray results and informed his "right-ankle was normal." November 2018 and August 2019 VA nursing notes show the Veteran complained, among other body-segments, of right-ankle pain. The Veteran periodically reported right-ankle pain through to August 2021. As directed in the Board's June 2020 Remand, the Veteran was afforded a VA examination for ankle conditions in September 2020, in which the examiner diagnosed right-ankle degenerative arthritis. She noted the Veteran's reports of injuring his right ankle by running and twisting the ankle during in-service physical training, he went to "medical" for treatment, he received treatment while on active duty, but experienced continued pain with marches and physical training. He further reported ankle pain has worsened and is unresolved, with pain being sharp and stabbing, moderate to severe in severity (at 10/10) and he has pain when "stepping down to walk." After extensive examination and testing, the examiner noted that available imaging studies did document degenerative or traumatic arthritis. She opined right-ankle disorder was less likely than not (less than 50 percent probability) incurred in or caused by the Veteran's military service, to include any injury or symptomatology therein or manifesting during active service. She explained in her rationale there is no chronic diagnosis of right-ankle disorder, April 2013, January 2015 and March 2016 x-rays showed normal findings and were negative for acute changes or degenerative changes, the separation examination is silent for complaints of right-ankle disorder, and there is a temporal gap of treatment of four years from discharge from active duty in January 2007 and the first complaint of an ankle disorder in January 2011. She added there are no ongoing reports or complaints of right-ankle pain in the period of January 2007 through January 2011. "Therefore, no plausible relationship is established. A Nexus has not been established." The examiner added that the Veteran's current right-ankle disorder is unrelated to any active-duty injury, "as degenerative changes in any joint is [sic] the natural progression of aging unless there is a traumatic joint injury" and further noted that the Veteran's medical active-duty records during the period of July 2003 through January 2007 are silent for any right or left-ankle fractures or joint injuries. Lastly, she observed, "Per medical literature Primary (idiopathic) osteoarthritis (degenerative joint disease/degenerative changes), OA [osteoarthritis] not resulting from injury or disease, is partly a result of natural aging of the joint. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates as a function of biologic processes. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. Retrieved from https://www.cdc.gov/arthritis/basics/faqs.htm." The Board notes that arthritis may be eligible for presumptive service connection as a "chronic disease." 38 C.F.R. § 3.309 (a). As stated above, the September 2020 examiner noted that imaging studies document arthritis. However, as already stated, the STRs show no treatment or diagnoses for any form of right-ankle disorder, to include arthritis. Moreover, looking to the possibility of continuity of symptomatology establishing a nexus between any in-service event, injury or disease and arthritis as a subsequent chronic disease, and putting aside the lack of medical evidence of any treatment prior to that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's current arthritis to any active-service event, injury or illness on any evidentiary basis. Consequently, the presumption of service connection for right-ankle arthritis, as a chronic disease, is not available to the Veteran. The Board has carefully considered the Veteran's statements accompanying the January 2014 Notice of Disagreement and the July 2014 Veterans Appeals Form 9, as well as his reports to treatment providers as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. Nonetheless, his lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran's statements and reports essentially contend that training exercises, for example, practicing the "fireman's carry" of another service member, caused him to injure his ankle numerous times, he did not report to sick call because he wanted to "push through" with training and not appear to be malingering. Throughout active service he states became susceptible to twisting the right ankle repeatedly. However, the Board notes again that, not only is there no record of treatment during active service, but the Veteran had the opportunity in several active-service examinations to report any past or current ankle injuries, as by that time initial trainings were completed and he would not be seen as faking or trying to avoid his duties. Moreover, each examiner's examination of the Veteran's lower extremities revealed no disorder whatsoever. As stated above, the Veteran is competent to report what he felt and observed, but it remains not credible that a disorder would not have been detected on examination or the Veteran would not have reported such a disorder to an examiner as, at the very least, an injury of "past" significance. The Board assigns more probative weight to the findings and opinion of the September 2020 VA examiner, as she is medical professional who conducted an in-person examination of the Veteran, she thoroughly reviewed the Veteran's medical history and her opinion therefore is adequate for VA adjudication purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). As stated, the STRs show no reports, complaints, treatment, or diagnoses for right-ankle disorder or related conditions, such as arthritis, nor do subsequent medical records show a right-ankle disorder of such severity to impel the Veteran to seek treatment directly upon separation from active service, in the period of 1 year afterward or in the years following until, as it appears from the record as it now stands, December 2010, when the Veteran reported bilateral ankle pain, nearly 4 years after separation from active service. The medical evidence of record subsequent to active service fails to establish a causal relationship or "nexus" on any basis between the current right-ankle disability and any event, injury or illness during active service. For the reasons stated and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection, direct or presumptive. Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 2. Entitlement to an increased disability evaluation in excess of 20 percent prior to July 20, 2015 for thoracolumbar strain disorder. 3. Entitlement to an increased disability evaluation in excess of 40 percent from July 20, 2015 for thoracolumbar strain disorder. A February 2013 rating decision granted service connection for thoracolumbar strain disorder at a 20 percent rating, effective October 18, 2010, the date VA received the Veteran's original claim for service connection. The Board has considered evidence from 1 year prior to that date. However, a September 2016 rating decision increased the rating to 40 percent, effective July 20, 2015, the date of the VA examination showing objective medical evidence indicating a higher evaluation was warranted. As the Veteran is presumed to seek the maximum benefits allowed under regulation, the Board has considered evidence for this claim in the above 2 stages of the appeal period. The Veteran's thoracolumbar strain disorder has been evaluated under Diagnostic Code 5237 for lumbosacral strain, which in turn defers to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), which provides a 20 percent rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. 38 C.F.R. § 4.71a. A 40 percent rating is available for forward flexion of the thoracolumbar spine of 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Note (2) of the General Rating Formula provides 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 motion 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. Id. Turning to the record, in the period prior to July 20, 2015, the Veteran underwent a VA examination for thoracolumbar strain conditions in February 2013, in which the examiner diagnosed thoracolumbar strain. He noted the Veteran's report of the onset of this disorder beginning in basic training with many marches carrying heavy rucksacks and the disorder has been worsening. Range of motion measurements showed forward flexion ending at 35 degrees (90 degrees, normal) and extension ended at 25 degrees (30 degrees, normal), both maneuvers with no objective evidence of painful motion. Repetitive-use testing showed the same findings. The Veteran reported the impact of flare-ups simply to be unable to do the things he loves. Further relevant findings by the examiner for the purposes of an increased rating in excess of 20 percent include he made no finding whatsoever for ankylosis. Additionally, there were no radicular symptoms, the Veteran did not have intervertebral disc syndrome (IVDS) and available imaging studies did not document arthritis. In an October 2013 VA examination for thoracolumbar strain, the examiner stated the 2013 diagnosis. He noted the Veteran's report of straining his back during training by carrying other service members in "firemen's" carries, but he added that, in falling backwards in one instance, he hurt his back. Range of motion measurements showed forward flexion ending at 55 degrees and extension ending at 15 degrees, both maneuvers with objective evidence of painful motion beginning at the same measurements. Repetitive-use testing showed the same findings. The Veteran reported the impact of flare-ups is a longer period of pain if bending over too long. The examiner added in his remarks at the end of the examination report there are contributing factors of pain, weakness, fatigability, and/or incoordination and there is additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time, but he could not estimate the loss in degrees. Further relevant findings by the examiner include making no finding for any sort of ankylosis. Additionally, there were no radicular symptoms, the Veteran did not have IVDS and available imaging studies did not document arthritis. A September 2014 VA primary care note shows on musculoskeletal examination the treatment provider found lumbar range of motion to be "intact." Each of the VA examinations prior to July 20, 2015 shows forward-flexion range of motion at no less than 35 degrees. Under the General Rating Formula, range of motion must be 30 degrees or less for a rating beyond 20 percent. As an alternative for higher ratings, there must be a finding of favorable or unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. None of the examiners made such a finding and, therefore, higher ratings at 40, 50 or 100 percent are not available to the Veteran. Without such findings based on the rating criteria provided by regulation, there is no evidentiary basis on which the Board can grant any higher rating. The Board briefly will note here that its June 2020 Remand requested the September 2020 VA examiner to offer estimations of ranges of motion in the previous February 2013 and October 2013 examinations, as well as the July 2015 thoracolumbar examination, discussed below, and if she could not, to provide an explanation. In her January 2021 addendum to the examination, the examiner stated she could not provide the requested estimates, as she was not present at the examinations and she cannot determine other clinical co-morbidities or situations at the time of the examinations which would have affected clinical findings. The Board concludes medical science cannot provide the estimates. In the period from July 20, 2015, the July 2015 VA examination for thoracolumbar strain shows the examiner diagnosed lumbar strain. She noted the Veteran's report of injuring his back during practice of firemen's carries during training, having fallen and subsequent worsening symptoms. Range of motion measurements showed forward flexion ending at 30 degrees and extension ended at 10 degrees, both maneuvers with objective evidence of painful motion beginning at the same measurements. The Veteran's pain on flexion and extension prevented repetitive-use testing. The Veteran reported the impact of flare-ups to be daily flares, lasting 1 to 2 hours, not being able to do many activities, and during flares it is hard to stand or sit for long periods. The examiner added in his remarks at the end of the examination report that there are contributing factors of pain, weakness, fatigability, and/or incoordination and there is additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time. "The degree of [range of motion] loss during pain on use or flare-ups is approximately 50 60 [percent] of the claimant's normal movements he states." Further relevant findings by the examiner include making no finding for any sort of ankylosis. Additionally, there were no radicular symptoms, the Veteran did not have IVDS and available imaging studies did not document arthritis. Based on the findings in this examination of thoracolumbar strain flexion at 30 degrees, the Veteran's rating was increased to 40 percent under the General Rating Formula. In March 2016, VA informed the Veteran his x-ray results include a normal finding for lumbar spine. May 2017 x-rays also showed spina bifida occult at S1, but otherwise an "unremarkable lumbosacral-spine examination." As directed in the Board's June 2020 Remand, the Veteran was afforded a VA examination for thoracolumbar strain conditions in September 2020, in which the examiner diagnosed degenerative arthritis of the spine and stated the February 2013 diagnosis of thoracolumbar strain. She noted the Veteran's reports of back pain beginning in basic training, physical training and during marches carrying rucksacks, as well as other heavy gear. He further reported that he had presented for medical treatment at the time and received medication for pain, pain has continued after active duty, it worsens with bending, standing, stooping, upon waking, and continues, despite treatment, with current symptoms of throbbing, sharp moderate pain and "a very tight uncomfortable feeling." For the purposes of a rating in excess of the 40 percent currently assigned in this period, the examiner made a specific finding of the Veteran not having ankylosis of any kind. Additionally, there are no radicular symptoms, the Veteran does not have IVDS and this examiner found available imaging studies do document arthritis. A November 2020 VA physical therapy consult note shows the treatment provider found thoracolumbar strain range of motion "wfl [within full limits]" and extension at "75 %." However, no goniometric range-of-motion findings were provided. The VA examinations in the entire appeal period include findings of pain or painful motion. As shown above, those findings, as well as other factors of weakness, fatigability, incoordination, and lack of endurance, have been considered and are ultimately reflected in the assigned disability ratings, consistent with DeLuca v. Brown, 8 Vet. App. 204-07; Burton v Shinseki, 25 Vet. App. at 5, above, as has consideration been given to pain affecting normal working movements of the body such as "excursion, strength, speed, coordination, and endurance," as defined in 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. at 37, above. Based on the findings of the VA examinations, the assigned ratings provide for the effects of limitation of motion, whether due to pain on movement or restricted movement due to the orthopedic injury itself. The Board has carefully considered the Veteran's statement accompanying his July 2014 Veterans Appeals Form 9, as well as his reports to treatment providers and VA examiners as they appear throughout the record. The Veteran's essential contentions included that at least 1 of the 2 VA examinations in 2013 was conducted before his condition worsened, the treatment record of his May 2014 private chiropractor was not given appropriate weight, he has difficulties with activities of daily living, and his quality of life is impacted. Once again, although the Veteran is wholly credible in his account of pain and decreased movement, the Board discounts the May 2014 chiropractor's evidence. Although Dr. D.B. noted reduced range of motion in both lumbar flexion and extension, she provided no goniometric measurements for range of motion, as required by VA regulation, and the Board therefore is prevented from considering her descriptions. The VA regulation states the use of a goniometer in the measurement of limitation of motion is "indispensable." 38 C.F.R. § 4.46. The Board interprets that word to mean mandatory. Therefore, the findings at this examination are not probative and the Board can only assign very limited probative weight to Dr. D.B.'s findings. Although the Veteran may feel the 2013 VA examinations findings were not made at the "right" time to show the extent of his disability, the record of treatment in the period prior to July 20, 2015 does not otherwise give evidence which is applicable to the rating criteria. Moreover, the Veteran had 2 lumbar VA examinations in February and October 2013, effectively on either end of that year. He was afforded another examination in July 2015, approximately 21 months later, showing worsened symptoms. The Board finds no evidence that any of the examinations is inadequate in its findings, nor does it find the number of examinations conducted in the period of 2 years and 5 months to be insufficient. The Board therefore assigns more probative weight to the findings of the September 2020 VA examiners. As a medical professional, she examined and tested the Veteran during an in-person session, she thoroughly reviewed the Veteran's medical history and record and, for the reasons discussed above at length, her findings therefore are adequate for VA rating purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Under the General Rating Formula, for a rating beyond 40 percent, there must be findings of favorable or unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. The September 2020 VA examiner specifically found the Veteran does not have ankylosis of any kind and, therefore, higher ratings of 50 or 100 percent are not available to the Veteran. (Continued on the next page) For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence does not support an increased rating in excess of 20 percent prior to July 20, 2015 for thoracolumbar strain disorder or in excess of 40 percent thereafter. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, Associate 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.