Citation Nr: 21067659 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 17-45 291 DATE: November 4, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for left shoulder strain is denied. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease with arthritis, left knee, is denied. Entitlement to a disability rating in excess of 10 percent prior to January 8, 2021, and in excess of 20 percent from January 8, 2021, for degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1, is denied. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU) prior to September 13, 2013, is denied. REMANDED The issue of entitlement to service connection for a right shoulder disability is remanded. The issue of entitlement to service connection for left upper extremity neurological disability, to include as secondary to service-connected disability, is remanded. The issue of entitlement to an effective date earlier than January 31, 2017 for the award of special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s) is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's service-connected left shoulder disability was manifested by motion limited to, at worst, shoulder level. 2. The Veteran's left knee disability was manifested by painful limited motion not compensable under the criteria for rating based on limited motion. 3. Prior to January 8, 2021, the Veteran's degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1 was not manifested by 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. 4. From January 8, 2021, the Veteran's degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1 is not manifested by forward flexion of the thoracolumbar spine of 30 degrees or less or by ankylosis of the thoracolumbar spine. 5. The severity, frequency, and duration of the Veteran's symptoms from PTSD did not more closely approximate total occupational and social impairment. 6. Prior to September 13, 2013, the Veteran was employed on a full-time basis. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 20 percent for left shoulder strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5003-5201. 2. The criteria for entitlement to an initial rating in excess of 10 percent for degenerative joint disease with arthritis, left knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Codes 5003-5261. 3. The criteria for entitlement to a disability rating in excess of 10 percent for degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1, prior to January 8, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5242. 4. The criteria for entitlement to a disability rating in excess of 20 percent for degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1, from January 8, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5242. 5. The criteria for entitlement to an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9411. 6. Prior to September 13, 2013, the criteria for a TDIU were not met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to November 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal of January 2013 and August 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in May 2019 and June 2020. The case has been returned to the Board for review. In June 2020, the Board remanded the claim of entitlement to service connection for a cardiac disability for additional development. A February 2021 rating decision granted entitlement to service connection for status post myocardial infarction. As this represents a total grant of the benefit sought on appeal with respect to this issue, it is no longer before the Board. See Grantham v. Brown, 114 F. 3d 1156, 1159 (Fed. Cir. 1997). In a February 2021 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran's low back disability to 20 percent, effective January 8, 2021. As the increase did not satisfy the appeal in full, the issue remains on appeal and has been characterized as shown on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to a TDIU prior to September 13, 2013, has been raised by the record as part and parcel of the Veteran's claim for an increased rating for his low back disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). A Notice of Disagreement does not need to be filed to challenge the effective date assigned for the award of a TDIU. Harper v. Wilkie, 30 Vet. App. 356 (2018) (holding that a grant of TDIU for a portion of the appeal period does not bifurcate the appeal and, therefore, is considered a partial grant of the benefit sought). In May 2021, the Veteran was informed his previously-appointed private attorney had withdrawn representation. This withdrawal was received prior to his appeal being returned to the Board. The Veteran has not appointed a new representative. Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). 1. Entitlement to an in increased initial rating for left shoulder strain. The Veteran seeks an increased initial rating for his service-connected left shoulder strain. The applicable rating period is from June 1, 2012, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The Veteran's service-connected left shoulder disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5201. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of Diagnostic Code 5003-5201 reflects that the Veteran's left shoulder strain is rated under Diagnostic Code 5201 which pertains to limitation of motion of the arm with reference to Diagnostic Code 5003 for degenerative arthritis. See 38 C.F.R. § 4.20. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, rating shall be on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. In the absence of any limitation of motion, a 10 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the shoulder is considered a major joint. 38 C.F.R. § 4.45. Under Diagnostic Code 5201 as in effect prior to February 7, 2021, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The changes to Diagnostic Code 5201 made effective February 7, 2021, amended the criteria only to specify that "at shoulder level" refers to flexion and/or abduction limited to 90 degrees and "midway between side and shoulder level" refers to flexion and/or abduction limited to 45 degrees. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The pertinent medical records show that the Veteran's left arm is his minor arm. Therefore, the ratings for the minor arm under Diagnostic Code 5201 are for application. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent under Diagnostic Code 5201 for the entire period on appeal. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakness, and incoordination, to include during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees. Specifically, a September 2013 private examiner reported that the Veteran has constant pain with intensifies with motion. The private examiner noted the Veteran's abduction was limited to 60 degrees. At a June 2014 VA examination, the Veteran reported weakness and fatigue. On examination, he had left shoulder flexion and abduction to 175 degrees. He was able to perform repetitive use testing without additional loss of range of motion. The VA examiner opined that with excess fatiguability the Veteran's left shoulder flexion and abduction would be 170 degrees. He had a 4 out of 5 muscle strength. The Veteran did not have left shoulder atrophy or ankylosis. At a January 2021 VA examination, the Veteran reported severe left shoulder flare-ups precipitated by prolonged writing, sleeping on his side, and stretching. The Veteran further reported reduction in strength and difficulty lifting his arm above his head. On examination, he had left shoulder flexion and abduction to 120 degrees. His left shoulder flexion and abduction reduced to 110 degrees with repetitive use testing, and the VA examiner opined that with repetitive use the Veteran's flexion and abduction would be 100 degrees. The VA examiner further opined that during flare-ups the Veteran's flexion and abduction would be 90 degrees. The Veteran did not demonstrate muscle atrophy or ankylosis of the left shoulder. Thus, the record does not show that, during the entire period on appeal, the Veteran had left shoulder flexion or abduction limited to 25 degrees from side, including on repeated use over time, during flare-ups, in passive motion, or in non-weight bearing. As noted above, the January 2021 VA examiner opined that the Veteran would have left shoulder flexion to 30-degree loss in flexion and abduction during his flare-ups. Even with a 30-degree loss in flexion and/or abduction, the Veteran would not have had left arm motion limited to 25 degrees from side at any time during the relevant period. Therefore, at no time during the relevant period did the Veteran have additional functional loss during flare-ups such that a rating in excess of 20 percent was warranted. The Board has considered whether any other diagnostic codes related to disabilities of the shoulder would provide for a higher disability rating. The evidence does not reflect that the Veteran's symptoms would warrant a separate rating under Diagnostic Code 5202, which pertains to impairment of the humerus, as the record does not show that the service-connected left shoulder disability has been productive of such impairment. Specifically, the Veteran has not had fibrous union or nonunion of the humerus or loss of head of the humerus due to the service-connected left shoulder disability. The evidence also does not reflect that the Veteran's symptoms would warrant a separate rating under Diagnostic Code 5203, which pertains to impairment of the clavicle or scapula. The record, to include the VA examination reports, does not show that the Veteran has had dislocation, malunion, or nonunion of the scapula or clavicle during the relevant period such that a rating under Diagnostic Code 5203 is warranted. Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected left shoulder disability, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). In summary, the Veteran's service-connected left shoulder disability was manifested by motion limited to no worse than shoulder level. The Board therefore finds that the criteria for entitlement to an initial rating in excess of 20 percent for left shoulder strain have not been met at any time during the rating period. Accordingly, the preponderance of the evidence is against the assignment of a higher initial rating, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement for an increased initial rating for left knee disability. The Veteran seeks an initial rating in excess of 10 percent for his degenerative joint disease with arthritis, left knee. The applicable rating period is from June 1, 2012, the effective date for the award of service connection for those disabilities, through the present. See 38 C.F.R. § 3.400. The Veteran's service-connected left knee disability is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5261. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of Diagnostic Code 5003-5261 reflects that the Veteran's left knee disability is rated under Diagnostic Code 5261 for limited extension of the leg with reference to Diagnostic Code 5003 for degenerative arthritis. See 38 C.F.R. § 4.20. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, rating shall be on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. In the absence of any limitation of motion, a 10 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45. The recent regulatory changes did not affect Diagnostic Codes 5260 and 5261. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a 10 percent rating is warranted for flexion of the knee limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, a 10 percent rating is warranted for extension of the knee 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 45 degrees. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71a, Plate II. Turning to the relevant evidence of record, the medical treatment records dated during the relevant period show that the Veteran has reported left knee pain. However, they do not contain specific range-of-motion measurements for the left knee. As such, the medical treatment evidence of record does not show that the Veteran was entitled to a disability rating in excess of 10 percent for his service-connected left knee disability at any time during the relevant period. The Veteran was provided a VA examination in June 2014. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. Upon examination, the Veteran demonstrated left knee flexion to 135 degrees and left knee extension to 10 degrees. He did not have additional loss of range of motion after repetitive use testing. He had normal left knee joint stability. The Veteran was provided a VA examination in September 2019. The Veteran reported moderate left knee pain that rarely gets severe. The Veteran reported flare-ups of the left knee after walking two blocks or standing 30 minutes. Upon examination, the Veteran had left knee flexion to 115 degrees and left knee extension to 0 degrees. There was no additional loss of range of motion after repetitive use testing. The VA examiner noted that after examining the Veteran, listening to his complete history and current subjective complaints, combined with a review of the available records, there was no basis to offer additional loss of range of motion after repetitive use or during a flare-up. The Veteran did not have ankylosis of the left knee. There was no history of instability. The Veteran was provided a VA examination in January 2021. The Veteran reported severe flare-ups of the left knee that occur daily that are precipitated by prolonged sitting, standing, and walking. Upon examination, the Veteran demonstrated left knee flexion to 90 degrees and left knee extension to 0 degrees. The Veteran demonstrated left knee flexion to 80 degrees upon repetitive use and the VA examiner estimated the Veteran's left knee flexion would be to 70 degrees and left knee extension to 0 degrees with repeated use over time and flexion to 60 degrees and extension to 0 degrees during flare-ups. There was no evidence of ankylosis or instability of the left knee. Thus, the record does not show that the Veteran had left knee flexion to 30 degrees or less or extension limited to 15 degrees or greater, including on repeated use over time, during flare-ups, in passive motion, or in non-weight bearing, such that a rating in excess of 10 percent was warranted based on loss of motion. As noted above, the January 2021 VA examiner opined that the Veteran would have left knee flexion to 70 degrees and extension to 0 degrees with repeated use over time and left knee flexion to 60 degrees and extension to 0 degrees during flare-ups. Therefore, at no time during the relevant period did the Veteran have additional functional loss during flare-ups such that a rating in excess of 10 percent was warranted for the left knee. The Board has also considered the other diagnostic codes pertaining to the left knee and leg. However, in this case, the record does not show that the Veteran's service-connected left knee disability has resulted in ankylosis. In addition, the record does not show that he has instability or frequent episodes of effusion into the joint on that knee. Therefore, higher or additional ratings under Diagnostic Codes 5256, 5257, 5258, and 5259 are not warranted. The Veteran has not raised any other issues with regard to the rating for the service-connected left knee disability, nor have any other such issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. The Veteran's knee pain and limited motion in the left knee are contemplated by his ratings under Diagnostic Codes 5003 and 5261. In summary, the Board finds that the criteria for higher ratings based on limited motion under Diagnostic Codes 5003, 5260, and 5261 were not met during the relevant period. To the extend the Veteran seeks ratings higher than or in addition to those previously assigned and those assigned herein, the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to higher disability ratings for low back disability. The Veteran seeks higher disability ratings for his service-connected degenerative disk and joint disease of the lumbar spine with narrowing at L4-L5 and anterior compression of L1 (low back disability). The applicable rating period is from May 31, 2011, one year prior to receipt of the claim, through the present. An increased rating may be assigned during the one-year period prior to receipt of the claim for increase if it is factually ascertainable based on all evidence of record that an increase in disability had occurred during that period. Otherwise, the earliest date an increased rating may be assigned is the date of the claim. 38 C.F.R. § 3.400 (o) (2). The Veteran's degenerative changes of the lumbar spine are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242, and the General Rating Formula for Diseases and Injuries of the Spine (General Formula). Under the General 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 an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Turning to the relevant evidence of record, the Veteran was provided a VA back examination in June 2014. The Veteran reported flare-ups manifested in weakness and stiffness 1 to 2 days per year. Upon examination, the Veteran demonstrated forward flexion to 85 degrees, extension to 25 degrees, bilateral lateral flexion to 25 degrees, and bilateral lateral rotation to 25 degrees. The Veteran was able to perform repetitive use testing without additional loss of range of motion. The Veteran did not have ankylosis or IVDS. The Veteran was provided a VA examination in August 2017. The Veteran reported pain was confined to his low back with no radiation to the extremities. The Veteran did not report flare-ups of the thoracolumbar spine. Upon examination, the Veteran demonstrated forward flexion to 70 degrees and extension, bilateral lateral flexion, and bilateral lateral rotation to 30 degrees. He was able to perform repetitive use testing without additional loss of function or range of motion after three repetitions. The Veteran did not have ankylosis of the spine. The Veteran was provided a VA examination in January 2021. The Veteran reported sharp, shooting pains. He further reported flare-ups of the back that occur 4 to 5 times per week precipitated by prolonged standing, walking, and laying down. Upon examination, the Veteran demonstrated forward flexion to 60 degrees and extension, bilateral lateral flexion, and bilateral lateral rotation to 20 degrees. After three repetitions the Veteran's forward flexion, extension, bilateral lateral flexion, and bilateral lateral rotation decreased by 5 degrees. The VA examiner opined that with repetitive use over time the Veteran's forward flexion would be 50 degrees and extension, bilateral lateral flexion, and bilateral lateral rotation to 10 degrees. The VA examiner opined that during flare-ups, the Veteran's forward flexion would decrease an additional 5 degrees. The Veteran did not have muscle atrophy or ankylosis of the spine. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to January 8, 2021, for his service-connected low back disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain and weakness. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating 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. At the June 2014 VA examination, the Veteran demonstrated forward flexion to 85 degrees and at the August 2017 VA examination the Veteran demonstrated forward flexion to 70 degrees. Therefore, the medical evidence of record, prior to January 8, 2021, reflects that the Veteran had forward flexion greater than 60 degrees and a combined range of motion greater than 120 degrees. Accordingly, the Board concludes that the criteria for an initial rating in excess of 10 percent was not warranted prior to January 8, 2021, under the General Formula. For the period from January 8, 2021, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for his lumbar spine disability. The record does not show that the Veteran forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. At the January 2021 VA examination, the Veteran's forward flexion was at worst 45 degrees during flare-ups. Additionally, the record does not show that the Veteran was diagnosed with ankylosis of the thoracolumbar spine at any time during the relevant rating period. The Board also considered the possibility of awarding a higher rating with consideration of 38 C.F.R. §§ 4.40 and 4.45. The U.S. Court of Appeals for Veterans Claims (CAVC) recently held in Chavis v. McDonough, No. 18-2928 (U.S. Vet. App., April 16, 2021) that application of §§ 4.40 and 4.45 permits consideration under the General Rating Formula for Diseases and Injuries of the Spine of an evaluation based on ankylosis if a claimant's functional loss is consistent with that contemplated by ankylosisin other words, if the demonstrated functional loss is the functional equivalent of ankylosis. In Chavis, the CAVC noted that the rating criteria define ankylosis in terms of limitation of motion. See 38 C.F.R. § 4.71a, General Rating Formula, Note (5) (ankylosis is a condition in which the spine or a spinal segment is fixed in flexion or extension). Essentially, ankylosis contemplates "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012); see also Villareal v. Principi, 18 Vet. App. 13 (2001) (defining ankylosis to mean that "a joint is fixed, or 'frozen' in one position."). In this case, although the Board acknowledges the Veteran's lay reports of symptoms indicative of some functional loss, the Board concludes that such alleged functional loss is not consistent with that contemplated by ankylosis. Notably, there is no suggestion of any limited motion of the spine comparable to any type of immobility; he was still able to perform forward flexion and his forward flexion was limited to 45 degrees at worst during flare-ups. Also, to the extent that the Veteran has experienced functional loss due to disturbance of locomotion, less movement than normal, pain on movement, and interference with sitting and standing, he has not alleged functional impairment comparable to that experienced by an individual with immobility of part of the spine. His symptoms are fully contemplated by the assigned schedular rating. The DeLuca concepts of functional loss, painful motion, etc. are still used to apply the rating criteria found in the diagnostic codes. Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016) and Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011). The Thompson court explained: "Section 4.40 also makes clear that functional loss may be due to pain and that pain may render a part seriously disabled. When evaluating a disability, § 4.40 provides a broad canvas. However, whatever the background, an applicant for disability benefits is rated based on the criteria set forth in § 4.71a." Thompson, 815 F.3d at 786. So, in other words, pain alone without it resulting in any functional loss is not enough to warrant an increased rating. The current rating adequately compensates him for his pain with limited motion, and a higher rating is not warranted under DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995), nor is his disability the equivalent of ankylosis. Therefore, the record provides no basis for awarding a rating in excess of 20 percent based on ankylosis of the spine from January 8, 2021. Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected lumbar spine disability, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). The Board notes that, for all musculoskeletal disabilities, the Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the Schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. Thus, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss, including the Veteran's reported pain. See also Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018). For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for entitlement to disability ratings in excess of 10 percent prior to January 8, 2021, and in excess of 20 percent thereafter, for his service-connected lumbar spine disability. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a higher initial rating for PTSD. The Veteran seeks a higher initial rating for PTSD. The applicable rating period is from September 13, 2013, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The Veteran's service-connected psychiatric disability is rated as 70 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411, and the General Formula for Mental Disorders (General Formula). Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). In relevant part, under the General Formula a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The medical treatment records, the VA examinations of record, private examination and the Veteran's Social Security Administration records show that the Veteran has reported or has been observed to exhibit a range of psychiatric symptoms. He has reported or has exhibited depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, impaired impulse control, neglect of personal appearance and hygiene, suicidal ideations, flashbacks, recurrent nightmares, trouble sleeping, irritability, concentration problems, and hypervigilance. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The Veteran's symptoms are similar to near-continuous panic or depression, impaired impulse control, and difficulty in adapting to stressful circumstances, which are contemplated by the assigned 70 percent rating. They are also similar to impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, which are contemplated under the criteria for a 50 percent rating. Additionally, the Veteran has been able to maintain relationships with his wife and family members, including his children. Therefore, the record does not show that he has total social impairment due to his service-connected psychiatric disability. The Board notes that the Veteran reports suicidal ideations. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records. Therefore, they do not rise to the level of persistent danger of self-harm contemplated by the 100 percent criteria. Accordingly, the evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. Therefore, the Board concludes that the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert, 1 Vet. App. 49. 5. Entitlement to a TDIU prior to September 13, 2013. The Board notes that a February 23, 2021 rating decision granted entitlement to a TDIU from September 13, 2013. However, since the issue is raised as part and parcel to the Veteran's claims for increased ratings, the period on appeal prior to September 13, 2013, remains for consideration. Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or nonservice-connected disability. See 38 C.F.R. §§ 3.340, 3.341 (a), 4.16 (a). Substantially gainful employment is defined as work which is more than marginal, and which permits the individual to earn a living wage. 38 C.F.R. § 4.16 (a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall generally be deemed to exist when a Veteran's earned income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16 (a). Marginal employment may also be established, on a facts found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. Id. In a May 2019 TDIU application, the Veteran reported that he last worked full-time on October 31, 2013, and because too disabled to work on October 31, 2013. During a September 2013 private psychological examination, the Veteran reported that he worked as a Child, Youth, and School liaison to the Wounded Warrior Program for over five years and anticipated getting laid off in September 2013 due to governmental cuts. In this case, the preponderance of the evidence shows that the Veteran had substantially gainful employment during the appeal period until September 13, 2013. On his TDIU application, he reported earning over $3,000 per month in his last job, so his earnings were gainful. There has been no allegation his employment was in a protected environment such that his earnings should be considered marginal. Where the evidence establishes that a Veteran is substantially gainfully employed on a full-time basis, a TDIU cannot be granted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As the most probative evidence of record demonstrates that the Veteran was gainfully employed on a full-time basis prior to September 13, 2013, a TDIU prior to that time may not be granted. Accordingly, the benefit-of-the-doubt rule does not apply, and entitlement to a TDIU prior to September 13, 2013, is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder strain is remanded. The Veteran contends that he has a right shoulder disability that is directly related to his active service. Specifically, he reported that he injured his right shoulder in 1985 after being involved in a truck accident. See February 2021 VA examination. Pursuant to the June 2020 remand, the Veteran was provided a VA examination in January 2021. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the January 2021 VA examination is inadequate for decision-making purposes since the examination report and opinion are internally inconsistent. The VA examiner diagnosed the Veteran with right shoulder strain. The VA examiner opined that the Veteran's right shoulder strain was less likely than not incurred in or caused by the claimed in-service injury, even, or illness. As rationale, the VA examiner explained that the medical records do not contain evidence of a current right shoulder disability. However, the VA examiner diagnosed the Veteran with right shoulder strain. Additionally, the Veteran's medical treatment records reflet that the Veteran was diagnosed with mild arthritic change, right glenohumeral joint space. As the examination is not adequate for decision-making purposes, the Veteran must be provided a new VA opinion to address whether the Veteran's right shoulder strain and mild arthritic change, right glenohumeral joint space, is etiologically related to an in-service event, injury, or disease to include the February 1990 notation of right shoulder pain. 2. Entitlement to service connection for left upper extremity neurological disability is remanded. The Veteran contends that he has a left upper extremity neurological disability that is directly related to his active service or secondary to a service-connected disability. The Veteran was provided a VA examination related to his left upper extremity neurological disability in January 2021. The VA examiner diagnosed the Veteran with left upper extremity peripheral neuropathy. The VA examiner opined that the Veteran's left upper extremity neurological condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the VA examiner explained that the Veteran was not evaluated for any left upper extremity neurological disability while in service or one year after service. The VA examiner further explained that the medical records do not show a current left upper extremity diagnosis. The VA examiner opined that the Veteran's claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected disability. As rationale, the VA examiner explained that there is no pathophysiologic relationship between the Veteran's left upper extremity peripheral neuropathy and left shoulder strain. The VA examiner further opined that the Veteran's left upper extremity neurological condition was less likely than not aggravated by the service-connected left shoulder strain. As rationale, the VA examiner explained that the current medical records do not show that the Veteran has a current left upper extremity neurological condition. Here, the Board finds the January 2021 VA examination is inadequate for decision making purposes. During examination, the VA examiner diagnosed the Veteran with left upper extremity peripheral neuropathy. However, when opining whether the Veteran's current left upper extremity peripheral neuropathy is directly related to service or aggravated by his service-connected left shoulder strain, the VA examiner noted that the Veteran does not have a currently diagnosed left upper extremity neurological condition. As such, the January 2021 VA examination is internally inconsistent and is inadequate for decision-making purposes, and the issue must be remanded to obtain an appropriate opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to an effective date earlier than January 31, 2017 for award of SMC is remanded. The claim for a SMC is inextricably intertwined with the Veteran's claims for entitlement to service connection for a right shoulder disability and entitlement to service connection for left upper extremity peripheral neuropathy. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The matters are REMANDED for the following action: 1. Forward the record and a copy of this remand to the examiner who conducted the January 2021 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current right shoulder disability (right shoulder strain and mild arthritic change, right glenohumeral joint space) is related to his active service, to include the February 1990 notation of right shoulder pain. Rationale must be provided for the opinion proffered. 2. Forward the record and a copy of this remand to the examiner who conducted the January 2021 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed left upper extremity peripheral neuropathy is related to his active service. Rationale must be provided for the opinion proffered. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left upper extremity peripheral neuropathy is proximately due to or the result of his service-connected disabilities, specifically his service-connected left shoulder strain. Rationale must be provided for the opinion proffered. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left upper extremity peripheral neuropathy is aggravated beyond natural progression by his service-connected left shoulder strain. Rationale must be provided for the opinion proffered. 3. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for a right shoulder disability and left upper extremity peripheral neuropathy and an earlier effective date for SMC may be granted. If any benefit sought remains denied, furnish the Veteran and his representative (if any) with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. G. LeMoine, 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.