Citation Nr: 21068902 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 15-33 721 DATE: November 15, 2021 ORDER Entitlement to a compensable rating for residual fracture of right mandibular ramus is denied. Entitlement to an initial compensable rating for mandibular malunion with slight displacement prior to August 9, 2021, is denied. Entitlement to a rating in excess of 10 percent for mandibular malunion with slight displacement from August 9, 2021, is denied. Entitlement to a rating in excess of 10 percent for lumbosacral strain prior to July 1, 2020, is denied. Entitlement to a rating in excess of 20 percent for lumbosacral strain from July 1, 2020, is denied. FINDINGS OF FACT 1. The Veteran did not have moderate displacement for residual fracture of right mandibular ramus. 2. Prior to August 9, 2021, the Veteran's mandibular malunion with slight displacement was not manifested in interincisal range of 40 mm or less, or lateral excursion limited to 4 mm or less. 3. From August 9, 2021, the Veteran's mandibular malunion with slight displacement has not resulted in limited ROM of interincisal range of 30 to 34 mm with dietary restrictions to soft and semi-solid foods or limited ROM of interincisal range of 21 to 29 mm without dietary restrictions to mechanically altered foods. 4. Prior to July 1, 2020, the Veteran's forward flexion was from zero to 90 degrees and combined ROM was 220 degrees. Additionally, she did not have muscle spasm or guarding severe enough to result in an abnormal gait, and there is also no evidence of abnormal spinal contour. 5. From July 1, 2020, the Veteran's lumbosacral strain has not been manifested by forward flexion limited to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, incapacitating episodes lasting a total duration of at least 4 weeks but less than 6 weeks during the last 12 months, or disc herniation with compression and/or irritation of the adjacent nerve root. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for residual fracture of right mandibular ramus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.150, Diagnostic Code (DC) 9904. 2. Prior to August 9, 2021, the criteria for an initial compensable rating for mandibular malunion with slight displacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.150, DC 9905. 3. From August 9, 2021, the criteria for a rating in excess of 10 percent for mandibular malunion with slight displacement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.150, DC 9905. 4. Prior to July 1, 2020, the criteria for a rating in excess of 10 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5242-5237. 5. From July 1, 2020, the criteria for a rating in excess of 20 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5242-5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1989 to February 1993. In November 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. In April 2019, the Board remanded the claims for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. Disabilities must be reviewed in relation to their history. Where there is a question as to which of two evaluations apply, the Board assigns the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Accordingly, separate ratings may be assigned for separate periods of time based on the facts found, which is a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. 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. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans' Claims stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). 1. Entitlement to an increase rating for residual fracture of right mandibular ramus and mandibular malunion with slight displacement The Veteran's residual fracture of right mandibular ramus is rated under 38 C.F.R. § 4.150, DC 9904, for malunion of the mandible. The Veteran's mandibular malunion with slight displacement is rated under DC 9905 for temporomandibular disorder (TMD). During the pendency of the Veteran's appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that address the schedule of ratings for dental and oral conditions. 82 Fed. Reg. 36080, 36083 (August 3, 2017). The final rule went into effect September 10, 2017. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Prior to September 10, 2017, DC 9904 provided for a rating of 10 percent for moderate displacement and 20 percent for severe displacement. A Note to DC 9904 states that the rating is dependent upon degree of motion and relative loss of masticatory function. From September 10, 2017, DC 9904 provides a 10 percent rating for displacement, causing moderate anterior or posterior open bite and 20 percent rating for displacement, causing severe anterior or posterior open bite. Prior to September 10, 2017, DC 9905 provided a 10 percent rating when the range of lateral excursion is limited from 0 to 4 millimeters (mm) or the inter-incisal range is limited to 31 to 40 mm; a 20 percent rating is applicable when the inter-incisal range is limited to 21 to 30 mm; a 30 percent rating is warranted when the inter-incisal range is limited to 11 to 20 mm; and a 40 percent rating is assigned when the range is limited to 0 to 10 mm. 38 C.F.R. § 4.150, DC 9905. A note to DC 9905 states that ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. From September 10, 2017, DC 9905 provides a 10 percent rating for limited motion of temporomandibular articulation if the interincisal range is 34 mm or less, or if the range of lateral excursion is limited to less than 4 mm; limited ROM of interincisal range of 30 to 34 mm with dietary restrictions to soft and semi-solid foods or limited ROM of interincisal range of 21 to 29 mm without dietary restrictions to mechanically altered foods warrants a 20 percent rating; limited ROM of interincisal range of 30 to 34 mm with dietary restrictions to full liquid and pureed foods, limited ROM of interincisal range of 21 to 29 mm with dietary restrictions to soft and semi-solid foods, or limited ROM of interincisal range of 11 to 20 mm without dietary restriction to mechanically altered foods warrants a 30 percent rating; limited ROM of interincisal range of 21 to 29 mm with dietary restrictions to full liquid and pureed foods, limited ROM of interincisal range of 11 to 20 mm with dietary restrictions to all mechanically altered foods, or limited range of interincisal range of 0 to 10 mm without dietary restrictions to mechanically altered foods warrants a 40 percent rating; and limited range of interincisal range of 0 to 10 mm with dietary restrictions to all mechanically altered foods warrants a 50 percent rating. 38 C.F.R. § 4.150. A note to DC 9905 states that ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. Analysis The Veteran contends that her disability is more severe than the ratings depict. Service connection for the Veteran's residuals of right mandibular ramus fracture was granted at a noncompensable rate under 38 C.F.R. § 4.150, DC 9904, effective February 12, 1993. The Veteran submitted a claim for an increased rating which was received May 28, 2014. Subsequently, a September 14, 2021 rating decision increased the rating to 10 percent, effective August 9, 2021. Thus, the Board will consider the severity of the disability from May 28, 2014, as well as whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). During her August 14, 2014, Dentistry Consult, the examiner noted that teeth numbers one, two, three, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, twenty, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two were missing. The Veteran had complete upper denture and restoration on tooth number 21. Also on August 14, 2014, the Veteran was afforded a VA examination to determine the severity of her Dental and Oral Conditions including Mouth, Lips and Tongue (other than Temporomandibular Joint (TMJ) Conditions). The Veteran stated that, while in service, she was hit in the jaw which resulted in a hairline fracture of the right ramus. The examiner confirmed the Veteran's malunion or nonunion of mandible diagnosis. The Veteran had not lost any part of the mandible or mandibular ramus, either condyle (condyloid process) of the mandible, or either coronoid process of the mandible. However, she had an injury resulting in malunion with slight displacement. Panographic or intraoral imaging (used to demonstrate loss of teeth, mandible, or maxilla) was within normal limits. The examiner stated that there was insufficient evidence or objective exam findings that would provide a reliable prediction of decreased functional ability during flare-ups or when the joint was used repeatedly of a period of time. Based on the available evidence and exam findings, the examiner stated that it was not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty, a potential loss of range of motion manifested as a consequence of a flare or exacerbation outside the clinical setting. There were no other significant diagnostic test findings and/or results. The Veteran's oral or dental condition did not impact her ability to work. In September, the Veteran was also afforded a TMJ VA examination. The examiner confirmed the Veteran's TMJ diagnosis. The Veteran did not report flare-ups that impacted the function of her TMJ. Her lateral excursion was greater than 4 mm with no objective evidence of painful motion. Range of motion for opening mouth, measured by inter-incisal distance was greater than 40 mm with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions. After three repetitive use testing with 3 repetitions, post-test ROM for lateral excursion was greater than 4 mm, and post-test ROM for opening mouth, measured by inter-incisal distance was greater than 40 mm. The examiner stated that there was insufficient evidence or objective exam findings that would provide a reliable prediction of decreased functional ability during flare-ups or when the joint is used repeatedly of a period of time. Based on the available evidence and exam findings, the examiner stated that it was not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty, a potential loss of ROM manifested as a consequence of a flare or exacerbation outside the clinical setting. The Veteran did not have any functional loss or functional impairment, localized tenderness, pain on palpation of joints or soft tissues, or clicking or crepitation of joints or soft tissues of either TMJ. She did not have any scars related to her disability or to the treatment of her disability, and there were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to any conditions. Imaging did not reveal degenerative or traumatic arthritis or any other significant diagnostic test findings and/or results. The Veteran's TMJ did not have an impact on her ability to work. During her November 2018 Board hearing, the Veteran stated that in approximately 2012, she had severe bone loss. The dentist told her that her bone loss was due to her jaw being broken. She stated that she had to have 14 teeth removed in one day. She wore top upper denture and was only able to open her mouth to a certain extent. She reported being in constant pain whenever she wore the denture. In August 2021, the Veteran was afforded a VA examination to determine the severity of her TMJ. The examiner confirmed the Veteran's trismus after treatment of left ramus fracture diagnosis. The Veteran did not report flare-ups of the TMJ. However, she reported functional loss or functional impairment, to include being unable to open her mouth fully. The Veteran's inter-incisal distance was between 30-34 mm. Bilaterally, lateral excursion was greater than 4 mm. There was no pain noted on exam and no evidence of pain with chewing (mastication), objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus or clicking of joints or soft tissue of the left or right TMJ. There was no objective evidence of pain when the right/left TMJ is used in non-weight bearing. Passive ROM for the right/left TMJ was the same as active ROM. There was no objective evidence of pain on passive ROM testing. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or ROM after three repetitions. She was not examined immediately after repetitive use over time or during a flare-up; the examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or during a flare-up. In terms of ROM, right and left lateral excursion was greater than 4 mm. There were no additional contributing factors of the disability. The Veteran did not require a mechanically altered food diet, which has been physician verified or documented. She did not have any other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to her disability. The Veteran's disability did not impact her ability to work. The examiner stated that there were two measurements on the exam. He explained, when measuring the Veteran's inter-incisal distance without her dentures, he got different numbers. The Veteran told him that she was unable to wear this upper denture and would like to have an implant for replacing upper teeth. The examiner stated that the Veteran did not open fully, but when she was told that in order to place an implant, she should have normal open range, she was able to open more. With upper denture in, she could open about 30 mm. Also in August 2021, the Veteran was afforded a VA examination for Oral and Dental Conditions Including Mouth, Lips and Tongue (Other Than TMD Conditions). The examiner confirmed the Veteran's malunion or nonunion of mandible, loss of teeth, limitation of motion of the TMJ due to causes other than TMD, and periodontal disease diagnoses. The examiner noted that the Veteran also had mandible (anatomical loss or bony injury) and teeth (anatomical loss or bony injury leading to loss of any teeth). She had not lost any part of the mandible to include the ramus, either condyle (condyloid process) of the mandible, either coronoid process of the mandible. The Veteran had an injury resulting in malunion, displacement, causing only mild or no anterior or posterior open bite. She did not have loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity, and she did not have loss of teeth due to trauma or disease. The examiner noted that the Veteran had masticatory surfaces restored by suitable prosthesis, i.e., she had full upper denture and partial lower denture. The Veteran's missing teeth included right upper one through eight and left upper nine through sixteen. The left lower 17 through 20 and right lower 28 through 32 were also missing. The Veteran's condition did not impact her ability to work. Regarding symptoms and functional impairments due to the Veteran's disability, the examiner stated that high extended flanges on maxillary denture could possibly be the reason that the Veteran was unable to fully open when she wore her upper denture. The upper denture was worn down on occlusion area of the teeth, so the Veteran may not be able to function normally for chewing. The examiner stated that the Veteran could possibly have some more bone resorption (normal process of resorption for edentulous individuals), so that could be a reason her upper denture did not fit properly. The Veteran's disability had an effect on her occupation functioning and activities of daily living, i.e., she was not able to open her mouth fully with her upper denture in. However, her speech was normal when she wore her dentures. Based on the evidence of record, the Board finds that a compensable rating is not warranted for the Veteran's residual fracture of right mandibular ramus. Under DC 9904, a 10 percent disability rating is warranted for moderate displacement. Here, during her VA examinations, the examiners noted slight or mild displacement. As the Veteran did not have moderate displacement, the Board finds that a compensable rating is not warranted under DC 9904. Regarding the Veteran's mandibular malunion with slight displacement, the Board finds that an initial compensable rating is not warranted prior to August 9, 2021. As noted above, prior to September 10, 2017, a 10 percent rating is warranted when the range of lateral excursion is limited from 0 to 4 millimeters (mm) or the inter-incisal range is limited to 31 to 40 mm, and, from September 10, 2017, a 10 percent rating is warranted for limited motion of temporomandibular articulation if the interincisal range is 34 mm or less, or if the range of lateral excursion is limited to less than 4mm. The Board notes that during this period, the Veteran's lateral excursion was greater than 4 mm with no objective evidence of painful motion and her inter-incisal distance was greater than 40 mm with no objective evidence of painful motion. As such, a compensable rating is not warranted under DC 9905 prior to or from September 10, 2017. Additionally, the Board finds that a 20 percent rating is not warranted for the Veteran's mandibular malunion with slight displacement. Under DC 9905, prior to September 10, 2017, limited motion of inter-incisal range of 21 to 30 mm warrants a 20 percent disability rating. From September 10, 2017, limited ROM of interincisal range of 30 to 34 mm with dietary restrictions to soft and semi-solid foods or limited ROM of interincisal range of 21 to 29 mm without dietary restrictions to mechanically altered foods warrants a 20 percent disability rating. Prior to September 2017, the Veteran's inter-incisal distance was greater than 40 mm with no objective evidence of painful motion. She did not have limited motion of inter-incisal range of 21 to 30 mm. From September 2017, the Veteran's inter-incisal distance was between 30-34 mm. However, there is no evidence that the Veteran required dietary restrictions to soft and semi-solid food. Additionally, the examiner noted that the Veteran did not require a mechanically altered food diet. As such, a rating in excess of 10 percent is not warranted. The Board has also considered the effect of pain and weakness in evaluating the Veteran's disability. 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca v. Brown, 8 Vet. App. 202 (1995). Prior to August 9, 2021, the Veteran denied functional loss/impairment or pain. The Board finds that, in the absence of pain on motion of the jaw, 38 C.F.R. § 4.59 is inapplicable and a minimal compensable evaluation is not warranted. The Board notes that from April 9, 2021, the Veteran reported functional loss or functional impairment, to include being unable to open her mouth fully. However, given the extent of the Veteran's inter-incisal distance, there is no evidence of a disability picture that is commensurate to a limitation of motion to the extent necessary to establish entitlement to a higher disability rating, even after taking her functional loss and/or impairment into full consideration. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 9905. The Board has considered whether a higher rating may be assigned under any other DC. Under both the old and new regulation, DC 9901, for complete loss of mandible, between angles, a 100 percent rating is warranted for complete loss of mandible between the angles. See 38 C.F.R. § 4.150, DC 9901. Prior to September 10, 2017, a 30 percent rating is warranted for loss of approximately one half of the mandible, not involving the temporomandibular articulation, and a 50 percent is warranted for loss of approximately one half of the mandible involving temporomandibular articulation. 38 C.F.R. § 4.150, DC 9902. From September 10, 2017, under DC 9902, for loss of mandible, including ramus, unilaterally and bilaterally not involving temporomandibular articulation is assigned a 20 percent if not replaceable by prosthesis. Loss of less than one-half the mandible including ramus unilaterally or bilaterally involving temporomandibular articulation is assigned a 50 percent if replaceable by prosthesis, and 70 percent is warranted if not replaceable by prosthesis. Loss of one-half or more of the mandible including ramus unilaterally or bilaterally not involving temporomandibular articulation is assigned a 30 percent if replaceable by prosthesis and 40 percent if not replaceable by prosthesis. Loss of one-half or more of the mandible including ramus unilaterally or bilaterally involving temporomandibular articulation is assigned a 50 percent if replaceable by prosthesis and 70 percent if not replaceable by prosthesis. 38 C.F.R. § 4.150, DC 9902. In this case, the VA examiners noted that the Veteran has not lost any part of her mandible or mandibular ramus. As a result, DCs 9901 and 9902 are inapplicable. Prior to and from September 10, 2017, DC 9903, for nonunion of mandible, confirmed by diagnostic imaging studies, a maximum 30 percent is warranted for severe, with false motion. The VA examiners noted that the Veteran had an injury resulting in malunion of the mandible. However, the evidence of record does not document nonunion of the mandible. As such, DC 9903 is inapplicable. During her Board hearing, the Veteran stated that in approximately 2012, she had severe bone loss. She was told that her bone loss was due to her broken jaw. Under DC 9913 for loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity, prior to and from September 10, 2017, 20 percent is warranted for all upper and lower anterior or posterior missing teeth. Here, the 2021 VA examiner noted that the Veteran did not have loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity or loss of teeth due to trauma or disease. As such, DC 9913 is inapplicable. The Board has considered the Veteran and her representative's statements regarding the severity of her dental disability. However, as lay persons, the Veteran and her representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners' findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the Board finds that increased ratings are not warranted for the Veteran's dental disability anytime during the periods on appeal. 2. Entitlement to an increased rating for lumbosacral strain The spine is rated under 38 C.F.R. § 4.71a, DCs 5235-5243 according to a General Rating Formula for Disease and Injuries of the Spine (General Formula) unless DC 5243 is evaluated under the Formula for Rating IVDS based on incapacitating episodes. During the pendency the Veteran's appeal, VA amended criteria for rating musculoskeletal disabilities. The new regulation applies to claims received on or after February 7, 2021 or previously filed claims that are pending on February 7, 2021 if the new regulation will render more favorable result for the Veteran. As such, the Board will evaluate the Veteran's disability under both old and new regulations for the entire appeal period and choose the more favorable result. The new regulation revises the rating criteria for DCs 5242 for degenerative arthritis, degenerative disc disease other than IVDS. It notes that the rater should also see either DC 5003 or 5010. Diagnostic Code 5243, IVDS, was also revised. The revision states that 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. Under the old regulation, DC 5003 was assigned to evaluate degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Diagnostic Code 5003 is now assigned to evaluate degenerative arthritis (other than post-traumatic). Under both regulations, degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DCs, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent rating is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The lumbar vertebrae are considered groups of minor joints, rated on a parity with major joints. 38 C.F.R. § 4.45. NOTE (1) states that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. The Board notes that the other DCs remain unchanged. Normal ROM of the thoracolumbar spine is 90 degrees of flexion, and 30 degrees for each of extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a, Plate II. Under the General Formula, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine was greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, when there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Under the IVDS Formula, a 20 percent rating is warranted when there are incapacitating episodes of IVDS having a total duration of at least two weeks, but less than four weeks during the past 12 months. Under the General Formula, a 40 percent rating contemplates forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Alternatively, under the IVDS Formula, a 40 percent rating contemplates incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Under the General Formula, a 50 percent rating contemplates unfavorable ankylosis of the entire thoracolumbar spine. There is no equivalent rating under the IVDS Formula. Under the IVDS Formula, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no equivalent rating under the General Formula. Under the General Formula, a 100 percent rating contemplates unfavorable ankylosis of the entire spine. There is no equivalent rating under the IVDS Formula. In evaluating 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). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with ROM measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). Analysis The Veteran contends that her disability is more severe than the ratings depict. Service connection for the Veteran's lumbar spine disability was granted at a 10 percent rate effective February 13, 1993. The Veteran submitted a claim for an increased rating which was received February 17, 2015. Subsequently, an August 2021 rating decision increased the rating to 20 percent, effective July 1, 2021. Thus, the Board will consider the severity of the disability from February 17, 2015, as well as whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). In her March 2015 correspondence, the Veteran stated that her back strain had gotten worse. She stated that she was unable to sit for long periods of time without her right leg becoming numb. Additionally, she was unable to stand straight up, and she experienced severe back pain. She noted that even breathing in and out caused pain. The pain was not on a daily basis, but it was constant enough to affect her quality of life. The Veteran regularly suffered from muscle spasms. She sought employment that required sitting; however, employment in a sit-down job began to give her enormous pain. In April 2015, the Veteran was afforded a VA examination to determine the severity of her lumbar spine disability. The Veteran stated, in the last few years, she began experiencing spasms in the lower back. She denied any pain radiation to the buttocks or legs. However, she reported intermittent numbness into the left leg, generally after sitting for a long time. She also reported increased pain with sitting or lying down for a long period of time. She worked at a casino at a desk job; so, she sat for long periods and had to get up and down often. The Veteran had been prescribed motrin and Flexeril to help with pain. She also used a heating pad with good relief. She had not missed work because of her back pain. She owns a split-level ranch and is independent with all ADLs and daily activities. At the time of the exam, the Veteran did not run secondary to back pain, and she avoided heavy exertion tasks such as snow shoveling. The examiner diagnosed the Veteran with lumbar strain. The Veteran reported flare-ups of the spine, to include days with significant amount of pain and spasms that responded to heating pad, and meds. She denied any functional loss or functional impairment of the spine. The Veteran's initial ROM was abnormal. Forward flexion was from zero to 90 degrees, extension from zero to 20 degrees, right and left lateral flexion from zero to 30 degrees, and right and left lateral rotation from zero to 25 degrees. The ROM itself did not contribute to functional loss. Pain was noted on forward flexion and right and left lateral rotation but did not result in/cause functional loss. There was no evidence of pain with weight bearing. The examiner noted objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the spine, i.e., mild tenderness throughout musculature of the lower back. The Veteran was able to perform repetitive use testing with at least three repetitions. The examiner noted no additional loss of function or ROM after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up; the examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner stated that due to insufficient objective evidence to predict whether there would be further functional loss/decreased ROM with flare or repeated activity, she was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. The Veteran did not have guarding or muscle spasm of the spine. There were no additional contributing factors of the disability. Muscle strength testing was normal with no muscle atrophy. Reflex and sensory exams were also normal. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. She did not have ankylosis or intervertebral disc syndrome (IVDS). She did not have any other neurologic abnormalities or findings related to her spine condition (such as bowel or bladder problems/pathologic reflexes). She did not use any assistive device(s) as a normal mode of locomotion, and there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to the Veteran's condition. Her spine condition did not impact her ability to work. During her November 2018 Board hearing, the Veteran stated that her back had gotten worse. She reported having a sit-down job, and during the day, she experienced spasms that travelled down the side of the leg. She also reported a numb foot. She constantly had to get up and walk around, but most recently, the spasms would come and go. Ibuprofen 800 milligrams and muscle relaxers helped her condition. In September 2019, the Veteran was seen for low back spasms. The examiner diagnosed the Veteran with back strain/spasm. The examiner noted that the Veteran's back did not have a deformity and was nontender. The Veteran had full ROM. She was able to heel toe walk and squat. In July 2020, the Veteran was afforded a VA examination to determine the severity of her lumbar spine disability. The Veteran stated since onset, the condition had progressed/worsened. The examiner confirmed the Veteran's lumbosacral strain diagnosis. The Veteran reported flare-ups of the spine, to include more pain. She also reported functional loss or functional impairment of the spine which made her less able to bend, turn, or twist. The Veteran's initial ROM was abnormal. Forward flexion was from zero to 45 degrees; extension, right lateral flexion, and right and left lateral rotation were from zero to 20 degrees; and left lateral flexion from zero to 10 degrees. The ROM itself contributed to functional loss, to include being less able to bend, turn, or twist. Pain was noted on forward flexion, extension, right and left lateral flexion, and right and left lateral rotation and caused functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the spine. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing with at least three repetitions. There was no additional loss of function or ROM after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up; the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during a flare-up. The examiner stated that pain significantly limited functional ability with repeated use over a period of time and during a flare-up. After repetitive use over time, the Veteran's forward flexion was from zero to 45 degrees, extension and right lateral flexion were from zero to 30 degrees, left lateral flexion was from zero to 10 degrees, and right and left lateral rotation were from zero to 20 degrees. During a flare-up, the Veteran's forward flexion was from zero to 45 degrees; extension and right lateral flexion and left and right lateral rotation were from zero to 20 degrees; and left lateral flexion from zero to 10 degrees. The examiner noted objective evidence of pain when the back was used in non-weight bearing. The Veteran's passive ROM was the same as her active ROM. There was objective evidence of pain on passive ROM; however, the Veteran's ROM was the same as her active ROM. She did not have guarding or muscle spasm of the spine. There were no additional contributing factors of the disability. Muscle strength testing was normal with no muscle atrophy. Reflex and sensory exams were also normal. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. She did not have ankylosis, IVDS, or any other neurologic abnormalities or findings related to her spine condition. She did not use any assistive device(s) as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran, and there were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars. The Veteran's spine condition impacted her ability to work, i.e., she was less able to tolerate weight bearing activities such as standing, walking, running, climbing, kneeling, squatting, or rising. The Veteran's VA treatment records note complaints and treatments for low back pain. Based on the evidence of record, the Board finds that prior to July 1, 2020, a rating in excess of 10 percent is not warranted. As noted above, a 20 percent disability rating is assigned when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or with a combined ROM 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. See 38 C.F.R. § 4.71a, DC 5235-5243. Here, at worst, the Veteran's forward flexion was from zero to 90 degrees and combined ROM was 220 degrees. Additionally, she did not have muscle spasm or guarding severe enough to result in an abnormal gait, and there is also no evidence of abnormal spinal contour. Therefore, a rating in excess of 10 percent is not warranted. From July 1, 2020, the Board finds that a rating in excess of 20 percent for a back disability is not warranted. As noted above, under the General Formula, a 40 percent rating contemplates forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Here, the Veteran's lumbar spine disability has not been more nearly manifested by forward flexion limited to 30 degrees or less, or favorable ankylosis of the entire lumbar spine. During this period, at worst, her flexion was to 45 degrees. Additionally, the examination revealed no ankylosis, favorable or unfavorable. Given the foregoing, the criteria for a disability rating higher than 20 percent are not met. Additionally, the Board finds that, prior to and from July 1, 2020, a higher rating is not warranted under the IVDS formula. Under the old IVDS formula, the evidence must demonstrate incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months. See 38 C.F.R. § 4.71a, DC 5243. Under the new regulation, 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root. In this case, the evidence does not show any incapacitating episodes of IVDS requiring prescribed bedrest and treatment by a physician. Additionally, there is no evidence of disc herniation with compression and/or irritation of the adjacent nerve root. Accordingly, a higher rating is not warranted under the IVDS formula. See 38 C.F.R. § 4.71a, IVDS Formula, Note (1). The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the DCs. "Functional loss" may occur as a result of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom. She also reported a reduction in her ability to bend, turn, or twist. However, given the extent of the Veteran's lumbar spine motion, there is no evidence of a disability picture that is commensurate to a limitation of flexion to the extent necessary to establish entitlement to a higher disability rating, even after taking her reported pain into full consideration. See DeLuca, 8 Vet. App. 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5243. The Board has also considered whether a separate rating is warranted for any associated neurological disorder. Although the Veteran reported intermittent numbness into the left leg, her reflex and sensory exams were normal. Additionally, the examiners noted no other neurologic abnormalities or findings related to her spine condition. Accordingly, a separate rating for an associated neurological disability is not warranted. The Board has considered the Veteran and her representative's statements regarding the severity of the Veteran's lumbar spine disability. However, as lay persons, the Veteran and her representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners' findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the Board finds that increased ratings are not warranted for the Veteran's lumbar spine disability prior to and from July 1, 2020. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Tara-Deen 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.