Citation Nr: 21069172 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 17-37 780 DATE: November 17, 2021 ORDER 1. Entitlement to a compensable rating for residuals of a left fifth metacarpal fracture (left little finger disability) is denied. 2. Entitlement to a rating in excess of 20 percent for right shoulder degenerative joint disease (DJD) is denied. 3. Entitlement to increases in the staged (10 percent prior to December 2, 2019, and 20 percent from that date) ratings assigned for a lumbar spine disability is denied. 4. Entitlement to a 10 percent rating for left Achilles tendonitis is granted. 5. Entitlement to a 10 percent rating for right Achilles tendonitis (with ruptured tendon) is granted. FINDINGS OF FACT 1. The Veteran's left little finger has not been amputated, and the residuals of fracture of the finger are not shown to have resulted in limitations of function in other fingers; symptoms or impairment that would require consideration of a rating under a diagnostic code (Code) other than Code 5230 are not shown. 2. The Veteran's right (major) shoulder disability is not shown to have been manifested by limitation of motion to midway between side and shoulder level, ankylosis, or impairment of the humerus, or malunion or nonunion of the clavicle or scapula. 3. Prior to December 2, 2019, the Veteran's lumbar spine disability was not shown to have been manifested by flexion limited to 60 degrees or less, combined range of motion of the thoracolumbar spine limited to 120 degrees or less, or muscle spasm or guarding severe enough to result in abnormal gait or spinal contour; incapacitating episodes of thoracolumbar disc disease and neurological manifestations were not shown. 4. From December 2, 2019, the lumbar spine disability is not shown to have been manifested by flexion limited to 30 degrees or less or ankylosis of the spine; incapacitating episodes of thoracolumbar disc disease and neurological manifestations are not shown. 5. The Veteran's right and left tendonitis is reasonably shown to throughout the course of the appeal have been manifested in each lower extremity by pain that limits function, consistent with moderate, but not moderately severe, foot injury. CONCLUSIONS OF LAW 1. A compensable rating for residuals of a left fifth finger fracture is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Codes 5156, 5227, 5230. 2. A rating excess of 20 percent for a right shoulder DJD is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Codes 5003-5201. 3. Rating for the Veteran's lumbar spine disability in excess of 10 percent prior to December 2, 2019, and in excess of 20 percent from that date are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Codes 5242-5237. 4. A 10 percent rating for left Achilles tendonitis is warranted, throughout. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Code 5284. 5. A 10 percent rating for right Achilles tendonitis is warranted, throughout. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who had active service from November 1994 to July 2014. This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2014 Department of Veterans Affairs (VA) rating decision that granted service connection for a left 5th finger fracture residual disability, rated 0 percent, each, effective August 1, 2014. A July 2017 rating decision increased the rating right shoulder DJD to 20 percent, effective August 19, 2016 and granted service connection and a separate 20 percent rating for muscle injury as secondary to the right shoulder DJD [the matter of the rating for muscle group (MG) II injury has not been placed in dispute, and is not before the Board]. An August 2020 rating decision increased the rating for right shoulder DJD to 20 percent throughout, from August 1, 2014, and also increased the initial rating the Veteran's low back disability to 10 percent, from August 1, 2014, and increased the rating to 20 percent, effective December 2, 2019. [The August 2020 rating decision also granted service connection for acid reflux, rated 10 percent, effective August 1, 2914, resolving the Veteran's appeal in the matter. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).] Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where, as here, the appeal is from the initial ratings assigned with an award of service connection, the severity of the disability during the entire period from the award of service connection to the present, and the possibility of "staged" ratings for distinct periods of time when varying degrees of disability were shown, must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). When a question arises as to which of two ratings applies under a particular Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In his substantive appeal, the Veteran asserted that he was entitled to higher ratings for his left little finger disability, right shoulder DJD, lumbar spine disability, and bilateral Achilles tendonitis. He also objected to the findings on August 2014 and June 2017 VA examinations as the VA examiner was a nurse practitioner but did not point to any specific deficiencies in the findings reported. Regarding the credentials of the examiner, the Board acknowledges these assertions but nonetheless finds the examinations and information provided was adequate. Nurse practitioners are medical professionals qualified through education, training, and experience to offer medical diagnosis, statements, and opinions. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). The Board may assume a VA medical examiner is competent. See Hilkert v. West, 12 Vet. App. 145, 151 (1999). The Veteran has provided no evidence or explanation to support his assertion that the VA examiner was not competent to conduct the examinations, and the Board finds the examination reports to be probative evidence in these matters. Residuals of Left Little Finger Fracture The Veteran's left little finger disability is evaluated under Code 5230 (for limitation of 5th finger fracture, which provides for a 0 percent rating for any limitation of 5th finger motion. Fifth finger disability may alternatively be rated under Code 5227 (for ankylosis of the little finger), and provides for a 0 percent rating for unfavorable or favorable ankylosis. A note to Code 5227 provides that consideration should be given whether rating as amputation is warranted and also whether rating under alternative criteria (for multiple finger disability) may be warranted for resulting limitation of motion of other digits or for interference with overall function of the hand. 38 C.F.R. § 4.71a. Under Code 5156, a 10 percent rating is warranted for little finger amputation, without metacarpal resection, at proximal inter phalangeal joint or proximal thereto; a 20 percent rating is warranted with metacarpal resection (more than 12 the bone lost). § 4.71a, Code 5156. The Veteran's treatment records do not show he has received any treatment for his left little finger disability. On August 2014 VA examination, the Veteran reported occasional discomfort with a strong grip. He denied having flare-ups. The examiner indicated that there was no limitation of motion or evidence of painful motion of any fingers or thumb. Repetitive use testing did not result in any additional limitation of motion for any finger. It was noted that the Veteran did not have a gap between the thumb pad and the fingers or between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips. The examiner indicated that the Veteran did not have any functional loss or functional impairment of any of the fingers or thumb, and did not have tenderness or pain on palpation of the fingers or thumb. The Veteran's hand strength was normal (5/5), as was left hand grip strength; there was no muscle atrophy. He did not have ankylosis of a finger. The examiner indicated that there was no functional impairment of the Veteran's left little finger disability such that no effective function remained other than that which would be equally well served by an amputation with prosthesis, and opined that the left little finger disability did not impact the Veteran's ability to work. On June 2017 VA examination, the Veteran reported having random decreased grip and pain at times, but denied having received treatment [for such complaints]. He reported having flare-ups about once a month, worse with cold weather, but the flare-ups did not restrict work responsibilities. He reported having functional loss due to pain. On examination, range of motion of all fingers and thumb was normal, with no pain noted on active or passive range of motion. The examiner indicated there was no evidence of pain when the left little finger was used in non-weight bearing; that there was no gap between the thumb and the fingers or between the finger and the proximal transverse crease of the hand; and that there was no evidence of pain with use of the hand or of localized tenderness or pain. Repetitive use testing did not result in additional functional or range of motion loss. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examiner was unable to say without mere speculation that pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups as the Veteran was not examined during a flare-up. The Veteran retained normal (5/5) left hand grip strength, and had no muscle atrophy. There was no ankylosis in the left hand. The examiner opined that there was no functional impairment of the Veteran's left little finger disability such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner noted that the Veteran's left little finger disability did not impact his ability to perform any type of occupational tasks. On December 2019 VA examination, the Veteran reported intermittent pain when struck or with excessive grasping and that cold weather could exacerbate the pain. He denied having any current treatment for his left little finger disability. He reported having flare-ups as pain was more easily induced with cold weather. He denied having any functional loss. On examination, range of motion of all fingers and thumb was normal with no pain noted on active or passive range of motion. The examiner indicated there was no evidence of pain when the left little finger was used in non-weight bearing. The examiner indicated that there was no gap between the thumb and the fingers or between the finger and the proximal transverse crease of the hand. The examiner indicated that there was no evidence of pain with use of the hand or evidence of localized tenderness or pain. Repetitive use testing did not result in additional functional loss or range of motion. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. The examiner indicated there was no additional contributing factors of disability. The Veteran retained normal (5/5) left hand grip strength, with no muscle atrophy. There was no ankylosis of the left hand. The examiner indicated that there was no functional impairment of the Veteran's left little finger disability such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the left little finger disability did not impact the Veteran's ability to perform any type of occupational tasks. The 0 percent rating assigned for the Veteran's left fifth finger is the rating that is to be assigned for any limitation of fifth finger limitation of motion. See Code 5230. For a compensable schedular rating for a fifth finger disability, such rating would have to be under alternate criteria, to include for ankylosis, under Code 5227, which also provides for a 0 percent rating for any ankylosis (favorable or unfavorable), but also cautions to consider whether manifestations are such as to warrant rating for amputation or based on associated limitations of other fingers or overall hand function. Here impairment equivalent to amputation of the little finger is not shown on an examination report or in any treatment record, and has not been specifically alleged. Likewise, related pathology/impairment of other fingers or impairment of overall hand function is not shown (or specifically alleged). The Board notes that the Veteran has reported occasional pain when struck or with hand-grasp, exacerbated in cold weather. However, the limitations he describes are encompassed by the schedular rating assigned; do not meet or approximate any schedular criteria for left fifth finger disability; and do not suggest he has any symptoms or impairment not reflected by the rating assigned. No functional limitation of the left little finger that would warrant a compensable rating is shown. The Board further finds that there is nothing exceptional or unusual about the Veteran's left little finger disability that would warrant referral for consideration of an extra-schedular rating. See Long v. Wilkie, 33 Vet. App. 167 (2020); see also Thun v. Peake, 22 Vet. App. 111 (2008). Considering the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the appeal in this matter must be denied. Right Shoulder DJD At the outset, the Board notes that the Veteran has established service connection for right shoulder MG II injury, secondary to his service-connected right shoulder DJD, separately rated 20 percent (but previously rated together with the right shoulder DJD), and that the rating for MG II injury is not at issue herein; the issue is thus limited to the rating for right shoulder DJD (which is now 20 percent, throughout). Right shoulder DJD is rated under Code 5003, for arthritis based on the degree of limitation of motion under the appropriate Code (for rating such limitation). 38 C.F.R. § 4.71a. The criteria for rating shoulder limitation of motion disabilities are in Code 5201, and as the Veteran is right-handed, his right shoulder is considered the major extremity. For the major upper extremity, a 20 percent rating is assigned for limitation at the shoulder level. A 30 percent rating is assigned for limitation at midway between the side and shoulder level. A 40 percent rating is assigned for limitation to 25 degrees from the side. 38 C.F.R. 4.71(a) Code 5200 pertains to ankylosis, Code 5202 pertains to ratings for other impairment of the humerus, and Code 5203 pertains to ratings for impairment of the clavicle or scapula. The record does should the right shoulder disability is manifested by such pathology or impairment, and these Codes are not applicable in this matter. The Board notes that, effective February 7, 2021, the criteria for evaluating musculoskeletal disorders were amended, including Code 5201. Under the new criteria for the major extremity under Code 5201, a 20 percent rating is assigned for limitation of motion limited to 90 degrees. A 30 percent rating is assigned for limitation of motion limited to 45 degrees. A 40 percent rating is assigned for limitation of motion limited to 25 degrees from side. As relevant here, the amended rating criteria for ratings in excess of 20 percent under Code 5201 are essentially unchanged from the previously existing version of the Code. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 to 180 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. The Veteran's treatment records show he has received treatment for his right shoulder; they do not show any motion findings warranting higher ratings under the criteria in Code 5201. For example, in August 2016, he was noted to have significantly decreased right shoulder range of motion, but the extent of limitation was not described in degrees of limitation. On August 2014 VA examination, the Veteran reported slight weakness and sporadic short sharp pain. He denied having flare-ups. On examination, right shoulder flexion was normal to 180 degrees and abduction was normal to 180 degrees, both without objective evidence of painful motion. Repetitive use testing did not result in additional limitation to range of motion. The examiner reported that the Veteran did not have any functional loss and/or functional impairment of the right shoulder. Right shoulder muscle strength was normal (5/5), with no muscle atrophy. The examiner noted that there was no ankylosis, no history of recurrent dislocation (subluxation) of the glenohumeral or scapulohumeral joint, and no impairment of the clavicle or scapula. On June 2017 VA examination, the Veteran reported having a sharp consistent pain in his right shoulder. He reported having weekly flare-ups that lasted from a few hours to up to a day. He reported having functional loss as he was limited by his right shoulder pain. On examination, right shoulder flexion was to 140 degrees and abduction was to 140 degrees. The examiner indicated that range of motion itself did not contribute to functional loss. The examiner reported that pain was noted on examination, but did not cause functional loss; there was no evidence of pain with weight bearing or non-weight bearing; and there was no evidence of localized tenderness or pain on palpation. Repetitive use testing did not result in additional functional or range of motion loss. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner was unable to say without mere speculation that pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups as the Veteran was not examined during a flare-up. Right shoulder muscle strength was normal (5/5), and there was no muscle atrophy. The examiner indicated that there was no ankylosis, impairment of the humerus, or impairment of the clavicle or scapula. On December 2019 VA examination, the Veteran reported having constant pain rated at 4/10. He reported having flare-ups of pain rated at 9/10 that limited right shoulder movement. He reported having functional loss of not being able to lift with the right arm due to weakness and immobility. On examination, right shoulder flexion was to 70 degrees and abduction was to 75 degrees. The examiner reported that no pain was noted on examination; there was no evidence of pain with weight bearing or non-weight bearing, and was no evidence of localized tenderness or pain on palpation. Repetitive use testing did not result in additional functional or range of motion loss. The examiner opined that pain from repeated use over a period of time and during flare-ups caused functional loss but did not result in additional limitation of motion. The right shoulder disability resulted in less movement than normal. Right shoulder muscle strength was reduced (3/5), and there was no muscle atrophy. It was noted that there was no ankylosis, impairment of the humerus, or impairment of the clavicle or scapula. The current 20 percent rating under Code 5003-5201 assigned for the Veteran's right shoulder disability reflects limitation of motion at approximately the shoulder level (90 degrees). A higher 30 percent rating requires limitation of major shoulder at a lower level, motion to midway between side and shoulder level (or 45 degrees). Such limitation (to include as due to pain) is not shown (or specifically alleged); the greatest limitation of right shoulder motion shown is to 70 degrees. The criteria for a 30 percent rating are not met or approximated. See 38 C.F.R. § 4.7. No examination found, and no treatment record shows, ankylosis, a humerus impairment, or a clavicle or scapula impairment; consequently, rating the disability under alternate criteria based on such manifestations and functional impairment is not for consideration. The Board has considered whether a higher disability evaluation may be warranted on the basis of functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. The June 2017 VA examiner indicated that that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. While the December 2019 VA examiner indicated that pain resulted in additional loss during flare-ups and with repeated use over a period of time, the examiner further indicated that such additional loss did not include additional limitation of motion. Accordingly, a higher rating for additional limitations (functional loss) due to pain is not warranted. While the Veteran reported experiencing right shoulder pain, pain alone is not sufficient to warrant a higher rating, unless it results in additional loss of function. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). The Board has no reason to question that the Veteran's right shoulder disability results in some functional limitations. Such limitations are contemplated by the criteria for the 20 percent rating that is assigned (and/or the separate rating assigned for MG II injury that is not being addressed). The record does not show or suggest that the rating criteria are inadequate for rating the Veteran's right shoulder disability so as to warrant referral for consideration of an extra-schedular rating. The effects of the disability (detailed above) are fully contemplated by the criteria for the 20 percent rating assigned under Code 5003-5201. Although the Veteran and his representative assert that the Veteran is entitled to an extra-schedular rating, they have not identified any symptoms or manifestations not encompassed by the schedular criteria that would warrant referral for such consideration. See Long, 33 Vet. App. 167; see also Thun, 22 Vet. App. 111. Considering the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the appeal in this matter must be denied. Lumbar Spine Disability Disabilities of the spine are rated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes (Incapacitating Episodes Formula), whichever method results in a higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under Code 5243 (for thoracolumbar disc disease) and the Incapacitating Episodes Formula, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks in a 12-month period. A 20 percent rating is assigned when there are incapacitating episodes having a total duration of at least two weeks but less than four weeks in a 12-month period. A 40 percent rating is assigned when there are incapacitating episodes having a total duration of at least four, but less than six, weeks is a 12-month period. A 60 percent rating is assigned when there are incapacitating episodes having a total duration of at least six weeks in a 12-month period. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Code 5243, Note (1). Under the General Rating Formula, a 10 percent rating is warranted if forward flexion of the thoracolumbar spine greater is greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; there is muscle spasm or guarding 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 evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or 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. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is limited to 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation 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. The criteria for evaluating musculoskeletal disorders were amended effective February 7, 2021. As relevant to this decision, the amended rating criteria limit the types of back disorders entitled to consideration of a rating under the criteria for rating IVDS based on incapacitating episodes but do not otherwise revise the substance of the pertinent rating criteria. The amended regulation specifies that only disc herniation with compression and/or irritation of the adjacent nerve root qualifies as IVDS; otherwise, the back disorder is to be rated under Code 5242. Since the prior rating criteria are less restrictive in the types of neck and back disorders that qualify for consideration of the IVDS criteria, and are more favorable to the Veteran, those former criteria will be applied in this case. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and lateral rotation from 0 to 30 degrees. 38 C.F.R. § 4.71, Plate V. The Veteran's lumbar spine disability is now rated 10 percent prior to December 2, 2019, and 20 percent from that date, under Codes 5242-5237. The evidence of record does not show that the Veteran has experienced incapacitating episodes of IVDS. The August 2014, June 2017, and December 2019 VA examiners noted that the Veteran did not have IVDS. There is no evidence in the record that bed rest has been prescribed to treat the Veteran's lumbar spine disability (and he has not alleged otherwise). Thus, the analysis turns (and is limited to) whether ratings in excess of 10 percent prior to December 2, 2019, and in excess of 20 percent from that date, are warranted under the General Rating Formula and whether a further separate rating is warranted for neurological manifestations. The Veteran's treatment records show that he has received treatment for his lumbar spine disability, but do not include any reports of range of motion studies that would warrant ratings in excess of those assigned. Regarding neurological manifestations, the Veteran's medical records do not show bowel or bladder incontinence. On August 2014, June 2017, and December 2019 VA examinations, he denied having incontinence. On August 2014, June 2017, and December 2019 VA examinations, he was found to not have any lower extremity radiculopathy. Therefore, the record does not show any neurological manifestations of the lumbar spine disability that would warrant a separate rating. On August 2014 VA examination, the Veteran reported one flare-up in the previous year that lasted a week and was triggered by moving wrong. On examination, forward flexion was normal to 90 degrees, extension was normal to 30 degrees, left and right lateral flexion was normal to 30 degrees (each), and left and right lateral rotation was normal, to 30 degrees (each). Repetitive use testing did not result in additional limitation of motion or functional loss. The examiner noted that the Veteran did not have localized tenderness or pain to palpation of the joints, muscle spasm of the thoracolumbar spine, or guarding of the thoracolumbar spine. He retained normal (5/5) lower extremity strength, and there was no muscle atrophy. Reflexes and sensation were normal. The examiner noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy; did not have any other neurological abnormalities or findings related to his lumbar spine disability, such as bowel or bladder problems; that his spine was not ankylosed. On June 2017 VA examination, the Veteran reported once a month flare-ups resulting in increased pain lasting several days that limited bending and lifting, but did not prevent him from working. On examination, forward flexion was normal to 90 degrees, extension was normal to 30 degrees, left and right lateral flexion was normal to 30 degrees, and left and right lateral rotation was normal to 30 degrees. The examiner indicated that there was no evidence of pain with weight- bearing or non-weight bearing; no evidence of localized tenderness or pain on palpation; and that repetitive use testing did not result in additional limitation of motion or functional loss. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. It was noted that the Veteran did not have muscle spasm or guarding of the thoracolumbar spine.; had normal (5/5) lower extremity muscle strength, and did not have muscle atrophy; and had normal reflexes and sensation. The examiner indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy; did not have any other neurological abnormalities or findings related to his lumbar spine disability, such as bowel or bladder problems; and that his spine was not ankylosed. On December 2019 VA examination, the Veteran reported having pain that reduced his range of motion. He reported having flare-ups once or twice a month that lasted one to two days. He reported having functional loss of inability to lift heavy items due to his lumbar spine disability. On examination, flexion was to 60 degrees. The examiner indicated that range of motion did not contribute to functional loss. The examiner noted that there was no evidence of pain on examination, with weight bearing, or with non-weight bearing. Repetitive use testing did not result in any additional limitation of motion or loss of function. The examiner opined that pain, fatigability, lack of endurance or incoordination did not significantly limit functional ability with repeated use time or during flare-ups and that while pain did result in functional loss, it did not result in additional limitation of motion. The Veteran had normal (5/5) lower extremity muscle strength, with no muscle atrophy, and had normal reflexes and sensation. It was noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy; did not have any other neurological abnormalities or findings related to his lumbar spine disability, such as bowel or bladder problems; and that his spine was not ankylosed. Prior to December 2, 2019, no examination during the period for consideration found limitation of thoracolumbar flexion to 60 degrees or less or a combined range of motion of the thoracolumbar spine limited to 120 degrees, or muscle spasms resulting in abnormal posture or spine contour, which would warrant a 20 percent rating. Indeed, he retained normal lumbar spine range of motion, even considering such factors as repetitive use and severity during flare-ups. The spine was not ankylosed, and neurological manifestations were not shown. From December 2, 2019, no examination has found thoracolumbar flexion limited to 30 degrees or less or ankylosis, which would warrant a 40 percent rating. Flexion was limited to no less than 60 degrees, even considering such factors as repetitive use and severity during flare-ups. The Board has considered whether a higher rating may be warranted based on functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement under 38 C.F.R. §§ 4.40 and 4.45 (or on the level of impairment present during flare-ups). See also DeLuca, 8 Vet. App. 202. The August 2017 VA examiner found that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The December 2019 VA examiner indicated that pain caused functional loss, but did not result in any additional limitation of motion. The Veteran's treatment records do not show functional limitations warranting ratings in excess of those assigned. Accordingly, Ratings in excess of 10 percent prior to December 2, 2019, and in excess of 20 percent from that date, based on functional limitations due to such factors are not warranted. While the Veteran reported experiencing lumbar spine pain, pain alone is not sufficient to warrant a higher rating, unless it results in additional loss of function. Mitchell, 25 Vet. App. 32, 36-38. The Board acknowledges the Veteran's reports that his lumbar spine disability results in pain that limits physical activities, such as heavy lifting. Such limitations are contemplated by the criteria for the ratings now assigned. The record does not show or suggest that the rating criteria are inadequate for rating the Veteran's lumbar spine disability so as to warrant referral for consideration of an extra-schedular rating. The effects of the disability (detailed above) are fully contemplated by the criteria for the 10 percent and 20 percent ratings assigned under Code 5242-5237. Although the Veteran and his representative assert that he is entitled to an extra-schedular rating, they have not identified any symptoms or manifestations not encompassed by the schedular criteria. Therefore, the criteria are not inadequate; there is nothing exceptional or unusual about the Veteran's lumbar spine disability; and referral for consideration of an extra-schedular rating is not necessary. See Long, 33 Vet. App. 167; see also Thun, 22 Vet. App. 111. The preponderance of the evidence is against this claim. Therefore, the appeal in this matter must be denied. Entitlement to 10 percent ratings, each, for right and left Achilles tendonitis is granted. The rating schedule does not provide a designated Code for Achilles tendonitis; accordingly, such disability is rated by analogy to the criteria that most closely align with the symptoms manifested and functions affected. The Veteran's right and left Achilles tendonitis are each rated 0 percent under Code 5299-5284. The Board finds such analogy reasonably appropriate. 38 C.F.R. § 4.20. Under Code 5284, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries, and a 30 percent rating is assigned for severe foot injuries. 38 C.F.R. § 4.71a. The words "moderate," "moderately severe," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. The Veteran's treatment records show that in May 2017 and August 2017he reported his right and left Achilles tendonitis resulted in pain. On August 2014 VA examination, he reported foot pain. He denied having flare-ups or functional loss. The examiner opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups or when used repeatedly over a period of time. On June 2017 VA examination, the Veteran reported a steady sharp Achilles tendon pain. He reported having flare-ups of pain. The examiner noted that the Veteran had pain on use of both feet and that he used arch supports and orthotics. The examiner indicated that the Veteran did not have functional loss due to his Achilles tendonitis, and opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups or when used repeatedly over time. On December 2019 VA examination, the Veteran reported having a constant, dull ache; he reported having flare-ups of pain at the heel. The examiner noted that there was pain on physical examination, and that pain, weakness, fatigability, or incoordination forced the Veteran to reduce his activities and use medication during repetitive use over time and during flare-ups. Based on the foregoing and the Veteran's persistent reports of Achilles tendon area pain that restricts his activities, the Board finds that he is entitled to a 10 percent rating under Code 5284, for his left and right Achilles tendonitis, each, on the basis that impairment consistent with moderate (but not moderately severe) foot injury is reasonably shown throughout the period for consideration. 38 C.F.R. § 4.59. The Board notes that the Veteran apparently has pes planus (as reflected by his reported use of arch supports); however, pes planus is not service-connected (and no provider has opined for the record that it is a manifestation of the Achilles tendonitis). Therefore, symptoms of pes planus are not for consideration in this matter, and the criteria for rating pes planus are not applicable. The Board also notes that weak foot, claw foot, metatarsalgia, hallux valgus, hallux rigidus, hammertoes, or malunion of the tarsal bones involve pathology and impairment distinct from Achilles tendonitis and do not provide a more appropriate basis for a rating by analogy. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berryman, 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.