Citation Nr: 21070648 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-63 822 DATE: November 24, 2021 ORDER Entitlement to an initial compensable rating for migraine headaches, prior to June 4, 2021, is denied. Entitlement to a rating in excess of 50 percent for migraine headaches, from June 4, 2021, is denied. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. Entitlement to a rating in excess of 20 percent for a right shoulder disability is denied. Entitlement to a rating in excess of 20 percent for a neck disability, from June 4, 2021, is denied. Entitlement to a rating in excess of 20 percent for a back disability, from June 4, 2021, is denied. REMANDED Entitlement to a rating in excess of 10 percent for a neck disability, prior to June 4, 2021, is remanded. Entitlement to a rating in excess of 10 percent for a back disability, prior to June 4, 2021, is remanded. FINDINGS OF FACT 1. Prior to June 4, 2021, the Veteran's migraine headaches did not manifest in characteristic prostrating attacks averaging one in 2 months over the last several months 2. From June 4, 2021, the Veteran's migraine headaches have been assigned a 50 percent disability rating, which is the maximum schedular rating authorized under the applicable criteria. 3. The Veteran is in receipt of the maximum available rating for limitation of motion in her left wrist; ankylosis of the left wrist has not been shown. 4. The Veteran's right shoulder disability is manifested by no more than arm limitation of midway between side and shoulder level (i.e., flexion and/or abduction limited to 45 degrees); limitation of motion to 25 degrees from side (i.e., flexion and/or abduction limited to 25 degree from side) is not shown or approximated. 5. For the period from June 4, 2021, the Veteran's neck disability manifested as, limitation of forward flexion to 30 degrees, without ankylosis or incapacitating episodes. 6. For the period from June 4, 2021, the Veteran's back disability manifested as, limitation of forward flexion to 40 degrees, without ankylosis or incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for migraine headaches, prior to June 4, 2021, have not been met. 38 U.S.C. §§ 1131, 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 8100. 2. The criteria for a rating in excess of 50 percent for migraine headaches, from June 4, 2021, have not been met. 38 U.S.C. §§ 1131, 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 8100. 3. The criteria for a rating in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 4. The criteria for a rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 5. The criteria for a rating in excess of 20 percent for the Veteran's service-connected neck disability, from June 4, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5237. 6. The criteria for a rating in excess of 20 percent for the Veteran's service-connected back disability, from June 4, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1985 to March 2011. This matter is before the Board of Veterans' Appeals (Board) on appeal from March 2012 and November 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. This case was before the Board in May 2021. The Veteran's claims were remanded for additional development. The case is now again before the Board for further appellate action. The Board notes that, in an August 2021 rating decision, the RO granted service connection for fibromyalgia. As this issue on appeal was granted, the issue is no longer before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). INCREASED RATING Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code (DC), the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). At the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board will consider entitlement to staged ratings to account for variations in the severity of a disability over time. Id. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Where arthritis results in painful motion of the joint, the rating criteria allow for at least the minimum compensable evaluation for the joint. 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Id. 1. Entitlement to a compensable rating for migraine headaches, prior to June 4, 2021, is denied. 2. Entitlement to a rating in excess of 50 percent for migraine headaches, from June 4, 2021, is denied. A March 2012 rating decision granted service connection for migraine headaches and assigned a noncompensable rating, effective April 1, 2011. An August 2021 rating decision granted an increased rating to 50 percent, effective June 4, 2021. The Veteran contends that she is entitled to higher ratings for her service-connected migraine headaches. The Veteran's service-connected headaches have been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Diagnostic Code 8100 provides for a 10 percent rating for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating, the highest available under Diagnostic Code 8100, is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The rating criteria do not define "prostrating" as used in Diagnostic Code 8100. By way of reference, the Board notes that according to WEBSTER'S NEW COLLEGE DICTIONARY 909 (3d Ed. 2008), "prostrate" is defined as "physically or emotionally exhausted." "Incapacitated" is listed as a synonym. A very similar definition is found in Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), in which "prostration" is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. Turning to the evidence, prior to the Veteran's discharge from active service in March 2011, a December 2010 VA-contracted examination diagnosed the Veteran with migraine headaches. The Veteran reported, when headaches occur, she had to stay in bed and was unable to do anything. She experienced headaches with a pain level of 10 out of 10 on the average of 4 times per month that last for 4 hours. The symptoms of the condition are sensitivities to light and noise. The Veteran had the ability to perform daily functions during flare-ups. An April 2012 VA treatment record reported that recent stress, including the death of her mother one month ago, increased her migraine headaches, which were now averaging approximately one every other day. The migraines were reported to last 3 to 5 hours depending on the administration of medication. A July 2012 VA mental health note reported the Veteran had experienced a migraine headache that lasted two or three days and she was just starting to feel better. In August 2012, the Veteran submitted a June 2012 headaches disability benefits questionnaire (DBQ), completed by S.C, an advanced registered nurse practitioner. The Veteran reported she experienced migraines before, during, and after her period or during stressful events. She reported having 3 to 4 migraines weekly. S.C. reported that the Veteran was taking Maxalt to treat her headaches but noted that sometimes Maxalt does not work, and the Veteran has to go to the emergency room for injections or "IV," usually "terdol and reglan." It was reported that the Veteran averages about 10 trips a year to the emergency room. She described having constant head pain on both sides of her head. She also experienced the following non-headache symptoms: nausea, sensitivity to light and sound, and sensory changes. The nurse practitioner reported the Veteran experienced characteristic prostrating attacks more frequently than once per month and very frequent prostrating and prolonged attacks of migraine headache pain. It was reported that the Veteran's headaches impacted her ability to work, as she needed to rest in a dark room for at least 5 to 6 hours. A December 2012 private treatment record completed by S.C reported the Veteran continued to have a lot of fatigue, muscle aches, and headaches. January 2013 and February 2013 private treatment records, completed by S.C., reported the Veteran's migraines were stable on current medications. A January 2013 VA primary care note reported the Veteran was seen for a routine 9-month follow-up examination. She reported that her headaches are about the same but are manageable with the Maxalt she had been prescribed. A February 2013 private treatment record reported the Veteran had a stress migraine yesterday, but it was improving on the day of the visit. The Veteran submitted a June 2013 statement in which she expressed that her migraines had increased. She reported having migraines 3 to 4 times a week, which she stated were triggered by stress or her menstrual cycle. According to the Veteran, "[w]hen I experience a migraine, I have to stop what I am doing, lie down, turn off the lights, turn off any noise, television, radio; people [sic] take my meds and go to sleep." She reported that if she takes her medications immediately, the migraines last 3 to 6 hours; otherwise, they can last a couple of days. She reported if that does not work, she has to go to the emergency room for a shot, though she could not describe what medication was administered. An August 2013 VA mental health note documented the Veteran's report that she had been getting migraine headaches that will last 2 to 3 days. A December 2013 VA primary care note reported the Veteran was seen for a routine annual examination. It was reported that her headaches were being well-controlled with Maxalt. A February 2014 private treatment record included a review of the Veteran's neurologic system in which it was reported that the Veteran denied headaches and dizziness but reported muscle spasms and paresthesias. A March 2014 private treatment record reported the Veteran had been suffering from migraines for many years. She noted the worst ones were around her menstrual cycle. An April 2015 VA primary care note documented the Veteran's report of not experiencing incapacitating or prostrating headaches. She reported one to two episodes of migraines per week that resolve with Maxalt and Naproxen. The Veteran was provided a VA headaches examination in June 2016. The Veteran reported she experienced frontal headache pain and pain behind her eyes. The Veteran was taking Maxalt and Naproxen, as needed, to treat her headaches. She also experienced non-headache symptoms: nausea and sensitivity to light and sound. The duration of the head pain was less than one day. The examiner reported the Veteran did not experience characteristic prostrating attacks of headache pains. It was reported that the Veteran's headaches did not impact her ability to work. VA primary care notes compiled in November 2016, October 2017, July 2018, June 2019, and August 2020 documented the Veteran's report of not experiencing incapacitating or prostrating headaches. She reported one to two episodes of migraines per week that resolve with Maxalt and Naproxen. At the Veteran's May 2021 Board hearing, the Veteran's representative stated that the Veteran's migraine headaches need to be re-evaluated because she was now starting to get prostrating attacks of migraine headaches. The Veteran stated that she did not take medication for her migraines because one of the side effects was losing a day or two because "it knocks me out." The Veteran was provided another VA examination in June 2021. The Veteran experienced constant headache pain on both sides of the head that are worsened by physical activity. The Veteran also experienced non-headache symptoms, which were reported as nausea, vomiting, photophobia, phonophobia, changes in vision, and sensory changes. The Veteran's typical head pain lasted more than two days. The examiner reported the Veteran had characteristic prostrating attacks of migraine once every month. The Veteran also had very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. The examiner reported the Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to her migraines. The examiner reported that the Veteran's headache condition impacted her ability to work, as she was unable to tolerate bright lights and loud sounds. A June 2021 VA primary care note documented the Veteran's report of not experiencing incapacitating or prostrating headaches. She reported one to two episodes of migraines per week that resolve with Maxalt and Naproxen. The Board concludes that, prior to June 4, 2021, the Veteran did not have characteristic prostrating attacks of migraine headache pain, which correspond to the criteria for a noncompensable rating under DC 8100. During the period prior to June 4, 2021, the Veteran underwent a VA examination in June 2016. The examination indicated that the Veteran suffered from headaches, but the examiner reported she did not have characteristic prostrating attacks of migraine headache pain. VA treatment records compiled in April 2015, November 2016, October 2017, July 2018, June 2019, and August 2020 documented the Veteran's report of not experiencing incapacitating or prostrating headaches. At the Veteran's May 2021 Board hearing, the Veteran's representative stated that her migraine headaches need to be re-evaluated because she was now starting to get prostrating attacks of migraine headaches. In August 2012, the Veteran submitted a June 2012 headaches DBQ completed by S.C, an advanced registered nurse practitioner. The Board finds that the June 2012 private DBQ is not probative as it describes symptoms which are not supported by medical evidence in the claims file. Prior to June 4, 2021, the Veteran's VA and private treatment records and VA examination do not describe any of the Veteran's headaches as being prostrating, thus, the finding on the June 2012 DBQ of characteristic prostrating attacks more frequently than once per month and very frequent prostrating and prolonged attacks of migraine headache pain contradicts the rest of the medical evidence in the claims file. Moreover, the nurse practitioner reported sometimes, when Maxalt was not an effective treatment for the Veteran's migraines, the Veteran had to go to the emergency room about ten times a year for injections or intravenous treatment of "terdol and reglan." However, other than the June 2012 DBQ, the medical evidence of record does not report any emergency room treatment for migraines with injections or intravenous treatment. In June 2013, the Veteran submitted a statement in which she reported having migraines 3 to 4 times a week, which she stated were triggered by stress or her menstrual cycle. She reported that, when she experienced a migraine, she would take her medication and lie down after turning off lights and anything making noise. She stated that, if that does not work, she has to go to the emergency room for a shot. However, as previously described, the evidence of record does not include any emergency room visits for a shot during the appellate period. She was also unable to describe what medication was administered through a shot. Considering all relevant evidence of record, the Board finds the evidence of the VA treatment records and VA examination to be more probative than the June 2012 private DBQ. Accordingly, the Board concludes that, prior to June 4, 2021, the Veteran's migraine headaches occurred with less frequent attacks throughout the appeal period, corresponding to the criteria for a noncompensable rating under DC 8100. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a compensable rating for her migraine headaches prior to June 4, 2021. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to an increased rating as described above, is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). For the period from June 4, 2021, the Board concludes that the Veteran's headaches do not warrant a rating in excess of 50 percent. After the Veteran's rating for migraine headaches was increased to 50 percent by the August 2021 rating decision, the Veteran's representative submitted a brief contending that the Veteran is entitled to a higher rating for her service-connected migraine headaches but has not submitted any argument providing a basis for a rating in excess of 50 percent. The June 2021 VA examiner reported the Veteran experienced constant headache pain on both sides of the head, as well as the following non-headache symptoms: nausea, vomiting, photophobia, phonophobia, changes in vision, and sensory changes. The examiner concluded the Veteran had very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. According to the examiner, the Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to her migraines. Considering all relevant evidence of record, the Board concludes that for the period from June 4, 2021, the Veteran's migraine disability has manifested as very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, which is commensurate with a rating of 50 percent under Diagnostic Code 8100. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 50 percent for migraines from June 4, 2021. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to an increased rating as described above, is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. A March 2012 rating decision granted service connection for degenerative joint disease of the left wrist and assigned a noncompensable rating, effective April 1, 2011. A November 2016 rating decision granted an increased rating to 10 percent, effective August 15, 2012. The Veteran contends that she is entitled to a higher rating for her service-connected left wrist disability. Diagnostic Code 5215 provides that limitation of motion of the major and minor wrist with palmar flexion limited in line with the forearm warrants a 10 percent disability rating. Alternatively, a 10 percent rating may be assigned for limitation of motion of dorsiflexion of the wrist less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Higher ratings are warranted only where there is ankylosis of the wrist. Diagnostic Code 5214. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. As the Veteran is right-handed, the major wrist disability ratings are applicable to that side. Turning to the evidence, in August 2012, the Veteran submitted a wrist conditions disability benefits questionnaire. The examiner reported the Veteran had a long history of intermittent left wrist pain. Range of motion testing showed that the Veteran's palmar flexion of the left wrist was to 80 degrees or greater, with painful motion at 65 degrees, and the dorsiflexion was to 80 degrees or greater, with painful motion at 60 degrees. The Veteran did not have ankylosis of the left wrist joint. The Veteran was provided a VA wrist conditions examination in June 2021. The Veteran was diagnosed with degenerative joint disease of the left wrist. The Veteran reported that she experienced constant pain in her left wrist with daily flare-ups that last 12 to 24 hours. The Veteran described functional loss of her left wrist as "I can't move my wrist." Range of motion testing of the left wrist showed active and passive dorsiflexion to 60 degrees, palmar flexion to 60 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. The examiner reported that pain was exhibited on all movements. Functional loss was described as difficulty carrying objects. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time. The examiner assessed that pain, fatigability, weakness, and lack of endurance significantly limited functional ability of the left wrist with repeated use over time. The examiner indicated she was able to describe the functional loss in terms of range of motion: dorsiflexion to 50 degrees, palmar flexion to 50 degrees, ulnar deviation to 40 degrees, and radial deviation to 15 degrees. The examiner indicated that the Veteran was not being examined during a flare up. The examiner assessed that pain, fatigability, and weakness significantly limited functional ability of the left wrist with flare ups. The examiner indicated she was able to describe the functional loss in terms of range of motion: dorsiflexion to 50 degrees, palmar flexion to 50 degrees, ulnar deviation to 40 degrees, and radial deviation to 15 degrees. Additional contributing factors of disability were reported as swelling, less movement than normal, and weakened movement. The Veteran did not have ankylosis of the left wrist joint. The examiner reported the Veteran would have difficulty with the following occupational tasks: typing, writing, holding objects greater than 10 pounds, turning knobs, twisting open jar lids. As the Veteran has been granted a 10 percent rating for her left wrist disability, she is in receipt of the maximum rating allowed based on range of motion. The only higher ratings available are for ankylosis of the wrist. However, there is no medical evidence showing ankylosis and the Veteran has not argued to the contrary. The Board gives great probative weight to the June 2021 examination findings. These findings were based on an in-person examination of the Veteran's left wrist disability. The examiner reported the Veteran's left wrist demonstrated dorsiflexion to 50 degrees and did not exhibit ankylosis. In consideration of the above, the Board finds that the preponderance of the evidence weighs against a disability rating for the Veteran's left wrist disability in excess of 10 percent. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to an increased rating as described above, is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to a rating in excess of 20 percent for a right shoulder disability is denied. A March 2012 rating decision granted service connection for status post, acromioclavicular joint separation of the right shoulder and assigned a noncompensable rating, effective April 1, 2011. A November 2016 rating decision granted an increased rating to 20 percent, effective August 15, 2012. The Veteran contends that she is entitled to higher ratings for her service-connected right shoulder disability. Initially, the Board observes that the record reveals that the Veteran is left hand dominant, as reported in June 2016 and June 2021 shoulder conditions disability benefits questionnaires. As such, the nondominant (minor) upper extremity ratings will be considered for the right shoulder disability. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Veteran's right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, 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. Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. Turning to the evidence, the Veteran submitted a shoulder conditions disability benefits questionnaire in August 2012. The examiner reported the Veteran had a long history of right shoulder pain. Range of motion testing of the right shoulder showed flexion to 180 degrees, with objective evidence of painful motion at 170 degrees, and abduction to 180 degrees, with objective evidence of painful motion at 165 degrees. The Veteran did not have ankylosis or recurrent dislocation of the right shoulder. It was reported that the Veteran also did not have impairment of the clavicle or scapula. The Veteran was afforded a VA shoulder examination in June 2016. The examination was inadequate as the examiner failed to estimate the degree of additional range-of-motion loss after repeated use over time. If an examination does not take place during a flare-up or after repeated use, the examiner should attempt to offer an estimate derived from information procured from relevant sources, including the Veteran's lay statements. An examination that fails to attempt to ascertain adequate information from relevant sources regarding frequency, duration, characteristics, severity, or functional loss during flare-ups or after repeated use will be considered inadequate. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). There is no indication that the June 2016 examiner made any attempt to ascertain adequate information from relevant sources to estimate the degree of additional range-of-motion loss after repeated use. The Veteran was afforded another VA shoulder examination in June 2021. The Veteran, who is left hand dominant, was diagnosed with right shoulder strain and right shoulder impingement syndrome. The Veteran reported experiencing daily flare-ups making his shoulder stiff and weak for two hours. The Veteran reported having functional loss or functional impairment of his right shoulder as "I can't lift my arm." Range of motion testing of the left shoulder showed flexion from 0 to 100 degrees, abduction from 0 to 100 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. Pain was noted on all movements, which caused functional loss. The Veteran was able to perform repetitive use testing with at least three repetitions without any functional loss. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time. The examiner assessed that pain, weakness, fatigability, and lack of endurance significantly limit functional ability with repeated use over time. The examiner indicated she was able to describe the functional loss with repeated use over time in terms of range of motion: flexion from 0 to 80 degrees, abduction from 0 to 80 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. The examiner indicated that the Veteran was not being examined during a flare-up. The examiner assessed that pain significantly limits functional ability with flare-ups. The examiner indicated she was able to describe the functional loss with flare-ups in terms of range of motion: flexion from 0 to 70 degrees, abduction from 0 to 70 degrees, external rotation from 0 to 80 degrees, and internal rotation from 0 to 80 degrees. The Veteran did not exhibit ankylosis of the right shoulder. The Hawkins' impingement test was positive and the empty-can test was negative. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. The examiner found that the Veteran had infrequent episodes and guarding of movement only at shoulder level. The Veteran had right shoulder dislocation. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's right shoulder disability. The June 2021 examination report shows that the VA examiner accepted the Veteran's description that pain caused functional loss during flare-ups that limited flexion to 70 degrees, abduction to 70 degrees, external rotation to 80 degrees, and internal rotation to 80 degrees. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements do not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity (including flexion and/or abduction since February 7, 2021). The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The June 2021 VA examination report shows that the VA examiner specifically determined that the Veteran did not have impairment of the humerus warranting a higher rating. The Veteran had infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90 degrees. None of the other evidence of record otherwise demonstrates pertinent impairment of the humerus, clavicle, or scapula. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for her right shoulder disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Entitlement to a rating in excess of 20 percent for a neck disability, from June 4, 2021, is denied. A March 2012 rating decision granted service connection for degenerative arthritis of the cervical spine and assigned a noncompensable rating, effective April 1, 2011. A November 2016 rating decision granted an increased rating to 10 percent, under 38 C.F.R. § 4.71a, Diagnostic Code 5242, degenerative arthritis, effective June 24, 2016. An August 2021 rating decision granted an increased rating to 20 percent, effective June 4, 2021. The Veteran contends that she is entitled to a higher rating for her service-connected neck disability for the period from June 4, 2021. Since June 4, 2021, the Veteran's service-connected cervical spine disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. 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 DC 5242-5237 reflects that the Veteran's cervical spine disability is partially described as degenerative arthritis under Diagnostic Code 5242 and that the rating assigned is based on cervical strain under DC 5237. During the pendency of the appeal, VA promulgated new regulations governing ratings for musculoskeletal system, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). Diagnostic Code 5242 was amended to make clear that its application was for degenerative arthritis/disc disease of the spine other than IVDS. Diagnostic Code 5243 was amended to make clear that it should only be applied for disc herniation with compression and/or irritation of the adjacent nerve root, and that all other disc diagnoses should be rated under Diagnostic Code 5242. Diagnostic Code 5237 was not changed. Diagnostic Codes 5237 and 5242 are evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned 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 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 assigned 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 is 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, reserved lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. 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. The Veteran was afforded a VA examination of her cervical spine in June 2021. The Veteran was diagnosed with cervical strain, degenerative arthritis, and intervertebral disc syndrome. The Veteran reported experiencing flare-ups of aching pain and stiffness that last from one to two days to a week. The Veteran reported having functional loss or functional impairment as "I can't move my neck because it hurts. I get very sore." A review of range of active motion testing shows forward flexion to 40 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees, left lateral rotation to 40 degrees, and right lateral rotation to 40 degrees. Pain was noted on all movements, but the examiner reported the abnormal range of motion did not contribute to functional loss. Passive range of motion testing showed the same ranges of motion as the active testing. Pain was noted on flexion and extension, which contributed to functional loss described as difficulty moving neck and shoulders. The Veteran was able to perform repetitive use testing with at least three repetitions without any functional loss. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time. The examiner assessed that weakness, fatigability, and lack of endurance significantly limit functional ability with repeated use over time. The examiner indicated she was able to describe the functional loss with repeated use over time in terms of range of motion: flexion to 30 degrees, extension to 10 degrees, left lateral flexion to 20 degrees, right lateral flexion to 20 degrees, left lateral rotation to 30 degrees, and right lateral rotation to 30 degrees. The examiner indicated that the Veteran was not being examined during a flare-up. The examiner assessed that pain significantly limits functional ability with flare-ups. The examiner indicated she was able to describe the functional loss with flare-ups in terms of range of motion: flexion to 30 degrees, extension to 10 degrees, left lateral flexion to 10 degrees, right lateral flexion to 10 degrees, left lateral rotation to 10 degrees, and right lateral rotation to 10 degrees. The Veteran had muscle spasms and guarding that resulted in abnormal gait or abnormal spine contour. There was no ankylosis of the spine. The Veteran had intervertebral disc syndrome (IVDS) but did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's cervical spine disability from June 4, 2021. The June 2021 examination report shows that the VA examiner accepted the Veteran's description that pain caused functional loss during flare-ups that limited forward flexion of the cervical spine to 30 degrees. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements do not result in symptoms more nearly approximating limitation of motion of the cervical spine to forward flexion to 15 degrees or less. Moreover, the June 2021 examiner reported that the Veteran did not have ankylosis of the cervical spine. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for her cervical spine disability from June 4, 2021. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 6. Entitlement to a rating in excess of 20 percent for a back disability, from June 4, 2021, is denied. A March 2012 rating decision granted service connection for degenerative disc disease of the thoracolumbar spine and assigned a noncompensable rating, effective April 1, 2011. A November 2016 rating decision granted an increased rating to 10 percent, effective August 15, 2012. An August 2021 rating decision granted an increased rating to 20 percent for degenerative disc disease of the thoracolumbar spine, effective June 4, 2021. The Veteran contends that she is entitled to a higher rating for her service-connected back disability for the period from June 4, 2021. For the period from June 4, 2012, the Veteran's lumbosacral strain with intervertebral disc syndrome and degenerative disc disease has been rated under Diagnostic Code 5243, intervertebral disc syndrome (IVDS). 38 C.F.R. § 4.71a, Schedule of ratings musculoskeletal system. During the pendency of the appeal, VA promulgated new regulations governing ratings for musculoskeletal system, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). The rating criteria for the spine were amended. Diagnostic Code 5242 was amended to make clear that its application was for degenerative arthritis/disc disease of the spine other than IVDS. Diagnostic Code 5243 was amended to make clear that it should only be applied for disc herniation with compression and/or irritation of the adjacent nerve root, and that all other disc diagnoses should be rated under Diagnostic Code 5242. Under the General Rating Formula, which include criteria for Diagnostic Code 5243, a 10 percent rating is warranted when the forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in 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 when forward flexion of the thoracolumbar spine is 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, 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 assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. 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. After the Board remanded the claim to the RO in May 2021, the Veteran was provided a VA back examination in June 2021. The Veteran was diagnosed with lumbosacral strain, degenerative disc disease, and intervertebral disc syndrome. The Veteran reported experiencing daily flare-ups of aching pain and sharp pain going down the left leg to the back of the thigh that last from 12 to 24 hours. The Veteran reported having functional loss or functional impairment as "I can't really do much with my back pain." A review of range of active motion testing shows forward flexion to 60 degrees, extension to 20 degrees, left lateral flexion to 20 degrees, right lateral flexion to 20 degrees, left lateral rotation to 20 degrees, and right lateral rotation to 20 degrees. Pain was noted on all movements, but the examiner reported that the Veteran exhibited objective signs of pain during forward flexion at 40 degrees. Passive range of motion testing showed the same ranges of motion as the active testing. The Veteran was able to perform repetitive use testing with at least three repetitions without any additional functional loss. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time. The examiner assessed that pain, weakness, fatigability, lack of endurance, and incoordination significantly limit functional ability with repeated use over time. The examiner indicated she was able to describe the functional loss with repeated use over time in terms of range of motion: flexion to 40 degrees, extension to 10 degrees, left lateral flexion to 10 degrees, right lateral flexion to 10 degrees, left lateral rotation to 10 degrees, and right lateral rotation to 10 degrees. The examiner indicated that the Veteran was not being examined during a flare-up. The examiner assessed that pain, weakness, fatigability, and lack of endurance significantly limits functional ability with flare-ups. The examiner indicated she was able to describe the functional loss with flare-ups in terms of range of motion: flexion to 40 degrees, extension to 10 degrees, left lateral flexion to 10 degrees, right lateral flexion to 10 degrees, left lateral rotation to 10 degrees, and right lateral rotation to 10 degrees. The Veteran had muscle spasms and guarding that resulted in abnormal gait or abnormal spine contour. There was no ankylosis of the spine. The Veteran had intervertebral disc syndrome (IVDS) but did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's thoracolumbar spine disability from June 4, 2021. The June 2021 examination report shows that the VA examiner accepted the Veteran's description that pain caused functional loss during flare-ups that limited forward flexion of the thoracolumbar spine to 40 degrees. The examiner also observed pain at exhibited on forward flexion at 40 degrees. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements do not result in symptoms more nearly approximating limitation of motion of the thoracolumbar spine to forward flexion of 30 degrees or less. Moreover, the June 2021 examiner reported that the Veteran did not have ankylosis of the spine. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for her thoracolumbar spine disability from June 4, 2021. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for a neck disability, prior to June 4, 2021, is remanded. The Board finds that a remand is necessary before a decision on the merits of the claims can be reached. The Veteran was afforded a VA neck examination in June 2016. The examination was inadequate as the examiner failed to estimate the degree of additional range-of-motion loss after repeated use. If an examination does not take place during a flare-up or after repeated use, the examiner should attempt to offer an estimate derived from information procured from relevant sources, including the Veteran's lay statements. An examination that fails to attempt to ascertain adequate information from relevant sources regarding frequency, duration, characteristics, severity, or functional loss after repeated use will be considered inadequate. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). There is no indication that the June 2016 examiner made any attempt to ascertain adequate information from relevant sources to provide the requested opinion. In consideration of the inadequacies of the June 2016 VA examination, the Board finds that a remand is warranted for an addendum retrospective opinion, if possible, as to the severity of the Veteran's service-connected neck disability for the period prior to June 4, 2021. By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. 2. Entitlement to a rating in excess of 10 percent for a back disability, prior to June 4, 2021, is remanded. The Board finds that a remand is necessary before a decision on the merits of the claims can be reached. The Veteran was afforded a VA back examination in June 2016. The examination was inadequate as the examiner failed to estimate the degree of additional range-of-motion loss after repeated use. Sharp, 29 Vet. App. at 35. There is no indication that the June 2016 examiner made any attempt to ascertain adequate information from relevant sources to provide the requested opinion. In consideration of the inadequacies of the June 2016 VA examination, the Board finds that a remand is warranted for an addendum retrospective opinion, if possible, as to the severity of the Veteran's service-connected back disability for the period prior to June 4, 2021. By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. The matters are REMANDED for the following action: 1. Obtain an addendum retrospective medical opinion from the examiner who conducted the June 2016 VA cervical conditions examination, if available, or another qualified medical professional. The examiner must review the entire claims file, to include this remand. If an additional examination is required for the examiner to sufficiently provide an addendum opinion, a new examination should be afforded. 2. If possible, the examiner should provide a retrospective opinion regarding functional limitations of the Veteran's cervical spine disability due to repeated use over time, prior to from June 4, 2021, based on the Veteran's lay statements of experienced symptomatology. 3. The examiner should also address, if possible, whether joint testing of the Veteran's cervical spine would have shown objective evidence of pain in passive motion and in non-weight-bearing motion. 4. If it is not possible to provide a retrospective opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner does not have the knowledge or training. 5. Obtain an addendum retrospective medical opinion from the examiner who conducted the June 2016 VA thoracolumbar conditions examination, if available, or another qualified medical professional. The examiner must review the entire claims file, to include this remand. If an additional examination is required for the examiner to sufficiently provide an addendum opinion, a new examination should be afforded. 6. If possible, the examiner should provide a retrospective opinion regarding functional limitations of the Veteran's lumbar spine disability due to repeated use over time, prior to from June 4, 2021, based on the Veteran's lay statements of experienced symptomatology. 7. The examiner should also address, if possible, whether joint testing of the Veteran's thoracolumbar spine would have shown objective evidence of pain in passive motion and in non-weight-bearing motion. 8. If it is not possible to provide a retrospective opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner does not have the knowledge or training. 9. Upon completion of the above actions, readjudicate the claim. If any determination remains unfavorable to the Veteran, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. § §§ 5109B, 7112. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.