Citation Nr: 21071953 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-32 415 DATE: December 1, 2021 ORDER Entitlement to service connection for right knee ligament disability, to include nerve damage, is denied. Entitlement to a disability rating in excess of 10 percent for service-connected left knee disability is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right knee disability is denied. Entitlement to a disability rating in excess of 20 percent for service-connected lumbar spine degenerative joint disease (back disability) is denied. REMANDED Entitlement to service connection for erectile dysfunction (ED), to include as due to Gulf War environmental exposures, is remanded. Entitlement to special monthly compensation (SMC) due to loss of use of a creative organ is remanded. FINDINGS OF FACT 1. The competent and probative evidence of record does not a demonstrate that the Veteran has a separate diagnosed right knee ligament disability, to include nerve damage. 2. Both the Veteran's right and left knee disabilities are productive of limitation of motion of, at worst, flexion of 90 degrees and normal extension, with no additional limitation due to flare-up, and no ankylosis. 3. The Veteran's back disability has manifested by a limitation of motion to, at worst, 50 degrees forward flexion, with no evidence of ankylosis, or any incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right knee ligament disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria for an increased rating in excess of 10 percent for a left knee disability manifested by limitation of motion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5260. 3. The criteria for an increased rating in excess of 10 percent for a right knee disability manifested by limitation of motion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5260. 4. The criteria for a disability rating in excess of 20 percent for a back disability, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.71a, DC 5240. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from November 1973 to November 1997. Service Connection Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Entitlement to service connection for right knee ligament disability, to include nerve damage The Veteran claims that he suffers from a separate right knee ligament disability, which includes nerve damage, due to his active service. Specifically, the Veteran asserts ligament and nerve damage to his right knee. However, a close review of the claims file, and evidence of record, to include the Veteran's lay statements and medical evidence, shows no separate ligament disability of right knee, currently or contemporaneous to the claim, which is not already contemplated by his currently service-connected disabilities. Therefore, without a current disability service connection is not warranted, and the claim for the right knee must be denied. As a preliminary matter, this claim for a right knee ligament disability was construed by the RO from the Veteran's December 2009 initial claim, which concurrently also included specific claims for peripheral neuropathy of the bilateral lower extremities (sciatica), bilateral varicose veins of the lower extremities, and a right knee disability for chronic right knee sprain and pain. As such, it is unclear whether such claim for a right knee ligament disability is an actual separate claimed disability for the right knee. To this end, the Board notes that the Veteran was subsequently granted service-connected for bilateral peripheral neuropathy of the bilateral lower extremities (sciatica), bilateral varicose veins of the lower extremities, and a right knee disability for chronic right knee sprain and pain. The Board notes that of record are several lay statements from the Veteran regarding his claimed ligament disability, as well as VA treatment records and examinations. A close review of such records, however, does not show any evidence of a diagnosed right ligament/nerve disability which may be reasonably encompassed by the Veteran's claim, and separate from the Veteran's already service-connected conditions. Notably, even considering the Veteran's lay statements, no evidence has been presented to establish even symptoms related to his claimed right knee ligament/nerve disability. Here, lay assertions, such as in his initial claim and in his Notice of Disagreement (NOD), have all only noted generalized statements regarding ligament or nerve damage, without noting any specific/separate descriptions of symptomology or manifestations of such disability. In his initial claim, the Veteran simply noted bilateral ligament, tendon, and nerve damage. In his NOD, the Veteran, again, only noted the terms ligament and nerve damage, without even noting any supporting subjective assertions of symptoms. The Veteran was afforded several VA examinations for various, now service-connected disabilities, to include his bilateral knees (December 2010, December 2014, November 2019, July 2021), his back disability for peripheral neuropathy (March 2010, December 2010, December 2014, November 2019, July 2021), and his varicose veins (December 2010, November 2019). A close review of all of these examinations reveals no additional right knee disability, to include no evidence of any right knee ligament damage/injury/disability, and/or a right knee nerve disability, other than those already contemplated by his service-connected disabilities. Knee examinations during this period reveal no evidence of any ligament issues, to include upon diagnostic review, for the right knee, with no evidence of specific nerve issues with the right knee. To this end, the Board notes that all VA treatment and examinations have also not diagnosed the Veteran's right knee with any ligament-related disability. The Board has also reviewed the submitted private medical treatment records. However, even these records fail to provide any diagnosis or X-ray evidence of a right knee ligament disability, as claimed by the Veteran. Even a close review of these private medical records reveals no explicit notation in which can be construed as any damage, residuals or otherwise, to his ligament of the right knee. To this extent, again, even the Veteran's subjective reports lack specific complaints or symptoms; he does not explicitly report any specific disability, pain, loss of range of motion, or loss of use, regarding his claim of a right knee ligament disability. The Board recognizes that the Veteran claimed in his initial claim filing a bilateral ligament disability. To this end, the Board notes that at that time, the Veteran had not been service-connected for varicose veins or peripheral neuropathy of the bilateral lower extremities. Also, the Veteran's left knee did in fact suffer a meniscus injury during his active service. However, as the Veteran has not demonstrated or even asserted a specific disability or even an array of symptoms relating to a potential diagnosable separate disability relating to his claim for a right knee ligament disability, much less presenting medical evidence of a competent clinical diagnose, the Board must find that the preponderance of evidence is against the finding of a separately diagnosable disability. As noted above, in the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Consequently, as no competent evidence of record demonstrates the Veteran does not have a currently diagnosed disability; therefore, service connection must be denied. Brammer, 3 Vet. App. at 225. The Board has considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, it does not apply. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Increased Rating Disability evaluations are determined by comparing a Veteran's present symptomatology 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 apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for a higher rating. 38 C.F.R. § 4.7. After careful 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 rating decisions. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994). "Staged" ratings (for periods when varying degrees of disability are shown) may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 2. Entitlement to a disability rating in excess of 10 percent for service-connected left knee disability 3. Entitlement to a disability rating in excess of 10 percent for service-connected right knee disability The Veteran contends that his bilateral knee disability warrants a higher rating than his current 10 percent ratings. Specifically, he asserts that he has pain and limited motion in both knees, which interferes with daily activities and work. The Board notes that the competent medical evidence of record, to include VA treatment records and VA examinations, shows that the Veteran's bilateral knee disability is manifested by range of motion limited to, at worst, 90 degrees of flexion and 0 degrees of extension, with evidence of pain. The Board finds that level of disability does not warrant a higher rating based on limitation of motion, or a separate rating under any other diagnostic codes for the knees. Therefore, the claim for an increased rating must be denied. The Veteran's bilateral knee disability is rated under Diagnostic Code 5260. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. The standard ranges of motion of the knee are zero degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The Veteran was provided VA examinations to assess the nature and severity of his service-connected bilateral knee disabilities in December 2010, December 2014, November 2019, and July 2021. A close review of all such noted VA examination reports revealed no objective evidence of limitation of motion that even approaches the requisite 30 degrees on flexion (or to 10 degrees on extension) required for a higher rating. The Board will review these examinations in turn. In his initial December 2010 VA examination, the report shows range of motion was limited to 120 degrees of flexion for the left knee, and 130 for the right knee, with normal extension (zero), for both knees. The examiner noted pain, stiffness, and weakness, with some evidence of occasional locking. While the examiner noted reports of flare-ups, to especially include after prolonged use/exercise, no additional objective loss of range of motion was noted upon repetitive testing. No instability was found in either knee upon testing, and there were no indications of ankylosis. Finally, regarding functional loss, the examiner noted that the Veteran, while experiencing pain, was limited to 15-20 minutes of walking and stand, and could walk about a quarter of a mile. When evaluating the Veteran's medical history, the examiner noted the Veteran's left knee meniscus tear, however, upon review, the examiner only noted occasional left knee locking, and only one instance of effusion, as reported by the Veteran. The Veteran was ultimately diagnosed with bilateral chronic knee sprain, to include chondromalacia of the left knee, with meniscus tear. In a December 2014 VA examination the Veteran was again diagnosed with chronic bilateral knee strain, with a left knee meniscal tear. On examination, the Veteran's range of motion for the left knee was limited to 90 degrees of flexion, with the right knee limited to 100 degrees of flexion; both with normal (zero) extension. Report noted pain on weightbearing, but no tenderness. Repeat motion was noted with no change in range of motion, and the examiner noted no future decrease during flare-ups. No instability or ankylosis were noted in either knee. For the left knee, the examiner noted the Veteran's in-service meniscal tear. While locking was reported during flare-ups by the Veteran, the examination report noted no effusion. The Veteran was noted to require the use of a knee brace, on a constant basis. Functionally, the examiner found that the Veteran was still able to do his work as a DMV driving examiner. The Veteran was afforded another VA examination in November 2019. During this examination, however, the Veteran was not able to complete any physical testing of his knees due to increased pain in his back the day of the examination. Upon interviewing the Veteran, the examiner noted that the Veteran reported increased pain in his knees, restricting his mobility and movement. On examination without physical range of motion testing, the examiner noted pain on weight bearing with tenderness on palpation. No ankylosis was found, and instability was not noted. With regards to the left knee, the examiner noted his meniscal tear, with frequent episode of locking and joint pain; no effusion was noted. Diagnostic testing, however, revealed degenerative changes, and the Veteran was ultimately diagnosed with degenerative joint disability (DJD) of the bilateral knees. Finally, in a July 2021 VA examination for the Veteran's knees, the Veteran was again diagnosed with bilateral chronic knee strain, with left knee meniscus tear. The Veteran was noted to suffer from severe limitation in function and increased pain, to include limitation of walking to 25 feet, and the regular need of a cane. Range of motion testing reveal that the Veteran's bilateral knees were both limited to 90 degrees of flexion, and normal extension, even after repeat motion testing. To this end, the examiner noted that even considered flare-ups, limitation of motion would be unchanged. Instability testing revealed normal for both knees, and no ankylosis was noted. For the left knee, the Veteran's left knee meniscus tear was noted to only include frequent episodes of pain, with no evidence of effusion and locking. The Board notes that these findings do not more nearly reflect the criteria for a higher rating based on limitation of motion under Diagnostic Code 5260. While there is functional loss due to pain, especially after prolonged use and exercise, it is not productive of the functional equivalent of flexion limited to 30 degrees or worse for either knee. In all VA examinations, and for both knees, the Veteran, while reporting flare-ups, performed repetitive testing without further decreases in range of motion. Even a review of the VA treatment records during the claims period reveals no additional evidence showing a disability of either knee that approaches the 30 degrees limitation of flexion required for a 20 percent rating under the appropriate diagnostic code. The Board finds that the Veteran's bilateral knee disability is manifested by no more than pain and range of motion limited to, at worst, 90 degrees flexion and normal extension, even considering additional functional loss after repetition. Therefore, as there is no evidence of limitation of motion limited to 30 degrees of flexion or below, for either knee, at any point during the claims period, the Board must find that the Veteran's claim for a rating in excess of 10 percent, for either knee, is not warranted under the Diagnostic Code for limitation of flexion. Likewise, a separate, or higher, rating is not warranted for limitation of extension, under Diagnostic Code 5261, or instability, under Diagnostic Code 5257. Here, again, the Board notes that the objective medical evidence of record ostensibly has noted that the Veteran's extension to be normal (zero degrees) throughout the claims period, and that extensive stability testing has revealed no instability or subluxation in either knee. As such, a separate, or higher rating, under either Diagnostic Code would not be warranted under the current facts of the claim. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Here, however, a higher or separate rating are not warranted under any other potentially applicable Diagnostic Codes. There is no lay or objective evidence of ankylosis (Diagnostic Code 5256); or frequent episodes of "locking," pain and joint effusion (Diagnostic Code 5258); or impairment of tibia and fibula (Diagnostic Code 5262); or genu recurvatum (Diagnostic Code 5263). As such, considering under these Diagnostic Codes would be inappropriate, and not warranted. The Board also acknowledge that, the Veteran's left knee disability has been diagnosed with a meniscus tear which is covered under Diagnostic Code 5259 (cartilage removal), which contemplates meniscal/ACL tear and subsequent surgery. However, such Diagnostic Code, requires specific symptoms other than pain, to include "frequent" episodes of locking and effusion. Here, again, looking at the VA examinations and treatment records, while there are instance of locking and effusion, at no point during the entire claims period are both conditions described as frequent. In-fact, the only instance in which effusion was noted for the left knee, was during his initial December 2010 VA examination, where it was explicitly noted that the Veteran has only experienced one incident of effusion. As such, the Board finds that the criteria for a separate rating under this Diagnostic Code is not warranted, as pain, in itself has been contemplated by his current rating for limitation of motion of the left knee. The Board has considered the Veteran's lay statements and complaints. With regard to the lay statements, the Board notes that while the Veteran is competent to speak to lay observable symptoms such as pain, he is not competent to speak to the specific objective criteria of exact measurements for range of motion as it pertains to the applicable diagnostic code. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Evaluations of the Veteran's bilateral knee disability have been provided by medical professionals of record and their results were considered in this decision. The Board assigns more probative weight to those examination results because of the experience and training of the examiners. Accordingly, the Board finds that the preponderance of evidence is against the claim for a higher rating for either knee disability, or any separate rating based on limitation of motion or instability, and the claims must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a disability rating in excess of 20 percent for service-connected back disability The Veteran service-connected back disability has been rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5237 is evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, at 38 C.F.R. § 4.71a , a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is assigned for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire (thoracolumbar and cervical) spine. 38 C.F.R. § 4.71a, General Rating Formula. These ratings are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. The General Rating Formula also provides further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Id. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) provides that each range of motion measurement is to be rounded to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) directs to separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. The Veteran claims that his current 20 percent rating for his service-connected back disability does not fully contemplate the severity of his disability during that period. The Board, however, finds that a close review of the relevant medical records, to include VA examinations for the back, reveal that the Veteran's back disability, during this relevant period, does not show a back disability severe enough to warrant the next higher rating based on the appropriate Diagnostic Code. Therefore, as the preponderance of the evidence is against the finding of a more severe back disability the Veteran's claim for increased rating must be denied. The evidence of record includes contemporaneous VA treatment records and several VA examination reports from March 2010, December 2010, December 2014, November 2019, and July 2021. A close review of the copious amounts of VA treatment records, contemporaneous to the claimed period, shows no evidence that the Veteran's back disability was ever limited to 30 degrees of flexion, or less, or had any indications of ankylosis. To this end, while the Veteran was noted to suffer from both pain and flare-ups, treatment records, showed no evidence of any incapacitating episodes or a finding of intervertebral disc syndrome (IVDS). In March 2010, the Veteran was afforded a VA examination for his back, which assessed the nature and severity of his disability. During the examination, the Veteran was noted to report pain, to include frequent flare-ups with increased pain. The examiner noted that the Veteran did not report any additional loss of motion during flare-ups and reported no incapacitating episodes. Upon physical examination, the Veteran demonstrated forward flexion to 60 degrees, and a total combined movement of 230 degrees; repeat motion testing revealed no additional limitations. The Veteran was ultimately diagnosed degenerative joint disease (DJD) of the lumbar spine. At the December 2010 VA examination, the Veteran again complained of back pain and stiffness, to include flare-ups, especially after prolonged use. This generalized examination, however, did not provide any objective testing regarding the physical range of motion limitations noted by the Veteran for his back. In a December 2014 VA examination, the Veteran was noted again to complain about increased pain in his back. On the physical examination, the Veteran's forward flexion was limited to 65 degrees, with pain noted on weight bearing, but no tenderness. Repetitive use testing was performed, with no evidence of further decreases in the Veteran's range of motion. Likewise, flare-ups were noted by the Veteran, however, the examiner noted no further functional loss due to such flare-ups. Neither ankylosis of the spine nor incapacitating episodes were found. The Veteran was again diagnosed with DJD of the lumbar spine, which required him to use a cane on a constant basis. In a November 2019 the Veteran was again afforded a VA examination to assess the nature and severity of his back disability. Here, the Veteran was again diagnosed with arthritis of the spine, with subjective complaints of increased pain and flare-ups, during which the Veteran claims increased pain with movements and decrease in range of motion. Upon physical examination, the Veteran's range of motion was noted to be limited to 60 degrees of forward flexion, with repeat motion testing revealing no further reductions in range of motion; while flare-ups were reported, the examiner note no finding of additional reductions in the Veteran's functional ability in range of motion. Pain was noted on weight bearing. The report noted no finding of ankylosis, and no evidence of incapacitating episodes. Muscle strengths were normal, and the Veteran noted occasional use of a cane for ambulation. Overall, the examiner noted functional loss to include difficulty getting in and out of cars, and some difficulties getting dressed. Finally, during the Veteran's most recent VA examination in July 2021, the Veteran was again diagnosed with DJD of the lumbar spine. The Veteran continued his claims of increased pain, to include during flare-ups which were triggered by increased/prolonged use such as walking and standing. To this end, the Veteran noted that he was limited to only half a block of walking and maybe 10 minutes of standing. Upon physical examination, the Veteran's back disability limited the Veteran's forward flexion to only 50 degrees, with a total combined range of motion of 165; such limitation was noted to be unchanged even after repeat testing, and consideration of flare-ups. Further examination reveals normal muscle strength with no evidence of muscle atrophy, no evidence of ankylosis, or reports of incapacitating episodes. Functionally, the VA examiner noted that due to the Veteran's back disability, the Veteran could no longer work as a driving examiner for the DMV, to which the Veteran had retired from in 2019. After consideration of the pertinent evidence of record, the Board concludes that a disability rating greater than 20 percent is not warranted for the Veteran's back disability. The evidence has not demonstrated flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine, to warrant a rating in excess of 20 percent. 38 C.F.R. § 4.71a, General Rating Formula. As described above, physical testing of the Veteran's range of motion has consistently found that the Veteran's forward flexion to be in excess of 30 degrees, during the entire claims period. To this end, no treatment records have showed any objective testing of the Veteran's range of motion that meet the objective criteria set out for the next higher rating. Here, the Veteran has only demonstrated forward flexion limited at worse to 50 degrees, during the entire claims period, and as such, does not meet the criteria for the next higher rating. The Board also notes that the medical records also show no evidence that the Veteran had a diagnosis of ankylosis of any kind (favorable or unfavorable) during the relevant time period. Ankylosis is the "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing SAUNDERS ENCYCLOPEDIA AND DICTIONARY OF MEDICINE, NURSING, AND ALLIED HEALTH at 68 (4th ed. 1987)). Here, ankylosis has not been diagnosed or identified by X-ray evidence of record; indeed, X-ray diagnostics during the claims period, to explicitly include during the VA examinations, only reveal evidence degenerative changes. Therefore, as the Veteran has also been able to extend, flex, and flex and rotate laterally, the Board must find that ankylosis is not shown. Finally, consideration has been given to an increased rating for the Veteran's lumbar spine disability under other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1995). Spine conditions may also be rated under Diagnostic Code 5243 for IVDS. The criteria for IVDS rates the disability according to the number of "incapacitating episodes" suffered per year. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). However, not only have the Veteran note been diagnosed with IVDS, but there has also been no evidence, during VA examinations, or in the VA/private treatment records to indicate any evidence of incapacitating episodes. 38 C.F.R. § 4.71a, General Rating Formula, DC 5243. As such, application of this Diagnostic Code would be inappropriate. The Board does acknowledge that during VA examinations, and in treatment records, the Veteran has noted reports of flare-ups which were described as severe by the Veteran. A close review of these subjective reports, however, reveal no claims, even by the Veteran, as being bedridden, or as to actually cause the need for bed rest. The Board points out that the notation under the regulations for IVDS explicitly call for "prescribed" bed rest by a physician or medical professional. 38 C.F.R. § 4.71a, DC 5243. To this end, a close review of the VA and private treatment records reveal no evidence of any reports of prescribed bed rest, or instances/reports of being confined to the bed, as contemplated by the prevailing regulations. Consequently, as there is no evidence of incapacitating episodes as contemplated by the Diagnostic Code for IVDS, a higher rating under such criteria is also not warranted. Therefore, as the preponderance of the evidence is against the finding of objective evidence of the Veteran's back disability limited to at least 30 degrees of flexion, and/or evidence of a diagnosis of ankylosis, the Board must find that the Veteran's claim for a higher rating, must be denied. In making this determination, the Board considered any functional loss caused due to flare-ups of pain, weakness, fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237; DeLuca v. Brown, 8 Vet. App. 202 (1995). The evidence does not show that the spine disability more nearly approximates the criteria for a higher rating for any period on appeal. To the extent that the Veteran has reported experiencing flare-ups and functional impairment, this impairment is contemplated by the current 20 percent rating and is not of such severity that it could be characterized as flexion of 30 degrees or less or ankylosis, as is required for a higher rating. As such, a higher rating based on pain and functional loss is not warranted. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca, 8 Vet. App. at 206-07. As the preponderance of the evidence is against the claim for an increased rating there is no doubt to be resolved, and a rating greater than 20 percent for the Veteran's back disability is not warranted. 38 C.F.R. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for ED, to include as due to Gulf War environmental exposure, is remanded. The Veteran's claim for service connection was previous remanded by the Board for further development, to include acquiring another examination and opinion that spoke to the nature and etiology of the Veteran's diagnosed ED, as secondary to his exposure during service in the Persian Gulf. In July 2021 the Veteran was afforded a VA examination for his claimed ED, which ultimately found against any finding of an etiological nexus to service. A close review of that opinion, however, reveals that examination report is inadequate, and further development is required by the VA. The July 2021 VA examiner's opinion again failed to specifically address elements of the Veteran's in-service environmental exposures during the Veteran's service in the Persian Gulf, and instead provided a generalized rationale that failed to address any specific assertions of the Veteran's actual claim and the evidence of record. As such, the Board must find that the VA examination to be inadequate and remand is required. The Board notes that the VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Here, the Board finds that by its own admission in its previous remand in May 2021, the previous VA examination on record was inadequate, and/or incomplete, as it failed to specifically address claims of exposure to toxic environmental elements during the Veteran's service in the Persian Gulf. As such, in the Board's May 2021 remand, the Board required further development, to specifically include the examination and opinion in which addressed the Veteran's claim of environmental exposure during his active service deployments. To this end, the Board notes that not only has the Veteran asserted specific instances of exposure to disposal of various munitions but has also submitted various articles noting the effects of such exposure to soldiers during their service in the Gulf region. The Board finds, however, that a review of the July 2021 nexus opinion reveals no analysis, or explicit acknowledgement of such evidence of statements from the Veteran, or with regards to any scholarly article noted in the claims file. Instead, the VA examiner simply noted generalized conclusory statements finding that there is no such thing as late onset ED, without addressing any particulars of the claim. The Board finds such opinion and rationale to be incomplete and inadequate. As such, as such development for this claim is incomplete, the Board must remand this claim for the VA to fulfill its duty to the Veteran. 2. Entitlement to SMC due to loss of use of a creative organ is remanded. Regarding the claim for a SMC, consideration of entitlement to SMC is dependent upon the impact of service-connected disability remanded herein. The matter of TDIU is therefore inextricably intertwined with his claim for ED. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. The matters are REMANDED for the following action: 1. Obtain all VA medical records of treatment to include any hospitalizations. 2. Schedule the Veteran for a VA examination to address the nature and etiology of his claimed ED, claimed as due to environmental exposure during deployment in the Gulf. The examiner must review the claims file and should note that review in the report. All appropriate tests and studies should be conducted, and any consultations deemed necessary should be accomplished. The examiner should record all noted signs and reported symptoms, document clinical findings, and provide a diagnosis where possible. All opinions are to be supported with citation to evidence in the record and to medically accepted knowledge. After conducting a complete examination, the examiner is asked to provide the following opinions: The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that his ED is related to service, to include service in the Southwest Asia Theater of Operations during the Persian Gulf War era, or any event, injury, or disease during service. The examiner must explicitly address both the lay statements and scholarly articles of record, about environmental exposures during his deployment. The examiner should provide a rationale for all opinions provided. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ziheng Zhu, 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.