Citation Nr: 21074792 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 14-41 257 DATE: December 16, 2021 ORDER Entitlement to an initial rating of 70 percent, but no higher, prior to April 29, 2021, for service-connected posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), associated with chronic low back pain with minimal ossifications at T10-11 (previously rated as adjustment disorder with mixed anxiety and depressed mood), is granted. Entitlement to a rating in excess of 100 percent from April 29, 2021, for service-connected PTSD and MDD, is denied. Entitlement to an initial rating in excess of 20 percent prior to April 20, 2021, and in excess of 40 percent thereafter for service-connected lumbosacral intervertebral disc syndrome (IVDS) with grade 1 spondylolisthesis L5-S1 is denied. Entitlement to a separate rating of 10 percent, but no higher, for left lower extremity radiculopathy, associated with service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1, is granted. Entitlement to a separate rating of 10 percent, but no higher, for right lower extremity radiculopathy, associated with service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1, is granted. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1, right trochanteric bursitis, or neuropathy of the bilateral lower extremity disabilities, is remanded. FINDINGS OF FACT 1. Prior to April 29, 2021, the Veteran's PTSD and MDD has been manifested by symptoms producing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total occupational and social impairment. 2. From April 29, 2021, the Veteran is in receipt of the schedular maximum for PTSD and MDD. 3. Prior to April 20, 2021, the Veteran's service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1 has not been manifested by at least IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months nor forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine at any time. 4. From April 20, 2021, the Veteran's lumbosacral IVDS with grade 1 spondylolisthesis L5-S1 is not productive of ankylosis or symptoms producing the functional equivalent of ankylosis, nor did it produce incapacitating episodes of IVDS totalling at least six weeks annually. 5. The Veteran's left lower extremity radiculopathy was manifested by mild symptoms. 6. The Veteran's right lower extremity radiculopathy was manifested by mild symptoms. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent prior to April 20, 2021, and in excess of 40 percent thereafter for service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5010-5243. 2. The criteria for a separate rating of 10 percent, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.27, 4.124a, Diagnostic Code 8520. 3. The criteria for a separate rating of 10 percent, but no higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.27, 4.124a, Diagnostic Code 8520. 4. The criteria for an initial 70 percent rating, but no higher, for PTSD and MDD prior to April 29, 2021 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. The criteria for a rating in excess of 100 percent for PTSD and MDD from April 29, 2021 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1986 to November 1989. The increased rating claims for psychiatric and low back disabilities are before the Board of Veterans' Appeals (Board) on appeal from March 2013 and May 2013 rating decisions, respectively, by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these matters in December 2018, March 2021, and June 2021 for additional development. The service connection claim for right knee disability comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter for additional development in April 2020. 1. Entitlement to increased ratings for PTSD and MDD Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155;38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). By way of history, a March 2013 rating decision granted service connection for adjustment disorder with mixed anxiety and depressed mood with an evaluation of 30 percent, effective May 13, 2011, the date of claim. An August 2020 rating decision increased the evaluation of MDD (previously rated as adjustment disorder with mixed anxiety and depressed mood) to 50 percent, effective November 13, 2014, and granted a staged rating of 70 percent, effective December 17, 2019. A January 2021 rating decision granted an effective date of August 28, 2013 for the increased rating of 50 percent for PTSD (previously rated as MDD). A July 2021 rating decision granted an increased rating of 100 percent for PTSD and MDD (previously rated as PTSD). The RO assigned the initial 30 percent rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9440 ("Chronic adjustment disorder"). Subsequent examination reports suggest that PTSD and MDD (Diagnostic Code 9411) may be the more appropriate diagnoses. Under either Diagnostic Code 9411 or 9440, a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Further, Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 71 and 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but is generally able to function "pretty well," and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran's increased rating claim was originally certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. Turning to the evidence, in April 2011, the Veteran reported to his VA psychiatrist that he was frustrated by chronic back pain and severe gastroesophageal reflux disease (GERD), as they prevented him from doing things he wanted to do, such as home projects and eating. He felt down and easily irritated, as well as tense, restless, and jumpy. He denied being a "worrier" but reported he was a perfectionist and found it difficult to relax until accomplishing things that needed to be done. He denied persistent feelings of depression, anhedonia, problems with appetite, concentration, energy, and suicidal/homicidal ideation. He sometimes woke up from pain or GERD, but otherwise slept "okay." He was given a trial of citalopram for about two months, which was helpful, but caused headaches. He stopped taking the medication because the benefit did not outweigh the risks. He dreamed about military drills that involved live ammunition and gas chambers and avoided small spaces since those experiences. He denied other symptoms of PTSD, as well as mania, psychosis, OCD, and alcohol or drug use. On examination, the Veteran was well groomed, calm, and cooperative. His mood was "frustrated," and his affect was reactive and slightly anxious. Thought process was linear and thought content showed no signs of delusions, hallucinations, or suicidal/homicidal ideations. Insight and judgment were fair. Cognition was grossly intact. The Veteran underwent a VA mental disorders examination in July 2011. The Veteran reported he had been married to his current wife for 23 years. He had a good relationship with his family, but his daughter and wife noticed him "being on the edge" and often commented for him to calm down. He had two close friends but spent the majority of his free time alone with his dogs. He also enjoyed working on home projects. He denied suicide attempts, violence/assaults, and issues with alcohol and substance use. He reported his depression and anxiety had become more frequent. He endorsed difficulty calming down after stressful situations, such as disagreements with family and co-workers. He endorsed more noticeable irritability during periods when he felt down, and occasional loss of interest when his GERD or back pain was present. He reported his anxiety focused on health concerns related to GERD and environmental stressors, such as work and family. He reported he stayed home from work during days when his GERD was more severe, or his back pain was more intense. On psychiatric exam, he was clean, appropriately dressed, and cooperative. His affect was constricted, and mood was "not that good." Attention and orientation were intact. He endorsed mild sleep difficulties due to acid reflux and ruminations about stress, including concerns about physical pain and/or reflux and work stress. He denied panic attacks, homicidal/suicidal thoughts, and episodes of violence. He reported good impulse control and denied problems with activities of daily living. Memory was normal. In his May 2013 NOD, the Veteran indicated that his anxiety and depression reflected symptoms listed for an increased 50 percent evaluation. In correspondence dated July 30, 2013, the Veteran's private psychiatrist noted that the Veteran had been employed as a building equipment mechanic for 14 years with the United States Postal Service (USPS). The Veteran reported he had nightmares twice a week, waking in panic and sweats, lasting at least 120 minutes. He experienced flashbacks twice a week, panic attacks two to three times a week, lasting at least 15 to 30 minutes, and slept an average of three to five hours a night. He startled easily and could not tolerate anyone behind him. He only socialized with family. Memory was moderately impaired, as he could not remember what he read. His working memory was 60 percent impaired. He experienced anger, sadness, and fear 50 percent of the time without his understanding, which indicated his prefrontal cortex was dysfunctional. He felt depressed 40 percent of the time, with low energy and little interest in things. He had frequent crying spells and angered/agitated easily. According to the psychiatrist, the Veteran was moderately compromised in his ability to sustain social and work relationships. In a July 2015 statement, the Veteran reported he was out of work because of his anxiety and depression. In correspondence dated May 6, 2015, the Veteran's private psychiatrist indicated the Veteran was unable to sustain social or work relationships. He was "permanently and totally disabled and unemployable." Private and VA psychiatric treatment records from 2011 to 2017 show the Veteran reported he experienced various symptoms, including sleep impairment, nightmares, panic attacks, night sweats, anger, depression, flat affect, short-term memory, irritability, flashbacks, agitation, fear, anhedonia, mood swings, anxiety, isolation, low libido, and auditory hallucinations. The Veteran was afforded a VA PTSD examination in December 2019. The Veteran commented that his protective factors were his dog and family. He reported he had worked with USPS for 25 years, and continued to work, despite memory problems and social isolation. He wanted to work until retirement, though it was very difficult. His panic attacks, chronic sleep impairment, and memory loss impacted each other, but more importantly, made it difficult for him to do his work successfully and confidently. He was close to tears when talking about his experiences and needed to talk about them with a therapist. His medication treatment consisted of Bupropion, Trazadone, Alprazolam, and Donepezil. The examiner found that the Veteran's psychiatric symptoms caused occupational and social impairment with deficiencies in most areas. The examiner noted that the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, and inability to establish and maintain effective relationships. On examination, the Veteran was dressed appropriately, cooperative, and engaged with the evaluation. He was oriented and had appropriate eye contact. There was no evidence of psychotic thinking and his thought content and processing were intact. Insight and judgment were fair, and he was a good historian. In a buddy statement submitted in December 2020, the Veteran's friend indicated he had known the Veteran since 1987 while they were stationed in Germany. He stated he witnessed the plane crash that "deeply affected [the Veteran's] life." The friend stated that since the Veteran witnessed the plane crash, he suffered severe PTSD, depression, anxiety, insomnia, nightmares, trust issues, anger issues, panic attacks three to five times a week, and memory problems. The Veteran was afforded another VA PTSD examination in April 2021. The Veteran reported passive suicidal ideation once a week, social isolation, low libido, lack of orientation to time and place, and hallucinations. He also reported feeling hopeless with the ongoing back pain, which caused depression, anxiety, disturbances of sleep, motivation, and mood, and thinking it would be okay to not wake up. The examiner found that the Veteran's psychiatric symptoms caused total occupational and social impairment. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, suicidal ideation, spatial disorientation, persistent delusions or hallucinations, neglect of personal appearance and hygiene, and disorientation to time or place. As discussed previously, the Veteran's PTSD and MDD has been rated in stages with a 30 percent rating from May 13, 2011, a 50 percent rating from August 28, 2013, a 70 percent rating from December 17, 2019, and a 100 percent rating from April 29, 2021. After careful review, the Board finds that an evaluation of 70 percent, but no higher, for the period prior to December 17, 2019 is warranted in this case, because the frequency, severity, and duration of the Veteran's symptomatology resulted in social and occupational impairment in most areas, particularly with respect to his persistent depression, anxiety, flattened affect, irritability, anhedonia, startle response, sleep impairment, hallucinations, restricted social relationships, inability to form productive working relationships or to focus on job-related tasks, and difficulty in adapting to stressful circumstances. See 38 C.F.R. § 4.130. However, in so finding, the Board further finds that at no time prior to December 17, 2019 have the criteria for a 100 percent rating for an acquired psychiatric disability been satisfied or approximated. See 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9433. The Veteran's examinations and treatment records consistently reflect the absence of any reports or observations of gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; or a memory impairment of such severity that he could not remember highly learned material such as his own name or the names of close relatives. The Veteran is in receipt of the maximum schedular evaluation for PTSD and MDD from December 17, 2019. There is no basis for a higher evaluation. In reaching this decision, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on individual unemployability (TDIU), if expressly raised by the veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for an increased rating). In this case, however, the Board finds that consideration of a TDIU is not warranted. The record on appeal reflects that the Veteran is already in receipt of a 100 percent disability rating, plus special monthly compensation at the housebound rate, from April 29, 2021. Thus, a TDIU is moot from that date. Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); see also Bradley v. Peake, 22 Vet. App. 280 (2008); Rice, 22 Vet. App. at 453-54 (2009). For the period prior to April 29, 2021, there is no indication in the record or allegation that the Veteran was unemployable solely as a result of his service-connected disabilities. The Veteran admittedly worked with USPS throughout the periods on appeal despite psychiatric symptoms, albeit with difficulty. See e.g., December 2019 VAX. As such, the record does not reasonably raise the issue of a TDIU. Rice, 22 Vet. App. 447, 453-54 (2009). 2. Entitlement to an increased rating for service-connected lumbosacral IVDS with grade 1 spondylolisthesis L5-S1 By way of history, the May 2013 rating decision granted service connection for lumbosacral IVDS with grade 1 spondylolisthesis L5-S1with an evaluation of 20 percent, effective May 2, 2011, the date of claim. A July 2021 rating decision increased the evaluation of lumbosacral IVDS with grade 1 spondylolisthesis L5-S1 to 40 percent, effective April 20, 2021. Effective February 7, 2021, the schedular criteria for rating the musculoskeletal system were amended. Prior to February 7, 2021, pursuant to 38 C.F.R. § 4.71a, disabilities evaluated under Diagnostic Code 5243 may be rated either under the General Formula for Diseases and Injuries of the Spine (General Formula) or the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. After February 7, 2021, Diagnostic Code 5243 for IVDS is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; otherwise, Diagnostic Code 5242 is assigned for all other disc diagnoses. Where the rating criteria is amended during the course of an appeal, the Board is to consider both the former and the current schedular criteria because, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991) (holding that, where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to appellant should and will apply unless Congress provides otherwise or permits the Secretary to do otherwise)). In the instant case, the Board will apply the pre-2021 amendment criteria as these criteria are more favorable to the Veteran. Under the pre-amendment General Rating Formula, a 20 percent rating is warranted where 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 is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted where forward flexion of the thoracolumbar spine is 30 degrees or less; or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Lastly, a 100 rating is warranted where there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2020). The Notes following the General Rating Formula provide further guidance in rating diseases or injuries of the spine. Note 1 specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero 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. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note 3 provides that in exceptional cases, an examiner may state that because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of 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 range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as 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. Recently, in Chavis v. McDonough, the Court held that the requirement of ankylosis under the General Rating Formula may also be satisfied with evidence of the functional equivalent of ankylosis. 34 Vet. App. 1, 19-20 (2021) (citations omitted). Comparatively, under the formula for rating IVDS, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note 1 to the formula for rating IVDS based on incapacitating episodes defines an incapacitating episode as "a period of acute signs and symptoms due to [IVDS] that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a. Importantly, VA is to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5235 to 5243, Note (1). Here, the Veteran's service-connected low back condition has associated left lower extremity and right lower extremity radicular symptoms. The Veteran does not have other objective neurologic abnormalities that rise to compensable levels. Radiculopathy will be addressed below. Mild incomplete paralysis warrants a 10 percent disability rating, moderate incomplete paralysis warrants a 20 percent disability rating, moderately severe incomplete paralysis warrants a 40 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. An 80 percent disability rating is warranted for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. Descriptive words such as "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Finally, the Board recognizes that, in some circumstances, it must consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination when deciding an appropriate rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Turning to the relevant evidence, the Board initially notes that the Veteran's VA and private treatment records do not contain definitive range of motion results for consideration, but do note the Veteran's reports of pain, radiating pain, and limited lifting and range of motion. Thus, this evidence does not provide a basis upon which to grant this appeal. The Veteran was afforded a VA internal medicine examination in July 2011. During the examination, the Veteran reported intermittent sharp, lower back pain that limited his full range of motion. The pain radiated to the right buttock, where it lasted a few hours. Pain was exacerbated by picking up heavy objects more than 30 pounds and relieved by TENs unit, back brace, rest, ice, and ibuprofen. The Veteran also reported a history of stiffness and spasm. He described his pain as moderate in severity, lasting three to seven days on a weekly to monthly basis. He reported no incapacitating episodes of spine disease. He used a brace and was able to walk one to three miles. The examiner noted that the Veteran's back condition resulted in increased absenteeism, problems with lifting and carrying, and pain. In a series of lay statements submitted from August 2011 to October 2011, the Veteran reported radiating pain, muscle spasms, pain when walking, cramps of the buttock, leg, hip, and foot numbness. He wore a back brace. His back pain caused him to be down 10 to 17 days at a time, preventing him from being able to perform work duties. In April 2013, the Veteran was afforded a VA back conditions examination. He reported on and off pain since 1986, which eventually migrated to his upper and lower legs. He described the pain as sharp in the lower back and numbing and tingling in the right leg. Pain recently extended to his right fourth and fifth toes. Pain limited movement of the back and right leg. He reported daily pain, throughout the day. He reported that from 2010 to 2013, he had lost three to fourteen days of work, but reported no physician directed bed rest. Treatment consisted of tramadol, cyclobenzaprine, acetaminophen, TENs unit, capsaicin topical cream, a back brace, prednisone, and occasional physical therapy exercises. The Veteran reported he had to take several sick days due to pain and requested prednisone treatments. He had to take an average of seven to ten days each year over the last three-year period due to his back condition. On initial range of motion testing, flexion was limited to 40 degrees and extension was limited to 15 degrees, with objective evidence of painful motion. He was able to perform repetitive use testing with no additional limitation of range of motion. Additional factors contributing to disability were noted as less movement than normal, pain on movement, and severe guarding were noted. Localized tenderness or pain to palpation was also noted on the L5-S1 and bilateral associated paraspinal regions. Guarding or muscle spasm was noted, which resulted in abnormal gait and abnormal spinal contour. Decreased sensation to light touch was noted on the right foot/toes (L5). The examiner found that the Veteran had mild constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the right lower extremity, which involved the right sciatic nerve. The examiner described the severity of radiculopathy as mild on the right side. The examiner indicated the Veteran had IVDS, but no incapacitating episodes over the previous 12 months due to IVDS. The examiner also indicated the Veteran's low back condition impacted his ability to work, as the Veteran reported he was often placed on light duty due to his back and leg pain when he was not able to take any sick time. He also reported he routinely was unable to pick up anything that weighed more than 15 pounds. In his May 2013 notice of disagreement (NOD), the Veteran reported he met the criteria for a 40 percent evaluation, as he experienced incapacitating episodes in excess of more than four weeks in the previous year. His doctor told him to rest when his "back goes out." He was prescribed prednisone, but could not continue the medication due to long-term effects of steroids, and he had to rest until he could return to work. In his November 2014 VA Form 9 (substantive appeal), the Veteran reported he had four incapacitating episodes of IVDS over the previous 12 months. He stated he was on FMLA at work because of his low back condition. He also reported his flexion was reduced to 40 degrees and he experienced localized tenderness, guarding, and muscle spasms that resulted in abnormal gait and spinal contour. In December 2019, the Veteran was afforded another VA back conditions examination. He reported worsening pain and stiffness in the lower back with increased pain radiating to the bilateral lower extremities, right greater than the left. The Veteran rated his pain as a 5/10. He reported exacerbation of pain with increased extraneous movement at work, at least two to three times per month. He reported difficulty putting on clothes or performing activities of daily living during a flare-up. He also reported reduced mobility due to pain and stiffness. He had limited ability to tolerate prolonged standing, sitting, or walking. On initial range of motion testing, flexion was limited to 60 degrees and extension was limited to 15 degrees. Pain was noted on exam but did not result in/cause functional loss. The Veteran had no additional limitation with range of motion after repetitive use testing. The examiner estimated that flexion was limited to 50 degrees and extension was limited to 10 degrees during repeated use over time and flare-ups. Pain, weakness, and lack of endurance were noted to cause functional loss with repeated use over time and flare-ups. Guarding and muscle spasm were noted which did not result in abnormal gait or abnormal spinal contour. Additional factors contributing to disability were noted as disturbance of locomotion, interference with sitting and standing, and weakened movement due to muscle or of peripheral nerves injury. Decreased sensation was noted on the right side. The examiner noted mild constant pain of the right lower extremity, mild intermittent pain of the left lower extremity, and mild paresthesias and/or dysesthesias and numbness of the right and left lower extremities, involving the sciatic nerve of the right and left sides. The examiner indicated the Veteran had mild radiculopathy of the right and left sides. No ankylosis or IVDS were noted. The examiner noted the Veteran was employed with the USPS and had lost two to four weeks work time in the last 12 months. The examiner found that the Veteran's low back disability impacted his ability to work as it limited his ability to tolerate prolonged standing, sitting, or walking. An addendum opinion dated December 2020 indicated that passive range of motion of the spine was not feasible to perform in a safe and reasonable manner. Nonweight-bearing assessment is not applicable. There was no objective evidence of pain when the spine was in a nonweight-bearing position at rest. Although there was no documented range of motion measurements between 2010 and 2013, the opinion indicated the Veteran's range of motion improved from 2013 and 2019. In April 2021, the Veteran was afforded another VA back conditions examination. The Veteran reported his back symptoms had worsened over the years. He reported his back pain was constant with varying intensity. He also reported he experienced pain in his hips and down his legs to his feet, as well as numbness of his lower extremities. He reported lower back pain as a 6/10. The Veteran denied flare-ups. He reported that prolonged sitting was difficult because of his back and lower extremities pain and lifting and bending was difficult because of his back pain. Flexion was limited to 30 degrees and extension was limited to 10 degrees, with pain. The examiner indicated that passive range of motion testing was not performed as it would result in severe pain. The Veteran did not perform repetitive use testing due to "fear of pain." With repeated use over time, the examiner estimated flexion was limited to 20 degrees and extension was limited to 0 degrees. Pain, fatigability, weakness, lack of endurance, and incoordination were noted to cause functional loss with repeated use over time. Decreased sensation was noted on the right lower leg/ankle (L4/L5/S1) and foot/toes (L5). The examiner noted mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the right and left lower extremities, involving the sciatic nerve of the right and left sides. No ankylosis was noted. The examiner determined that while the Veteran had IVDS, his IVDS did not result in any incapacitating episodes over the past 12 months. Additionally, the examiner noted that the Veteran required regular use of a brace and cane. The examiner noted that the Veteran was employed as a building mechanic and had lost two to four weeks of work in the previous 12 months. After considering the evidence of record, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 20 percent for the Veteran's service-connected low back disability prior to April 20, 2021. To meet the next-higher 40 percent criteria, forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine is needed. Flexion during the appeal period was not limited to 30 degrees or less. The Board finds that the preponderance of the evidence is also against the claim for a rating in excess of 40 percent for the Veteran's service-connected low back disability from April 20, 2021. As noted, in order to warrant a rating in excess of 40 percent, the record must reflect that the Veteran's disability is productive of unfavorable ankylosis of the entire thoracolumbar spine or the entire spine or of symptoms which more nearly approximate ankylosis. Upon review of all the evidence of record, both lay and medical, the Board finds that the Veteran's low back symptomatology does not approximate or meet the symptoms of unfavorable ankylosis of the entire thoracolumbar spine at any time during the periods on appeal. As reflected above, repeated examination has shown that the Veteran has retained motion in his thoracolumbar spine, albeit limited, and clinicians have expressly determined that ankylosis is not present. While there is no evidence of a clinical diagnosis of ankylosis of the thoracolumbar spine, the Court has held that the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (U.S. 2021). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland's Illustrated Medical Dictionary (28th ed. 1994) at 86). As outlined in Note (5) of the rating formula, fixation of a spinal segment in neutral position (zero degrees) indicates favorable ankylosis. Here, the Veteran denied having flare-ups during the April 2021 VA examination. Although he has reported difficulty with activities of daily living and limited range of motion, he has not exhibited symptoms such as difficulty walking because of a limited line of vision or breathing limited to diaphragmatic respiration. The Board therefore finds that the overall evidence reflects that the functional equivalent of ankylosis is not more nearly approximated and a rating in excess of 40 percent for low back disability is not warranted. 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59; Chavis, supra. The Board also finds that the preponderance of the evidence is against a rating in excess of 40 percent for the Veteran's low back disability under the criteria for evaluating IVDS. Despite the Veteran's reports, the Veteran's low back disability has, at no point during the pendency of the appeal, produced incapacitating episodes of IVDS or required bed rest as prescribed by a physician. In a statement received in October 2011, the Veteran expressed dissatisfaction with the July 2011 examiner regarding the attitude of the examiner, as well as the examiner's termination of the examination due to pain during range of motion testing. However, a mere allegation of inadequacy, without more, does not warrant an additional examination or render the examination inadequate. See Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011). Even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, the examination's adequacy is challenged solely on the seemingly short duration of the examination and the examiner's attitude. In fact, the examiner did assess the spine, including range of motion and strength. In addition, no additional evidence or compelling argument has been submitted to indicate that the examination was not complete or that the Veteran's complaints were not considered. Accordingly, the Board finds that the July 2011 examination is adequate for adjudication purposes. Based on the evidence, the Board finds that the Veteran is entitled to separate ratings of 10 percent, but no higher, for his left lower extremity and right lower extremity radiculopathy symptoms. According to the lay and medical evidence, the Veteran suffered from mild left lower extremity and right lower extremity radiculopathy symptoms due to his service-connected low back condition. However, the Veteran is not entitled to a higher rating. A higher rating would require there to be moderate, moderately severe incomplete paralysis, severe incomplete paralysis with marked muscular atrophy, or complete paralysis. The Veteran has not been found to have muscular atrophy or complete paralysis. As such, 10 percent ratings, and no higher, are assigned for radiculopathy in each lower extremity. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability The Veteran contends that his right knee disability is due to or aggravated by his service-connected low back disability. See, e.g., August 2018 Form 9. Alternatively, his representative has argued that his right knee disability is due to or aggravated by his service-connected right hip bursitis or neuropathy of the bilateral lower extremities. See March 2020 Informal Hearing Presentation. Pursuant to the April 2020 remand, an addendum medical opinion was obtained regarding the nature and etiology of the Veteran's right knee disability in June 2020. The June 2020 VA examiner opined that the Veteran's right knee disability was less likely as not incurred in or caused by an in-service injury, event, or illness. The examiner's rationale was that during service, the right knee injury was acute only and no other right knee injuries were noted in two years at ETS. There is no evidence of chronicity of care and symptoms are subjective only. The June 2020 VA examiner also opined that the right knee disability was less likely as not proximately due to, the result of, or aggravated by service-connected low back, right hip, and neuropathy disabilities. With regard to proximity, the examiner's rationale was that the current severity of the low back, right hip, and neuropathy is not sufficient for a nexus to the right knee disability. With regard to aggravation, the examiner was unable to determine a baseline level of severity for the right knee disability prior to aggravation or the earliest medical evidence following aggravation; however, the examiner concluded that the current severity of service-connected conditions does not plausibly impact the right knee, as separate joints, etc. are involved. The Board finds the June 2020 opinion inadequate, as the examiner did not consider the Veteran's contentions that his low back pain caused so much knee pain and weakness that he eventually tore his right anterior cruciate ligament (ACL), which required surgery in 2005. Lastly, the June 2020 examiner's rationale is conclusory and not sufficiently detailed. In September 2020, an addendum opinion clarifying service connection on a secondary basis was provided. The examiner rationalized that the Veteran's service-connected low back, neuropathy and right hip disabilities are not shown to affect/adjust gait currently. The 2005 right ACL surgery is not objectively in the claims file, as no orthopedic data is available to view. A history of knee buckling in 2005 to 2007 with a fall is not conclusively shown. Onset of right knee condition is not otherwise specified. The Veteran's exit examination of five years of right knee problem is pre-service and silent for any visit in service. The low back and hip disabilities do not necessarily impact the right knee. Also, the lack of clear history for right knee surgery is a large gap. Thus, no secondary or aggravation is warranted. The Board finds the September 2020 opinion is also inadequate. While the September 2020 examiner addressed aggravation, the examiner failed to address causation. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. §§3.310(b)). The Board also notes that subsequent to the September 2020 addendum opinion, in December 2020, the Veteran submitted an August 2005 operative report for right knee ACL and lateral meniscal tears. As such, the Board finds that a remand is warranted to obtain an addendum VA medical opinion that separately considers both causation and aggravation, considers all relevant evidence of record, including lay statements, and provides a sufficiently detailed rationale. See El Amin, 26 Vet. App. at 140; Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 23Vet. App.120 (2007). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion on the nature and etiology of the Veteran's right knee disability. The Veteran's claims file and a copy of this remand should be furnished to the examiner, who should indicate that he or she has reviewed the claims file. The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) the Veteran's service-connected low back disability, right hip disability, or bilateral lower extremity neuropathy either (a) caused, or (b) aggravated the Veteran's right knee disability. (Continued on the next page) If the Veteran's right knee disability is aggravated by any of these disabilities, to the extent possible, the examiner is asked to provide an opinion as to the approximate baseline level of severity of the right knee disability before the onset of aggravation. A complete rationale for these opinions should be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. K. R. Laffitte Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.N., 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.