Citation Nr: 21076032 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 17-38 317 DATE: December 22, 2021 ORDER Entitlement to increased ratings for degenerative disc disease of the cervical spine, presently rated as 10 percent disabling prior to July 19, 2019, and 20 percent disabling thereafter, is denied. Entitlement to a separate rating for left upper extremity radiculopathy with a 20 percent rating effective July 13, 2015, and 30 percent rating effective July 19, 2019, is granted. Entitlement to a separate 20 percent rating for right upper extremity radiculopathy, effective July 19, 2019, is granted. Entitlement to an increased rating for lumbosacral strain with degenerative changes, presently rated 20 percent disabling, is denied. Entitlement to a separate noncompensable rating for erectile dysfunction, associated with lumbosacral strain with degenerative changes, is granted. Entitlement to special monthly compensation under 38 U.S.C. § 1114(k) is granted. Entitlement to a 20 percent rating for left lower extremity sciatic radiculopathy, associated with lumbosacral strain with degenerative changes, is granted. FINDINGS OF FACT 1. Prior to July 19, 2019, the Veteran's cervical degenerative disc disease resulted in 40 degrees of forward flexion of the cervical spine without evidence of abnormal gait or spinal contour; thereafter his cervical spine disability resulted in 30 degrees of forward flexion and a combined range of motion of 150 degrees of the cervical spine, accounting for periods of flare without abnormal spinal contour or gait; he has not been found to have intervertebral disc syndrome. 2. From the date of the claim for an increase, July 13, 2015, the Veteran has had mild radiculopathy affecting the left upper extremity, associated with his degenerative disc disease of the cervical spine; from July 19, 2019, his left upper extremity radiculopathy has increased in severity and is now considered moderate in nature. 3. From July 19, 2019, the Veteran has had mild radiculopathy affecting the right upper extremity, associated with his degenerative disc disease of the cervical spine. 4. For the period on appeal, the Veteran's lumbosacral strain with degenerative changes, has resulted in no less than 40 degrees of forward flexion when accounting for pain and periods of flare; he does not have ankylosis or fixation of the spine. 5. For the period on appeal, the Veteran's left lower extremity sciatic radiculopathy, associated with lumbosacral strain with degenerative changes, has been manifested by moderate symptoms. 6. The Veteran has erectile dysfunction which is a likely neurological complication of his low back disability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to July 19, 2019, and 20 percent thereafter for degenerative disc disease of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5242, 5243. 2. From July 13, 2015, to July 19, 2019, the criteria for a separate 20 percent rating for left upper extremity radiculopathy, associated with cervical degenerative disc disease, have been met; from July 19, 2019, the criteria for a 30 percent rating have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242, Note (1), DCs 8511, 8512 3. From July 19, 2019, the criteria for a separate 20 percent rating for right upper extremity radiculopathy, associated with cervical degenerative disc disease, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242, Note (1), DC 8511. 4. The criteria for a rating in excess of 20 percent for lumbosacral strain with degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242. 5. For the period on appeal, the criteria for a 20 percent rating for left lower extremity sciatic radiculopathy, associated with lumbosacral strain with degenerative changes, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242, Note (1), DC 8520. 6. For the period on appeal, the criteria for a noncompensable rating for erectile dysfunction, associated with lumbosacral strain with degenerative changes, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242, Note (1), 4.115b, DCs 7520-7524. 7. For the period on appeal, basic entitlement to special monthly compensation due to loss of use of a creative organ has been met. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1972 to November 1979, and from March 1980 to October 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Although not explicitly included in the appeal at the time of the hearing, included in this decision are claims of entitlement to a separate rating and special monthly compensation (SMC) for erectile dysfunction, and right and left upper extremity radiculopathy. Those grants are made possible as part of the increased rating claim for his low back disability. The Board notes that the supplemental statement of the case (SSOC) in this matter, issued in July 2018, implied that the rating for the cervical spine dated as far back as the date of service connection in November 1998. While the Veteran has been in receipt of service connection for a cervical spine disability since 1998, there is no indication that he ever contested the ratings assigned at the time of the initial grant, and they became final. He filed his claim for an increased rating of that disability in July 2015. As such, the Board will consider the evidence relevant to the appeal period commencing in July 2015 to the present. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the issues on appeal in this matter, entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consideration of the medical evidence since the date of the claim for increase and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119 (1999). "Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 1. Entitlement to increased ratings for degenerative disc disease of the cervical spine, presently rated as 10 percent disabling prior to July 19, 2019, and 20 percent disabling thereafter 2. Entitlement to a separate 20 percent rating for moderate left upper extremity cervical radiculopathy, effective July 13, 2015 3. Entitlement to a separate 10 percent rating for mild right upper extremity cervical radiculopathy, effective July 19, 2019 The Veteran's cervical spine disability is presently rated 10 percent disabling prior to July 19, 2019, and 20 percent disabling thereafter. He seeks higher ratings. The Board finds that the claim should be denied. The Veteran's cervical spine disability is rated pursuant to Diagnostic Code (DC) 5243, which compensates for intervertebral disc syndrome (IVDS). When rating diseases and disabilities of the spine, there are two options for rating the disability. The primary option for rating a spine disability is the application of the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), pursuant to DCs 5235-5242. In this matter, DC 5242 would be most appropriate as it rates for degenerative arthritis or degenerative disc disease of the spine. Under the General Rating Formula, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 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. 38 C.F.R. § 4.71a, DC 5242. A 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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. Id. Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine is assigned a 30 percent rating. Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine is assigned a 40 percent rating. Finally, a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the spine have been amended. Specifically, DC 5242 was amended to clarify that it included degenerative disc disease other than IVDS, effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's cervical spine disability under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. In the alternative, if IVDS is found to be present, a spine disability may be rated based on the presence of that condition with incapacitating episodes, if it would afford a higher rating. It is noted that a rating for IVDS is an alternative rating, and not to be combined with a rating under the General Formula. Under the rating criteria for IVDS, a 10 percent rating is assigned for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is assigned 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 assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Finally, a 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. The Board notes that the rating criteria for IVDS was also amended in February 2021, to include an explanation stating that DC 5243 should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. For all other disc diagnoses, DC 5242 should be assigned. Id. It should be further noted that the rating criteria using the General Formula instructs that neurological complications of a spine disability should be rated pursuant to an appropriate diagnostic code. 38 C.F.R. § 4.71a, DC 5242, Note (1). Essentially, this allows the Board to assign additional separate ratings for any neurological complication of a spine disability. Relevant to this appeal, radiculopathy affecting the lower radicular group associated with the cervical spine allows for a 20 percent rating for mild radiculopathy for both the dominant and non-dominant upper extremity. Moderate radiculopathy of the dominant hand allows for a 40 percent rating, while the nondominant hand is assigned a 30 percent rating. For higher ratings, severe incomplete paralysis of the nerve, or complete paralysis, described as "all intrinsic muscles of hand, and some or all of flexors of wrist and fingers, paralyzed (substantial loss of use of hand)." 38 C.F.R. § 4.124a, DC 8512. Radiculopathy of the middle radicular group associated with the cervical spine allows for a 20 percent rating for mild radiculopathy for both the dominant and non-dominant upper extremity. Moderate radiculopathy of the dominant hand allows for a 40 percent rating, while the nondominant hand is assigned a 30 percent rating. For higher ratings, severe incomplete paralysis of the nerve, or complete paralysis, described as "adduction, abduction and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected." 38 C.F.R. § 4.124a, DC 8511. For the purposes of evaluating this claim, the evidence suggests that the Veteran's right hand is his dominant hand. Terms such as "mild," "moderate," and "severe" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The Veteran was afforded a VA examination in November 2015, in connection with his increased rating claim. At that time he was diagnosed with degenerative arthritis of the spine, and also with mild radiculopathy affecting the left upper extremity. He reported flare ups, described as causing pain when turning his head. Functionally, he reported limitation in turning the head. Initial range of motion showed 40 degrees of forward flexion with a combined range of motion of 275 degrees. Pain was noted at the terminal degrees and caused the noted functional loss. The examiner found no additional loss of function on repetitive use, and did not find that repetitive use over time or flare ups would further limit range of motion. Guarding was noted, but did not cause abnormal gait or spinal contour. Weakened movement was noted, although muscle strength testing showed normal strength and no muscle atrophy was found. Reflexes were normal. Sensory testing was normal. There was some evidence of mild intermittent pain in the left upper extremity, although no other symptoms were noted. The examiner found the radiculopathy to be mild at most. No ankylosis or fixation of the spine was found. No other neurological abnormalities were identified. The examiner did not find evidence of IVDS. He did not use an assistive device. Functionally, the disability made it difficult to watch a monitor for a long time at work. Based on this evidence, the Board does not find that an increased rating is warranted from the date of the claim for the cervical spine disability itself. In this regard, the Veteran's cervical spine was capable of forward flexion greater than 30 degrees, with a combined range of motion greater than 170 degrees. While guarding was present, there was no abnormal gait or spinal contour. Further, there was no evidence of IVDS or incapacitating episodes during that period of time. While the Veteran certainly did have some functional impact from his cervical spine disability, even affording the Veteran the benefit of the doubt and considering his lay statements regarding loss of use, there is nothing upon which to give a higher rating. However, based on this examination report, there is evidence in the record of mild radiculopathy affecting the lower radicular group of the cervical spine. At most, the Veteran showed some evidence of mild intermittent pain in the left hand and arm, which the examiner attributed to the C8/T1 nerve roots (lower radicular group), which is separate from any other neurological complications such as his service-connected carpal tunnel syndrome. There was no evidence of constant pain, paresthesias and/or dysesthesias, or numbness. As such, the Board does not find evidence of radiculopathy in the left upper extremity which is greater than mild in nature. However, because mild radiculopathy affecting the left upper extremity is found, the Board will grant a separate 20 percent rating for that radiculopathy effective the date of claim for an increase, July 13, 2015. On July 19, 2019, the Veteran was afforded a new VA examination in connection with his appeal. At that time he was diagnosed with cervical degenerative disc disease, as well as left and right cervical radiculopathy. The Veteran reported constant daily neck pain, rated 5/10 with intermittent worsening with additional radiation of pain, numbness and tingling down the arms, left greater than the right. He reported having difficult with work (he worked as a facility manager). Flare-ups occurred 2-3 times per week, moderate to severe in nature, precipitated by sleeping wrong, too much physical activity at work, or too much time on the computer. Flare-ups were alleviated with warm compresses and over-the-counter medications. Forward flexion was to 30 degrees with combined range of motion of 200 degrees. range of motion itself did not contribute to functional loss. Pain was noted at the terminal ranges of motion. Forward flexion was not further limited with repetitive use, but combined range of motion was further limited to 150 degrees. The examination was consistent with the Veteran's reports of limitations with repetitive use over time and during periods of flare. He did have guarding but it did not result in abnormal gait or spinal contour. No additional factors contributed to his disability. No muscle atrophy was found and muscle strength testing was normal. Reflexes were normal. Right sensory testing showed decreased but not absent sensation in the inner/outer forearm. Left sensory testing showed decreased but not absent sensation in the shoulder area and inner/outer forearm. Neurologically, radiculopathy was found in both upper extremities. The right arm showed mild intermittent pain, paresthesias and/or dysesthesias, and numbness. Moderate findings for the same were found in the left arm. There was no evidence of constant pain in either arm. The examiner opined that the radiculopathy was mild in the right arm and moderate in the left. There was no ankylosis or functional fixation of the spine. No additional neurological abnormalities were identified. No IVDS was identified and he had not had any incapacitating episodes. He occasionally used a brace and walking stick, although he denied using them at the time of his hearing. The examiner noted objective evidence of passive range of motion pain. There was no evidence of pain on non-weight bearing movement. Based on this evidence, the Board again finds no criteria to rate higher than the 20 percent assigned from July 19, 2019. Specifically, forward flexion of the cervical spine far exceeds 15 degrees, even when considering the Veteran's complaints of loss of use during periods of flare. There is no evidence of ankylosis nor any evidence of functional fixation of the spine. He has never been found to have IVDS associated with the cervical spine, let alone be prescribed bed rest for at least 4 weeks. Thus, there is no basis upon which to grant a higher rating for the cervical spine itself. However, from the date of the examination, July 19, 2019, the Board will increase the left upper extremity rating from 20 to 30 percent, due to a finding of increased radiculopathy symptoms affecting the middle radicular group. The Veteran's symptoms have increased such that moderate intermittent pain, paresthesias and/or dysesthesias, and numbness are present, and the Veteran shows decreased but not absent sensation in the left shoulder and arm. The Board is satisfied that this is evidence of left upper extremity radiculopathy that is moderate in nature, although not so significant as to cause "severe" residuals. Thus, a 30 percent rating is warranted. Likewise, from the same date, the Veteran should be afforded a 20 percent rating for mild radicular symptoms affecting the upper right extremity. Here the Veteran shows intermittent pain, paresthesias and/or dysesthesias, and numbness are, as well as decreased but not absent sensation in the left arm. The examiner has explicitly linked this to the middle radicular group, and it is separate from the Veteran's other neurological conditions of the right arm, such as carpal tunnel syndrome. As such, the Board will assign a separate rating for right upper extremity radiculopathy effective July 19, 2019. The Board has carefully reviewed the remaining available evidence, but finds none that would give rise to a higher rating for the cervical spine. In reaching this conclusion, the Board has considered the Veteran's assertions in his hearing that his neck disability has resulted in some missed work, and thus implied that he may be entitled to a higher rating on an extraschedular basis. The Court of Appeals for Veterans Claims (Court) has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. In this matter, the Board is satisfied that the schedular criteria are adequate to evaluate the Veteran's disability. For his part, the Veteran asserts that the primary symptom of his disability is neck pain, which interferes with his ability to lift, stand, and also engage in long-term sessions at a computer, and also radicular pain in his upper extremities. As was noted above, although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell, 25 Vet. App. at 38-43 (quoting 38 C.F.R. § 4.40 ); see DeLuca , 8 Vet. App. at 206-207. In this regard, even though the Veteran asserts pain as the primary issue, resulting in interference with activities of daily living, it is precisely the type of symptom which is anticipated by the rating criteria. Additionally, while the Veteran has asserted some missed work, he has remained employed throughout the appeal period, without any indication that his symptoms have negatively affected his career such that it may be in jeopardy due to significant missed work or inability to complete work tasks. He has not required any specific hospitalization for his neck condition, let alone significant hospitalizations. Further, separate ratings based on mild to moderate radiculopathy have increased the overall rating for the cervical spine far beyond that which is available based on the neck pain alone. As such, the Board is satisfied that the rating criteria are adequate to rate the Veteran's disability, and referral for consideration of an extraschedular rating is not warranted in this matter. In sum, the Board does not find that higher ratings should be assigned for the cervical spine itself, based on the evidence of record. However, from July 13, 2015, the Board will assign a separate 20 percent rating for left upper extremity cervical radiculopathy. Effective July 19, 2019, the Board will increase the rating for the left upper extremity cervical radiculopathy to 30 percent; it will also assign a 20 percent rating for right upper extremity cervical radiculopathy. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to an increased rating for lumbosacral strain with degenerative changes, presently rated 20 percent disabling 5. Entitlement to a separate noncompensable rating for erectile dysfunction, associated with lumbosacral strain with degenerative changes, 6. Entitlement to special monthly compensation under 38 U.S.C. § 1114(k) 7. Entitlement to a rating in excess of 10 percent for left lower extremity sciatic radiculopathy, associated with lumbosacral strain with degenerative changes The Veteran's lumbosacral strain with degenerative changes is presently rated 20 percent disabling. He seeks a higher rating. The Board finds that the spine claim itself should be denied, but that a separate noncompensable rating and entitlement to special monthly compensation due to erectile dysfunction should be granted. The Veteran's lumbosacral strain is rated under DC 5242, which compensates for degenerative changes of the spine and applies the General Formula, discussed above. For purposes of adjudicating a lumbar spine disability, as opposed to a cervical spine disability under the General Formula, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, DC 5242. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, as noted above, a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id. Ratings based on IVDS are also for consideration, although no such pathology is found in this matter. Also, as noted above, neurological complications of a spine disability are to be rated separately under a relevant diagnostic code. Id., Note (1). For purposes of this appeal, the Board notes that the Veteran has a separate 10 percent rating for sciatic radiculopathy of the left lower extremity, which is rated pursuant to DC 8520 from February 5, 2015. Under the applicable rating criteria a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve. A moderate incomplete paralysis of the sciatic nerve is assigned a 20 percent rating. A moderately severe incomplete paralysis is assigned a 40 percent rating. Severe incomplete paralysis of the sciatic nerve, defined as "with marked muscular atrophy" is assigned a 60 percent rating. Finally, complete paralysis of the sciatic nerve, defined as "he foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost" is assigned an 80 percent rating. 38 C.F.R. § 4.124a, DC 8520. Also potentially applicable are ratings for erectile dysfunction. There is no specific rating criteria for erectile dysfunction, and generally speaking, that disability is rated as noncompensable, indeed, the rating criteria for a compensable rating with erectile dysfunction generally requires deformity or removal of a creative organ. See 38 C.F.R. § 4.115b, DCs 7520-7524. However, VA has a duty to maximize benefits to a claimant. Bradley v. Peake, 22 Vet. App. 280 (2008). Therefore, the Board notes that when erectile dysfunction is found, basic entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(k) is also met, which provides for special monthly compensation due to loss of a creative organ. 38 C.F.R. § 3.350(a)(1). A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The Veteran was afforded a VA examination in November 2015 in connection with this increased rating claim. At that time, the Veteran was shown to have lumbosacral strain with degenerative arthritis of the spine. He also had radiculopathy of the left leg affecting the sciatic nerve. The Veteran reported worsening pain. Flare-ups were described as painful to stand, bend, and lay flat. Overall, the Veteran reported painful standing, sitting and bending. Range of motion testing was initially normal with forward flexion to 90 degrees with a combined range of motion of 240 degrees. Pain was noted on the exam, but did not cause functional loss. No additional loss of function was noted on repetitive use testing, and the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran's reports of loss of use over time. The examiner noted that the examination was being conducted during a flare-up. Guarding and localized tenderness were noted, but did not result in abnormal gait or spinal contour. He had some weakened movement, disturbance of locomotion and interference with sitting and standing. Muscle strength testing was normal and there was no evidence of any atrophy. Reflexes were normal. Sensory testing showed decreased, but not absent sensation in the left lower leg/ankle, but normal sensation in all other areas and in the right leg. The straight leg raising test was positive in the left leg, but negative in the right. The examiner found radiculopathy only in the left leg, with evidence of mild intermittent pain, paresthesias and/or dysesthesias, and numbness in the left leg. The examiner found evidence of mild radiculopathy in the left leg and none in the right. There was no evidence of ankylosis or other fixation of the spine. No other neurological abnormalities were identified. He did not have IVDS. He did not use an assistive device. Functionally, the examiner stated that he needed to walk frequently to alleviate lower back pain. A new examination was conducted in July 2019. At that time he was diagnosed with lumbosacral strain with degenerative arthritis of the spine and left lumbar radiculopathy. The Veteran reported constant daily low back pain 5-6/10 with intermittent worsening to 10/10. He also stated that he had intermittent radiation of pain with associated numbness and tingling down both legs, the left greater than the right. He reported that he had issues with work and recreational activities. Flare-ups occurred daily, lasting hours to days. He denied being able to walk more than 2 miles. He reported that his sex life is significantly affected. Forward flexion was to 50 degrees with a combined range of motion of 180 degrees. Pain was noted at the terminal points of motion, contributing to that limitation. There was no evidence of pain with wight bearing. There was evidence of localized tenderness. The Veteran was tested during a spasm and could not complete repetitive use testing, however, the examination was medically consistent with the Veteran's statements of loss with repetitive use over time and during a flare. During such periods, the examiner anticipated 40 degrees of forward flexion with a combined range of motion of 130 degrees. Spasm was noted, but did not result in abnormal gait or spinal contour. No additional factors contributed to his disability. Muscle strength testing was normal. He did not have any muscle atrophy. Reflexes were normal. Sensory testing was normal in the right leg and decreased but not absent in the left knee/thigh and lower leg/ankle, but normal in the upper left thigh and foot/toes. Straight leg raising test was positive on the left and negative on the right. Radicular pain in the left leg was found to include mild intermittent pain, paresthesias and/or dysesthesias, and numbness in the left leg. No symptoms were found in the right leg and the examiner declined to diagnose radiculopathy of the right leg during the examination. No other radicular symptoms were observed. The examiner found the sciatic nerve root to be affected. There was no ankylosis of the spine or other fixation of the spine. No other specific neurological abnormalities were identified. He did not have IVDS or require bed rest to treat incapacitating episodes. He occasionally used a brace or walking stick. Functionally, the examiner stated that he was limited in his capacity to carry heavy objects or even moderate weight repeatedly. He had difficulty with prolonged standing, sitting or walking moderate distances. He had reduced capacity for bending, squatting or crouching repeatedly. During his hearing before the undersigned, the Veteran testified that he experienced erectile dysfunction, which he explicitly linked to his nerve pain radiating from his low back. He also testified to increased weakness and increased pain in the left leg since the time of his claim for an increase. Indeed, he stated that he would not likely be able to drive if he were required to operate the gas pedal with his left foot due to pain and weakness. The Board has also reviewed the available private and VA treatment records and does not find any specific criteria such as range of motion testing upon which it may rate the Veteran's low back disability. His sciatica and erectile dysfunction are confirmed throughout those records. Based on this evidence, the Board does not find that a rating in excess of 20 percent is warranted for the Veteran's low back disability. In order to warrant a higher rating, the Veteran's low back must be manifested by 30 degrees or less of forward flexion, but at most his forward flexion was limited to 40 degrees when accounting for pain and during periods of flare. Likewise, there is no evidence of functional fixation of the spine nor any evidence of ankylosis as a diagnosed condition. He does not have lumbar IVDS. As such, the Board cannot grant a rating in excess of 20 percent for the low back disability itself. The Board has carefully reviewed the remaining available evidence, but finds none that would give rise to a higher rating for the lumbar spine. In reaching this conclusion, the Board has considered the Veteran's assertions in his hearing that his low back disability has resulted in some missed work, and thus implied that he may be entitled to a higher rating on an extraschedular basis. As noted above, the Court of Appeals for Veterans Claims (Court) has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this matter, the Board is satisfied that the schedular criteria are adequate to evaluate the Veteran's disability. For his part, the Veteran asserts that the primary symptom of his disability is low back pain, which interferes with his ability to lift, stand, and also engage in long-term sessions at a computer, in addition to radicular pain the left leg and erectile dysfunction. As was noted above, although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell, 25 Vet. App. at 38-43 (quoting 38 C.F.R. § 4.40 ); see DeLuca , 8 Vet. App. at 206-207. In this regard, even though the Veteran asserts pain as the primary issue, resulting in interference with activities of daily living, it is precisely the type of symptom which is anticipated by the rating criteria. Additionally, while the Veteran has alleged some missed work, he has remained employed throughout the appeal period, without any indication that his symptoms have negatively affected his career such that it may be in jeopardy due to significant missed work or inability to complete work tasks. He has not required any specific hospitalization for his neck condition, let alone significant hospitalizations. Further, separate ratings for radiculopathy and erectile dysfunction raise the Veteran's overall rating for this disability beyond that which is available using the General Rating Formula alone. As such, the Board is satisfied that the rating criteria are adequate to rate the Veteran's disability, and referral for consideration of an extraschedular rating is not warranted in this matter. However, based on the Veteran's testimony regarding his left leg sciatic radiculopathy, as well as the symptoms documented throughout his treatment record, the Board will afford the Veteran the benefit of the doubt and assign an increased rating of 20 percent for left lower extremity radiculopathy. In this regard, the Board finds that the symptoms are more significant than that which a "mild" rating might anticipate. At the same time, there is no evidence of any atrophy, even mild atrophy of the muscles, no trophic changes, and the Veteran is still able to ambulate. As such, it does not find that moderately severe or greater radiculopathy is present. At most, moderate symptoms are noted, and a 20 percent rating is more appropriate for the period on appeal. The Board will also afford the Veteran the benefit of the doubt and assign a noncompensable rating for erectile dysfunction, which the Veteran is competent to report and has explicitly linked to his nerve pain radiating from the low back. While a noncompensable rating is assigned (the Veteran experiences exclusively erectile dysfunction and not any loss of an actual reproductive organ), the Board also finds that due to this erectile dysfunction, and considering its duty to maximize benefits to the Veteran, basic entitlement to SMC under 38 U.S.C. § 1114(k) is also met, and should be assigned from the date of the claim for an increased rating for the low back, as a neurological complication of the low back disability. In sum, the Board does not find that an increased rating in excess of 20 percent is warranted for the low back itself, however, a 20 percent rating for left lower extremity sciatic is warranted. Additionally, a noncompensable rating with associated entitlement to SMC based on loss of use of a creative organ should also be assigned. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel