Citation Nr: 21076283 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 17-19 259 DATE: December 23, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for lumbosacral degenerative joint and disc disease with intervertebral disc syndrome (IVDS) (a back disability), from July 1, 2013 through September 6, 2018, is denied. Entitlement to a rating in excess of 20 percent for a back disability, from September 7, 2018, is denied. (The issues of entitlement to higher ratings for right shoulder acromioclavicular joint degenerative joint disease and migraine headaches will be the subject of a future Board decision) FINDINGS OF FACT 1. From the July 1, 2013 effective date of service connection through September 6, 2018, the Veteran's back disability was not manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, a 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; or, by spinal ankylosis or the functional equivalent of ankylosis; or by incapacitating episodes of IVDS having a total duration of at least two weeks but less than four weeks during the past twelve months. 2. Since September 7, 2018, the Veteran's back disability has not been manifested by forward flexion of the lumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; or, the functional equivalent of ankylosis; or, or by incapacitating episodes of IVDS having a total duration of at least four weeks but less than six weeks during the past twelve months. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent, from July 1, 2013 through September 6, 2018, for a back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5242-5243. 2. The criteria for a rating in excess of 20 percent, from September 7, 2018, for a back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5242-5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1992 to June 2013. His awards include the Joint Service Commendation Medal and the Army Commendation Medal. These matters initially came to the Board of Veterans' Appeals (Board) from an August 2013 rating decision, in which the agency of original jurisdiction (AOJ) awarded service connection for lumbosacral spine degenerative joint disease and degenerative disc disease and assigned an initial 10 percent disability rating, from July 1, 2013. The Veteran timely appealed. In August 2019, the AOJ assigned a 20 percent rating for the service-connected back disability, from August 6, 2019. The Veteran's appeal has previously been before the Board. In June 2021, the Board remanded the Veteran's claims to the AOJ for additional development. In August 2021, the AOJ assigned a 20 percent rating for the service-connected back disability, from September 7, 2018. In the June 2021 remand, the Board instructed the AOJ to, among other things, obtain and associate with the claims file all outstanding VA treatment records. Pursuant to the Board's remand, all outstanding relevant treatment records have been obtained and associated with the claims file. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Higher Initial Rating A disability rating is determined by applying VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. 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. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 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; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Veteran's back disability is rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) for the entirety of the appeal period. 38 C.F.R. § 4.71a, DCs 5242-5243. Under the General Rating Formula, both prior to and since the regulatory change, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 10 percent rating contemplates forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating contemplates 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. A 40 percent rating contemplates forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating will be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. Note (2) provides that normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all 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. Each range of motion measurement is to be rounded to the nearest five degrees. The rating criteria provide that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The United States Court of Appeals for Veterans Claims (Court) has held that a veteran may be entitled to a rating higher than 40 percent under the General Rating Formula if he experiences the functional equivalent of ankylosis when considering the provisions of 38 C.F.R. §§ 4.40 and 4.45. Chavis v. McDonough, 34 Vet. App. 1, 23-24 (2021). Under DC 5243, both prior to and since the regulatory change, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the following ratings apply: IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months warrants a 10 percent rating; IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months is assigned a 20 percent rating; IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrants a 40 percent rating; and IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrants a 60 percent rating. 38 C.F.R. § 4.71A. For purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. 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). With any form of arthritis, painful motion is an important factor of disability. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Moreover, the Court has held that the application of 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. When § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). 1. Entitlement to an initial rating in excess of 10 percent for a back disability from July 1, 2013 through September 6, 2018 The Veteran contends that his lumbosacral degenerative joint and disc disease with IVDS is more severely disabling than represented by the assigned 10 percent rating from July 1, 2013 through September 6, 2018. The claim period begins on July 1, 2013, the effective date of service connection for the Veteran's back disability. The Veteran's back disability is rated as 10 percent disabling under the General Rating Formula from July 1, 2013 through September 6, 2018. A July 2015 scan showed no acute fracture or malalignment of the lumbar spine, transitional anatomy of the thoracolumbar and lumbosacral junctions, which was predisposing to low back pain, and probable pars interarticularis defects at L6. In an April 2017 correspondence and an April 2017 Form 9, the Veteran wrote, "I do not recall declining the physical examination part. I have had incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. I have muscle spasms." In March 2018, the lumbosacral spine did not demonstrate full range of motion. The lumbosacral spine exhibited no tenderness on palpation and no muscle spasms. The Veteran reported decreased range of motion over time. He also reported a tingling sensation in the back of his legs. He denied flare-ups of his chronic low back pain. He had some subjective weakness for three days, which had resolved. In a May 2018 Back Conditions Disability Benefits Questionnaire (DBQ), the Veteran complained of dull and throbbing pain on the lumbar spine and stiffness. He also complained of aching pain throughout the day. The pain was located on the lumbar spine and sometimes radiated to the bilateral lower extremities with numbness and tingling. He rated his pain intensity at 10 out of 10 in the morning, while lifting, or with prolonged sitting and bending. Treatment included NSAIDs, a lidocaine patch, and physical therapy. He reported flare-ups, described as aching pain caused by being active around the house and doing yard work. Functional loss or impairment was described as not being able to sit for long, mow the lawn or do yard work. Forward flexion of the spine was 0 to 85 degrees. Extension and right and left lateral flexion and rotation were all 0 to 30 degrees. Range of motion did not contribute to a functional loss. The Veteran exhibited pain on forward flexion and right and left lateral rotation. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the back. There was evidence of pain with weight bearing. He was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. Pain significantly limited functional ability with repeated use over a period of time. This was described in terms of range of motion as forward flexion 0 to 85 degrees and extension and right and left lateral flexion and rotation all 0 to 30 degrees. Pain significantly limited functional ability with flare-ups described in terms of range of motion as forward flexion 0 to 85 degrees and extension and right and left lateral flexion and rotation all 0 to 30 degrees. He had muscle spasms of the back not resulting in abnormal gait or spinal contour, described as intermittent shooting pain on the lumbar spine. He did not have guarding. He did not have muscle atrophy, ankylosis, or IVDS. In a June 2018 lumbar spine initial evaluation, the Veteran complained of chronic back pain with stiffness in the morning and with prolonged inactivity, such as lying down or prolonged sitting. At rest, pain was a 1 out of 10, and with activities it was a seven to eight out of 10. Prolonged standing and yard work increased symptoms. Range of motion was flexion to 70 degrees and extension and rotation to 30 degrees. A June 2018 scan of the back showed early degenerative changes of the lumbar spine and circumferential broad-based disc bulge was identified at multiple levels. There was secondary central canal stenosis at multiple levels most prominent at L3/4. Foraminal stenosis was also seen at multiple levels, again most prominent at L4-5 where it was moderate in severity on the left. There was no evidence of focal disc protrusion. The foregoing evidence preponderates against granting a rating in excess of 10 percent for lumbosacral degenerative joint and disc disease with IVDS at any time during the claim period prior to September 7, 2018. In this regard, there is no evidence from July 1, 2013 through September 6, 2018 indicating limitation of thoracolumbar flexion to 60 degrees or less, a combined range of motion of the thoracolumbar spine limited to 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, or incapacitating episodes of IVDS having a total duration of at least two weeks but less than four weeks during the past twelve months. On the contrary, the evidence regarding thoracolumbar range of motion pertinent to this period shows that forward flexion was, at its worst, limited to 70 degrees. Thus, forward flexion during this period was not greater than 30 degrees but less than 60 degrees. As for functional impairment, the Veteran experienced back pain and stiffness, pain was associated with ranges of spinal motion, and there was functional loss/functional impairment of the thoracolumbar spine in terms of not being able to sit for long, mow the lawn, or do yard work. Nevertheless, the ranges of spinal motion have remained the same following repetitive-use testing. The Veteran reported flare ups of back symptoms, caused by being active around the house and doing yard work, but the examiner who conducted the May 2018 examination specified that the ranges of spinal motion following repeated use over time and during flare ups would be flexion to 85 degrees and extension and left and right lateral flexion and rotation all to 30 degrees. The Veteran is competent to report the symptoms associated with his service-connected back disability and the extent of his impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion was documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's back symptoms most closely approximated the criteria for at most a 10 percent rating for limitation of spinal motion under the General Rating Formula during the claim period prior to September 7, 2018. Specifically, the above evidence reflects that the flare ups and other functional impairments were not so severe, frequent and/or prolonged to warrant the next higher percent rating at any time during this period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's back symptoms were not shown to have been so disabling to actually or effectively result in limitation of forward flexion of the thoracolumbar spine more nearly approximating 60 degrees or less, or limitation of the combined range of motion of the thoracolumbar spine to 120 degrees or less, which are the requirements for a 20 percent rating based on limitation of spinal motion. Moreover, the Veteran did not have muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. Also, there was no showing of any actual ankylosis at any time during the claim period prior to September 7, 2018, and the above evidence reflects that even considering pain, flare ups, and other functional factors, the Veteran's back symptoms were not shown to be so disabling to actually or effectively result in fixation of the entire thoracolumbar spine in flexion or extension with any of the additional symptoms or limitations listed in Note (5) of the General Rating Formula. Additionally, prior to September 7, 2018, the Veteran did not have IVDS. While the Veteran contended that he had incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, the Board notes that prior to September 7, 2018, the evidence of record shows that the Veteran did not have IVDS, much less any incapacitating episodes of IVDS as defined above. Accordingly, a higher rating cannot be awarded based on incapacitating episodes of IVDS. In this case, the Veteran's symptoms, including during flare-ups, do not reveal thoracolumbar flexion to 60 degrees or less, a combined range of motion of the thoracolumbar spine of 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, spinal ankylosis or the functional equivalent of ankylosis, or incapacitating episodes of IVDS having a duration of at least two weeks during the past twelve months prior to September 7, 2018. Based on the foregoing, the preponderance of the evidence is against finding that an initial rating in excess of 10 percent for lumbosacral degenerative joint and disc disease with intervertebral disc syndrome from July 1, 2013 through September 6, 2018 is warranted. 2. Entitlement to a rating in excess of 20 percent for a back disability from September 7, 2018 The evidence of record is supportive of a 20 percent rating, but no higher, for the Veteran's back disability from September 7, 2018. 38 C.F.R. § 4.7. In making this determination, the Board has considered the competent and credible medical and lay evidence of record. In a September 2018 back conditions DBQ, the Veteran reported constant pain in his back. Current symptoms included constant lower back pain, stiffness, decreased range of motion, numbness, and tingling in the right lower extremity. He used medication, a lidocaine patch, and heat for treatment. He reported flare-ups described as some days when I wake up in the morning my back is flared up with increased tightness and pain in my back. He reported functional loss or impairment described as I have difficulty with bending, standing, lifting, squatting, or doing physical activities with my sons. Forward flexion was 0 to 40 degrees. Extension was 0 to 5 degrees. Right and left lateral flexion and rotation were 0 to 15 degrees. Pain was noted on examination but did not result in or cause functional loss. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue which was a four out of 10 on the pain scale. There was no evidence of pain with weight bearing. He was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. Pain and fatigue significantly limited functional ability with repeated use over a period of time, described in terms of range of motion as forward flexion 0 to 40 degrees, extension 0 to 5 degrees, and right and left lateral flexion and rotation all 0 to 15 degrees. Pain, fatigue, weakness, and lack of endurance significantly limited functional ability with flare-ups, described in terms of range of motion as forward flexion 0 to 35 degrees, extension 0 to 0 degrees, and right and left lateral flexion and rotation all 0 to 10 degrees. He did not have muscle spasms. He had guarding not resulting in abnormal gait or spinal contour. He did not have muscle atrophy, ankylosis, or IVDS. In January 2019, the Veteran complained of low back pain. He stated the pain was worse with sitting and relieved with cold/hot pads. His pain was a five out of 10 and occurred daily. Lifting, reaching, and bending made it worse. In February 2019, the Veteran had full range of motion with lumbar flexion and extension. Pain was greater with flexion than extension. In an April 2019 back conditions DBQ, the Veteran reported pain in his lumbar spine some of the time. He could sit for an hour and walk for 15-20 minutes. He did not report flare-ups or functional loss or impairment. Forward flexion was 0 to 55 degrees. Extension, right and left lateral flexion and rotation were all 0 to 30 degrees. Pain was noted on examination but did not result in or cause functional loss. There was no evidence of pain with weight bearing or evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. He did not have guarding or muscle spasms. He did not have muscle atrophy, ankylosis, or IVDS. In a July 2019 medical treatment record, the Veteran complained of lower back pain. Pain was a three out of 10. The pain was worse in the morning, with stooping and bending. It was described as sharp, stiff, and achy, and occurred intermittently. In an August 2019 back conditions DBQ, the Veteran stated that his condition had gotten progressively worse. He took Mobic and used a lidocaine patch for the pain. His back pain radiated into his left leg. He did not report flare-ups. He reported functional loss or impairment described as not being able to stand or walk for a long time. Forward flexion was 0 to 60 degrees. Extension, right and left lateral flexion and rotation were all 0 to 25 degrees. Pain was noted on exam, but did not result in or cause functional loss. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue in the lower back described as a six out of 10 on the pain scale. There was evidence of pain with weight bearing. He was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. Pain and weakness significantly limited functional ability with repeated use over a period of time described in terms of range of motion as forward flexion 0 to 50 degrees and extension, and right and left lateral flexion and rotation all 0 to 20 degrees. He did not have guarding or muscle spasms. There were no additional contributing factors. There was no muscle atrophy, ankylosis, or IVDS. In a September 2020 back conditions DBQ, the Veteran complained of pain with range of motion, and an inability to lift, squat, bend, and stand for long hours. He also complained of numbness and tingling in the lower extremity. He stated the condition had progressively gotten worse. He could not do sit-ups and stairs made it worse. He complained of sharp back pain that radiated to the left leg, a tingling and numbness feeling in both legs, and stiffness. Treatment included physical therapy and exercises at home. He also took medication. He had flare-ups described as back spasms, numbness and tingling of the lower extremity, sitting for long hours, bending, and lifting heavy objects. Flare-ups occurred once a month. Pain was a seven to eight out of 10 for five to six hours. He reported functional loss or impairment described as unable to sit for long hours, bending, and lifting heavy objects. Forward flexion was 0 to 60 degrees. Extension and right and left lateral flexion, and rotation were all 0 to 20 degrees. Pain noted on examination caused functional loss. There was no evidence of pain with weight bearing or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He was unable to perform repetitive-use testing with at least three repetitions due to fear of pain. Pain, fatigue, weakness, lack of endurance, and incoordination significantly limited functional ability with repeated use over a period of time and with flare-ups. This was described in terms of range of motion as forward flexion 0 to 60 degrees and extension and right and left lateral flexion and rotation all 0 to 20 degrees. The Veteran had muscle spasms not resulting in abnormal gait or spinal contour. He had no guarding. He did not have muscle atrophy or ankylosis. He had IVDS, but it did not require bed rest prescribed by a physician and treatment by a physician in the past 12 months. In October 2020, the Veteran complained of lower back pain. He stated the pain was a four out of 10. He had throbbing, sharp, stiff pain in his lower back. In December 2020, the Veteran reported waking up from sleeping due to lower back pain. He reported an increase in lower back pain with sustained postures such as weed whacking and reported that there was an increased level of pain with increased activity. He reported that medication helped somewhat. He reported difficulty performing household chores and yardwork. He was unable to sit or stand for more than an hour. He noted decreased strength and endurance with dully and achy lower back pain. Spine disabilities may be rated either under DC 5242 or DC 5243, whichever method results in the higher evaluation. 38 C.F.R. § 4.71A, DC 5243. Addressing IVDS first, DC 5243 allows for the assignment of a disability evaluation based on the presences of symptoms of IVDS. While the Veteran has reported pain that radiates from his back into his lower extremities and has IVDS of the thoracolumbar spine, the record does not reflect that the Veteran has experienced any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. See September 2020 VA examination report. The Veteran has not actually asserted that he has incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months that would be required for a higher rating of 40 percent. Accordingly, a rating based on IVDS with incapacitating episodes is not warranted at any time since September 7, 2018. Turning to DC 5242, the evidence of record does not reveal any ankylosis of the spine. There is no diagnosis of ankylosis of the thoracolumbar spine in the evidence of record and range of motion findings, although limited at times, are not equivalent to favorable or unfavorable ankylosis. The September 2018, April 2019, August 2019, and September 2020 VA back examinations specifically noted that there was no thoracolumbar spine ankylosis. Also, the above evidence reflects that even considering pain, flare ups, and other functional factors, the Veteran's back symptoms have not been shown to be so disabling to actually or effectively result in fixation of the entire thoracolumbar spine in flexion or extension with any of the additional symptoms or limitations listed in Note (5) of the General Rating Formula at any time since September 7, 2018. Therefore, a rating higher than 20 percent is not warranted on the basis of ankylosis during this period. Moving on to the other avenue for a higher rating under DC 5242, the Veteran has not been shown to have forward flexion of the thoracolumbar spine limited to 30 degrees or less. 38 C.F.R. § 4.71a. That is, even with consideration of pain, functional loss, repetition times three, and flare-ups, limitation of forward flexion has exceeded 30 degrees. At worst, forward flexion was limited to 35 degrees. While the Board acknowledges that this is very limited range of motion, these range of motion findings are consistent with a 20 percent rating, and do not support a higher rating for the thoracolumbar spine. With regard to functional loss, as discussed above, the Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell. In light of the above evidence, repetitive motion and pain were considered, but the thoracolumbar spine was not additionally limited to the point of demonstrating ankylosis or flexion limited to 30 degrees or less. The Board has considered the Veteran's difficulty with bending, standing, lifting, squatting, or doing physical activities, inability to sit for long hours, and other functional impairments described above. The Veteran is competent to report the symptoms of pain and limited function that he experiences, and the Board finds no reason to doubt his credibility when considering functional loss. Nevertheless, the effects reported are contemplated in the 20 percent rating assigned. Indeed, as previously discussed, the evidence does not show that pain or other factors cause functional loss more closely approximating favorable ankylosis or limitation of motion to 30 degrees or less. Therefore, a rating in excess of 20 percent for the Veteran's back disability from September 7, 2018 is not warranted on the basis of functional loss due to pain or weakness or weakened movement or excess fatigability or incoordination in this case, as the Veteran's symptoms are consistent with the assigned 20 percent rating, but no higher from September 7, 2018. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 3. Additional Considerations The Board acknowledges that the Veteran has experienced lower extremity neurological impairment associated with his service-connected back disability during the claim period, and that he has already been awarded separate ratings for right and left lower extremity radiculopathy. The Veteran has not expressed disagreement with any aspect of the award of separate ratings for his left and right lower extremity neurological symptoms, and the propriety of these ratings will not be discussed by the Board. As a final point, the Board notes that in conjunction with the appeal for a higher initial rating for the service-connected back disability, the Veteran has not raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Brian J. Elwood Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Minock 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.