Citation Nr: 21006758 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 12-32 821 DATE: February 5, 2021 ORDER A rating in excess of 20 percent prior to September 28, 2020, and in excess of 40 percent thereafter for degenerative arthritis of the spine with intervertebral disc syndrome (IVDS) is denied. The assignment of a separate rating for radiculopathy of the left lower extremity (LLE), evaluated as 10 percent disabling as of February 27, 2015, and 20 percent disabling as of September 28, 2020 is proper; the appeal is denied. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. FINDINGS OF FACT 1. Prior to September 28, 2020, the Veteran’s degenerative arthritis of the spine with IVDS was manifested by forward flexion greater than 30 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, incapacitating episodes of IVDS, or associated objective neurological abnormalities other than radiculopathy of the LLE. 2. As of September 28, 2020, the Veteran’s degenerative arthritis of the spine with IVDS did not result in ankylosis, incapacitating episodes due to IVDS, or associated objective neurological abnormalities other than radiculopathy of the LLE. 3. Prior to September 28, 2020, the Veteran’s radiculopathy of the LLE resulted in, at most, mild incomplete paralysis of the sciatic nerve. 4. As of September 28, 2020, the Veteran’s radiculopathy of the LLE resulted in, at most, moderate incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent prior to September 28, 2020, and in excess of 40 percent thereafter for degenerative arthritis of the spine with IVDS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5243-5242. 2. The assignment of a separate rating for radiculopathy of the LLE, evaluated as 10 percent disabling as of February 27, 2015, and 20 percent disabling as of September 28, 2020, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.120, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training (ACDUTRA) from July 2000 to February 2001. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in May 2009 and November 2015 by a Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2018, the Veteran testified at a Board hearing conducted before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In April 2018, the Board reopened the Veteran’s claims for service connection for bilateral knee disorders and remanded the reopened claims, as well as his claim for an increased rating for his service-connected back disability, for additional development. While on remand, in an April 2020 rating decision, the Agency of Original Jurisdiction (AOJ) awarded a separate rating for radiculopathy of the left lower extremity, evaluated as 10 percent disabling as of February 27, 2015. While the Veteran did not enter a notice of disagreement with regard to the propriety of the assigned effective date or rating for such award, the Board notes that such issues are part and parcel of his claim for entitlement to an increased rating for his lumbar spine disability. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Thus, the Board has assumed jurisdiction over such matters. In September 2020, the Board again remanded the case for additional development. While on remand, in an October 2020 rating decision, the AOJ awarded an increased ratings of 40 percent for the Veteran’s back disability and 20 percent for his radiculopathy of the LLE, effective September 28, 2020. However, as he is presumed to be seeking the maximum available benefit for a disability, the claims for higher ratings remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues have been recharacterized to reflect that staged ratings are in effect. Hart v. Mansfield, 21 Vet. App. 505 (2007). The case now returns for further appellate review. Increased Rating Claims The Veteran contends his back disability and radiculopathy of the LLE are more severe than as reflected by the currently assigned ratings. In this regard, he claims that his back disability results in pain, muscle spasms, cramps, and difficulty in walking and sitting, while his radiculopathy results in numbness, tingling, and pain in the LLE. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The appeal period before the Board begins on April 8, 2015, the date VA received the Veteran’s claim for an increased rating for his back disability, plus the one-year look-back period. See Gaston v. Shinseki, 605 F.3d. 979, 982 (Fed. Cir. 2010). 1. Entitlement to a rating in excess of 20 percent prior to September 28, 2020, and in excess of 40 percent thereafter for degenerative arthritis of the spine with IVDS. The basis of disability evaluation 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. 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. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). As referenced above, the Veteran’s back disability is rated under DC 5243-5242, which provides that such is evaluated under either the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula) or the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating where there is 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 is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): 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): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and 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): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. As noted above, IVDS may be evaluated under either the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.25 (combined ratings table). The IVDS Rating Formula provides that a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is 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. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he ever had an incapacitating episode of IVDS as defined by VA regulations, i.e., required physician prescribed bed rest. In this regard, a September 2015 VA examination found that the Veteran did not have IVDS. Furthermore, VA examinations conducted in July 2015 and September 2020 revealed that, while the Veteran had IVDS, such did not result in any incapacitating episodes. Therefore, higher ratings under the IVDS Formula are not warranted at any point pertinent to the appeal. Further, the Board finds that a rating in excess of in excess of 20 percent prior to September 28, 2020, or in excess of 40 percent thereafter is not warranted under the General Rating Formula. In this regard, the record does not reflect that his range of motion was limited to the extent necessary to warrant higher ratings at any point during the periods on appeal. With regard to the appeal period prior to September 28, 2020, during which the Veteran is in receipt of a 20 percent rating, the next higher rating of 40 percent requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. In this regard, the Veteran underwent a VA examination of his spine in July 2015; however, at such time, he was recovering from March 2015 lumbar spine surgery, specifically a L 4-5 microdiskectomy, and was unable to complete range of motion (ROM) testing. In this regard, the examiner indicated that the Veteran may take up to a year to fully recover from surgery and actual ROM is not really representative of his permanent function. Thus, he recommended that the Veteran be reevaluated for ROM and residuals one year from March 2015. Nonetheless, ankylosis was not present. It was also noted that the Veteran denied flare-ups, but had pain on weight-bearing. The Veteran had normal muscle strength and reflexes and, other than his left lower leg/ankle and foot and toes, sensation was normal throughout the extremities. There was no evidence of radiculopathy of the right lower extremity (RLE), or other neurologic abnormalities or findings related to the Veteran’s back disability, to include bowel or bladder problems. The Veteran underwent another VA examination September 2015, at which time he reported flare-ups, which he described as occurring out of nowhere and being manifested by pain and muscle spasms. ROM testing revealed forward flexion to 60 degrees with pain that caused functional loss; however, there was no pain on weight-bearing. Following repetitive use testing, the Veteran’s flexion was further limited to 40 degrees due to pain, fatigue, and lack of endurance. The examiner also estimated that the Veteran had flexion limited to 40 degrees following repeated use over time and during flare-ups. Ankylosis was not present. Muscle strength, reflexes, and sensation was normal in the bilateral lower extremities. There was no evidence of radiculopathy of the bilateral lower extremities, or other neurologic abnormalities or findings related to the Veteran’s back disability, to include bowel or bladder problems. The Veteran’s VA treatment records from this time period document his reports of back pain, but do not include the specific ranges of motion applicable to the rating criteria. See June 2016, April 2018, May 2018 treatment records. Pursuant to the April 2018 remand, the Veteran was afforded another VA examination in October 2019. At such time, he reported that he was only able to walk a limited distance, but denied flare-ups. ROM testing revealed forward flexion to 65 degrees with pain that did not result in/cause functional loss and there was no pain on weight-bearing. Following repetitive use testing, there was no additional loss of ROM. The examiner further indicated that he could not estimate the additional loss of ROM following repeated use over time without resorting to speculation, and fully explained why he was unable to do so. Jones v. Shinseki, 23 Vet. App. 382 (2010). The Veteran had normal muscle strength and reflexes and, other than his left foot and toes, sensation was normal throughout the extremities. There was no evidence of radiculopathy of the RLE, to include as found on a May 2019 EMG, or other neurologic abnormalities or findings related to the Veteran’s back disability, to include bowel or bladder problems. The Veteran was afforded another VA examination for his back disability on September 28, 2020, which was the basis for the assignment of his increased rating of 40 percent as of such date. In this regard, in order to warrant a rating in excess of 40 percent, the evidence must show unfavorable ankylosis of the entire thoracolumbar spine. However, while such VA examination revealed severely limited ROM of the back, there was no evidence of ankylosis. The Veteran had normal muscle strength and reflexes of the RLE and, while such was noted to have decreased sensation upon sensory testing, it appears that the examiner inverted the responses for the LLE as such was marked as normal. Nonetheless, the examiner found that there was no evidence of radiculopathy of the RLE, or other neurologic abnormalities or findings related to the Veteran’s back disability, to include bowel or bladder problems Based on the foregoing, for the period prior to September 28, 2020, the Board finds that, as the Veteran’s back disability was manifested by forward flexion greater than 30 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, a rating in excess of 20 percent is not warranted under the General Rating Formula. Specifically, his flexion was noted to be limited to, at most, 40 degrees following repeated use over time and during flare-ups at the September 2015 VA examination. There are no ROM findings during such period that reflect that the Veteran’s back disability was manifested by a greater limitation of flexion. Thus, a higher rating under the General Rating Formula for such period is not warranted. Furthermore, as of September 28, 2020, as the Veteran’s back disability is not shown to result in ankylosis, a rating in excess of 20 percent is not warranted under the General Rating Formula. Specifically, while he had severely limited motion of his back at the September 2020 VA examination, to include following repeated use over time and during flare-ups, he was still capable of ROM and no ankylosis was found to be present. Thus, a higher rating under the General Rating Formula for such period is not warranted With regard to Note (1) of the General Rating Formula, the Board observes that the Veteran has been awarded separate rating for LLE radiculopathy as associated with his back disability, the propriety of which will be discussed further herein. However, the evidence fails to show that such disability is manifested by any other associated objective neurologic abnormalities, including, but not limited to, radiculopathy of the RLE, or bowel or bladder impairment. In this regard, the VA examinations conducted during the appeal period, as well as treatment records, fail to show the presence of any such associated objective neurologic abnormalities. Consequently, separate ratings for associated objective neurologic abnormalities other than radiculopathy of the LLE are not warranted. 2. Propriety of the assignment of a separate rating for radiculopathy of the LLE, evaluated as 10 percent disabling as of February 27, 2015, and 20 percent disabling as of September 28, 2020. As noted previously, the Veteran has been assigned a separate rating for radiculopathy of the LLE associated with his back disability. Specifically, he is in receipt of 10 percent rating percent rating for his radiculopathy of the LLE as of February 27, 2015, the date such disability was factually ascertainable within the year prior to the receipt of the Veteran’s April 8, 2015, increased rating claim, and 20 percent disabling as of September 28, 2020, pursuant to DC 8520. Such provides for a 10 percent rating for mild incomplete paralysis of the sciatic nerve; a 20 percent rating for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating for moderately severe incomplete paralysis of the sciatic nerve; and a 60 percent rating for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. A maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Descriptive words such as “slight,” “moderate” and “severe” as used in the various diagnostic codes are not defined in VA’s 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. As noted previously, the Veteran underwent lumbar spine surgery in March 2015, at which time, it was noted that he had a pattern suggestive of lumbar radiculopathy of the LLE that had its onset one month previously. At a May 2015 surgical follow-up appointment, the Veteran reported his left leg pain was gone. At the Veteran’s July 2015 VA examination, he had full muscle strength with no atrophy of the LLE, and normal left knee and ankle reflexes. Upon sensory testing, he had decreased sensation to the left lower leg/ankle and foot/toes, but such was normal in the left upper anterior thigh and thigh/knee. The Veteran reported mild numbness, but denied constant pain, intermittent pain, and paresthesias and/or dysesthesias. Based on the foregoing, the examiner determined that the Veteran had radiculopathy of the LLE resulting in no more than mild impairment of the sciatic nerve. However, upon VA examination in September 2015, muscle strength, reflexes, and sensory testing were normal, and the examiner found that the Veteran did not have radiculopathy of the LLE. VA treatment records dated January 2016 reflect the Veteran reported intermittent leg cramps but did not have leg pain, weakness, numbness, or difficulty walking. However, at his February 2018 hearing, he reported feeling worsening symptoms since his back surgery. At an October 2019 VA examination, the examiner observed that a May 2019 EMG revealed subacute/early chronic left L4-L5 radiculopathy of mild severity. Physical examination revealed the Veteran had normal muscle strength without muscle atrophy and reflexes. Sensory examination was normal with the exception of decreased sensation to light touch in his left foot/toes. The Veteran reported mild paresthesias and/or dysesthesias, but denied constant pain, intermittent pain, and numbness. Based on the foregoing, the examiner determined that the Veteran had radiculopathy of the LLE resulting in no more than mild impairment of the sciatic nerve. VA treatment records dated in February 2020 reflect the Veteran’s report of decreased strength in the left peroneal due to pain. He had no left patellar reflexes, decreased vibration on LLE, and tingling in his left toes, but no weakness. In June 2020 he reported worsening radiculopathy symptoms over the past five years. At the Veteran’s September 28, 2020, VA examinations, he had 4/5 muscle strength of his left hip flexion, knee flexion and extension, ankle plantar flexion, and great toe extension, with 5/5 strength of ankle dorsiflexion. His left knee reflexes were normal, and his left ankle was hyperactive without clonus. As noted previously, while sensory examination was noted to be normal for the LLE, it appears that such findings were inverted with those for the RLE, which reflected decreased sensation in the upper anterior thigh, knee/thigh, lower leg/ankle, and foot/toes. The Veteran reported moderate constant pain, paresthesias and/or dysesthesias, and numbness, but denied intermittent pain. Based on the foregoing, the examiner determined that the Veteran had radiculopathy of the LLE resulting in no more than moderate impairment of the sciatic nerve. Based on the foregoing, the Board finds that, prior to September 28, 2020, the Veteran’s radiculopathy of the LLE resulted in no more than mild incomplete paralysis of the sciatic nerve. Specifically, the evidence demonstrates that such disability was manifested primarily by subjective reports of mild paresthesias and/or dysesthesias, numbness, and tingling with full muscle strength, normal reflexes, and intact sensation with the exception of the left lower leg/ankle and foot/toes. Additionally, upon consideration of the Veteran’s subjective reports and objective examination findings, the July 2015 and October 2019 VA examiners found that his radiculopathy of the LLE resulted in no more than mild impairment of the sciatic nerve, and the September 2015 VA examiner found no evidence of radiculopathy. Furthermore, such determination is consistent with the May 2019 EMG that revealed subacute/early chronic left L4-L5 radiculopathy of mild severity. In this regard, the Board notes that, in February 2020, the Veteran reported increased symptomatology of decreased strength and sensation, and a lack of patellar reflexes; however, subsequent examination in September 2020 was negative for absent reflexes and, as will be discussed below, it was not until such date that a factually ascertainable increase in the Veteran’s radiculopathy of the LLE occurred. Consequently, the Board finds that, for the period prior to September 28, 2020, the assignment of a 10 percent rating for such disability is proper. As of September 28, 2020, the Board the Veteran’s radiculopathy of the LLE resulted in no more than moderate incomplete paralysis of the sciatic nerve. Specifically, the evidence demonstrates that such disability was manifested primarily by subjective reports of moderate constant pain, paresthesias and/or dysesthesias, and numbness with slightly reduced muscle strength, a single hypoactive reflex, and decreased, but not absent, sensation. Additionally, upon consideration of the Veteran’s subjective reports and objective examination findings, the September 2020 VA examiner found that his radiculopathy of the LLE resulted in no more than moderate impairment of the sciatic nerve. Consequently, the Board finds that, as of September 28, 2020, the assignment of a 20 percent rating for such disability is proper. Other Considerations In reaching the foregoing determinations, the Board recognizes the Veteran’s sincerely held belief that his back disability with associated radiculopathy of the LLE are more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds the medical evidence in which professionals with medical expertise examined the Veteran in regard to his psychiatric and lumbar spine disabilities, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such disabilities. The Board considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected back disability with associated radiculopathy of the LLE; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in connection with the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Therefore, the Board finds that an increased rating for the Veteran’s back disability is not warranted, and the separate rating assigned for his associated radiculopathy of the LLE are proper. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 3. Entitlement to service connection for a left knee disorder. 4. Entitlement to service connection for a right knee disorder. With respect to the Veteran’s claims for service connection for bilateral knee disorders, he underwent a VA examination in October 2012. Although the examiner determined the Veteran’s bilateral knee symptomatology impacted his ability to work, he provided a negative nexus opinion based, at least in part, on the lack of a current diagnosis of a bilateral knee disorder. In April 2018, the Board remanded the case and directed the examiner to assume the Veteran has a bilateral knee disability and offer an opinion as to whether such is related to any instance of his ACDUTRA, to include his reported complaints in August 2000 and November 2000 and/or an injury when he hyperextended his knee when stepping into a divot. The Veteran was provided a VA examination in October 2019. At such time, the examiner found that the Veteran did not have a current diagnosis of a bilateral knee disorder, and thus, opined that such claimed disorder was less likely than not a result of his service. As rationale, he stated that service treatment records document one time complaints referable to the left and right knees. Specifically, in August 2000, left knee pain was documented and, in November 2000, right knee pain diagnosed as a right knee strain due to overuse was documented. The examiner found that both complaints resolved without sequelae or residuals, and thus, there is no current diagnosis of a chronic left/right knee disorder. Further, he stated the diagnoses were carried forward as historical diagnoses and no chronicity was established. In September 2020, the Veteran was afforded another VA examination for his claimed bilateral knee disorder, at which time, his historical diagnoses of knee strains were noted, but no disorder was diagnosed on examination and no etiological opinion was offered. However, as noted previously, the Board had found in the April 2018 remand that the Veteran had a current bilateral knee disability as evidenced by the October 2012 VA’s examiner determination that his bilateral knee symptomatology impacted his ability to work. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Thus, as the October 2019 VA examiner offered an unfavorable opinion based primarily on a lack of current bilateral knee disorder, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing the etiology of such disorder. The matters are REMANDED for the following action: Return the record, to include a copy of this remand, to the VA examiner who conducted the September 2020 knee examination in order to obtain an addendum opinion addressing the etiology of the Veteran’s bilateral knee disorder. If he is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. In offering the below opinion, the examiner is directed to assume that the Veteran has a current disability of the left and right knees as demonstrated by the fact that his symptomatology impacted his ability to work as determined by the October 2012 VA examiner. Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s left and/or right knee disability, is related to his period of ACDUTRA, to include his treatment for left knee pain after running in August 2000, his treatment for a sprain or over use injury of the right knee in November 2000, and/or his reported injury when he hyperextended his knee when stepping into a divot. The examiner is advised that an unfavorable opinion may not be based solely on the fact that the Veteran does not have a current diagnosis of a left and/or right knee disorder. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.