Citation Nr: 21007660 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 12-25 409 DATE: February 10, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome prior to February 22, 2019, is denied. Entitlement to a 20 percent rating, but no higher, from February 22, 2019, for left knee patellofemoral syndrome is granted. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral syndrome is denied. Resolving all reasonable doubt in the Veteran’s favor, separate 10 percent ratings for slight bilateral knee instability is granted. Entitlement to an initial rating in excess of 10 percent for service-connected cervical spine strain with degenerative disc disease and spinal stenosis prior to February 5, 2020, and in excess of 20 percent thereafter is denied. FINDINGS OF FACT 1. Prior to February 22, 2019, the Veteran’s left knee patellofemoral syndrome was manifested by painful, noncompensable limitation of flexion with slight knee instability. 2. From February 22, 2019, the Veteran’s left knee patellofemoral syndrome was manifested by slight knee instability and dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion. 3. The Veteran’s right knee patellofemoral syndrome was manifested by slight knee instability and painful, noncompensable limitation of flexion to, at worst, 90 degrees. 4. Prior to February 5, 2020, the Veteran’s cervical spine disability is manifest by forward flexion of the cervical spine greater than 30 degrees and/or a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; however, thereafter, his cervical spine disability is manifest by forward flexion of the cervical spine greater than 15 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome prior to February 22, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5024-5260. 2. The criteria for a 20 percent rating for left knee patellofemoral syndrome from February 22, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5024-5260. 3. The criteria for separate 10 percent ratings for bilateral slight knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.71a, DC 5257. 4. The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5024-5260. 5. The criteria for a rating in excess of 10 percent for cervical spine strain with degenerative disc disease and spinal stenosis prior to February 5, 2020, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1988 to December 2008. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2013, the Veteran testified before the undersigned Veterans Law Judge at a travel Board hearing. A transcript is of record. The Veteran explicitly waived his right to another hearing in October 2019 correspondence. The Board remanded the appeal in May 2015, November 2017, August 2018, and December 2019. In August 2018, the Board denied this matter, and the Veteran appealed the decision to the United States Court of Appeals for Veteran’s Claims (the Court). In an April 2019 Joint Motion for Remand (JMR), the Court vacated the August 2018 Board decision and remanded this matter for readjudication consistent with the JMR. In December 2019, the Board remanded this matter for further development. There has been substantial compliance with the Board’s prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination.] 1. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome prior to February 22, 2019, is denied. 2. Entitlement to a 20 percent rating, but no higher, for left knee patellofemoral syndrome from February 22, 2019, is granted. 3. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral syndrome is denied. 4. Resolving all reasonable doubt in the Veteran’s favor, separate 10 percent ratings for slight bilateral knee instability is granted. The Veteran seeks a rating in excess of 10 percent for his bilateral knee patellofemoral syndrome. Service connection for bilateral knee patellofemoral syndrome was granted in an August 2010 rating decision with a 10 percent rating effective January 1, 2009. The appeal stems from the August 2010 rating decision. The Veteran’s bilateral knee patellofemoral syndrome is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis of the evaluation assigned. Pursuant to the schedule of ratings for the musculoskeletal system, Diagnostic Code 5024 will be rated on limitation of motion of the affected parts, as degenerative arthritis. In this case, both knees are rated based on limitation of flexion of the leg under Diagnostic Code 5260. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A review of the evidentiary record reflects that the bilateral knee disability has been rated based on painful noncompensable limitation of motion and has not had compensable limitation of motion at any time during the rating period. A review of the evidence reflects that the knee disabilities were previously found to have manifested as osteoarthritis. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee patellofemoral syndrome at any time during the appeal period and for left knee patellofemoral syndrome prior to February 22, 2019. As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in June 2010, July 2015, and February 2018; these examinations were not fully compliant with the requirements set forth by Correia, 28 Vet. App. 158 and Sharp, 29 Vet. App. at 33. However, the reports do contain some relevant findings that are included herein. Additionally, the Board acknowledges that the Veteran contends his February 2018 VA examination is inadequate because the examiner did not use ‘any type of device to measure my range of motion.’ See April 2018 correspondence. To this point, the Board notes that it has considered the Veteran’s arguments, but finds however, that the VA examination in question is not inadequate because it does not specifically note the use of a goniometer. The Court has ruled that there is a “presumption of regularity” under which it is presumed that VA examiners and other government employees have properly discharged their official duties. Clear evidence to the contrary is required to rebut the presumption of regularity. Ashley v. Derwinski, 2 Vet. App. 307, 308 (1992) (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926)). The Board has reviewed the VA examination report and has found no clear evidence that the VA examiner did not conduct the examination in an appropriate manner. While the examiner did not indicate that a goniometer was used for the measurements, the examination report provided range of motion measurements in degrees, and there is no evidence showing that the recorded measurements are inaccurate. A May 2010 VA treatment record notes bilateral knee patella femoral syndrome and a normal study of the bilateral knees. An October 2010 VA treatment record notes chronic diffuse knee pain with crunching sensation in the knees. The June 2010 VA examination notes a diagnosis of patellofemoral syndrome and constant throbbing, achy pain that worsens when staying in one position too long. The Veteran reported associated weakness, stiffness, locking-up, and giving way. The examiner noted no effusion, no dislocation, signs of inflammation, significant tenderness or drainage. The examiner noted flare-ups of pain with increased activity but noted the Veteran can still function during those episodes. The Veteran reported use of an ace wrap to provide stability. Range of motion testing revealed full extension and 120 degrees of flexion with a generalized pressure and stiffness at 120 degrees bilaterally. There was no weakness, decreased endurance, or easy fatigability with repetitive range of motion. Repetition did not change degrees or increase pain. A June 2011 VA treatment record reflects treatment with bilateral hinged knee braces. June 2011 VA treatment records also reflect reports of bilateral knee pain primarily under the patella but also in the popliteal fossa area. The Veteran reported pain is exacerbated by going up and down stairs and being on his feet. During his April 2013 Board hearing, the Veteran reported use of knee braces for stability, difficulty going uphill, loss of balance, pain with sitting, popping, grinding, and swelling. See April 2013 Board hearing transcript at 4-16. A May 2013 correspondence from the Veteran’s private physician notes physical therapy for chronic bilateral knee pain. The physician noted bilateral knee range of motion within normal limits. Knee strength was noted as ‘4/5.’ A March 2013 VA treatment record notes worsened knee pain exacerbated by activities such as driving a relatively short distance and walking up stairs. The Veteran reported wearing bilateral knee braces. A September 2013 VA treatment record notes chronic knee pain. June 2014 VA treatment records note intermittent knee pain and stiffness exacerbated by exposure to cold water. An April 2015 VA treatment record notes internal derangement of the knee. A July 2015 VA examination reflects patellofemoral pain syndrome and degenerative arthritis. During the examination, the Veteran reported pain in the center of the patella, frequent popping and creaking, He indicated it is better for him to be in a standing position verses a sitting position due to knee pain. He reported intermittent flare-ups of pain with cutting his grass in a yard that is 200 yards, prolonged walking for one-hour, prolonged sitting after 20 minutes, and rainy or cold weather. The Veteran reported being unable to run, jump on a trampoline, and swimming. Range of motion testing revealed flexion to 110 degrees and extension to 0 degrees. The examiner indicated that range of motion does not contribute to functional loss. The examiner noted pain with weight bearing and localized tenderness at the center of the patella. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of range of motion. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time but noted pain limits functional ability during a flare-up such that flexion is limited to 100 degrees. Disturbance of locomotion and interference with sitting were noted as additional contributing factors of disability. The examiner found no history of recurrent subluxation, lateral instability, joint instability, or recurrent effusion. The examiner also noted no recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, and/or meniscal condition. The Veteran reported regular use of braces. A February 2017 VA treatment record notes knee pain with a normal examination and history of patellofemoral malalignment syndrome. The Veteran underwent a VA examination in February 2018. During the examination, the Veteran reported flare-ups of sharp, stabbing pain with activities like climbing stairs, squatting, and long drives. The Veteran did not report having any functional loss of impairment. Range of motion testing revealed normal flexion and extension. There was evidence of pain with weight bearing, crepitus, and localized tenderness. The Veteran was able to perform repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner was unable to say whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period time or during a flare-up without mere speculation. Antalgic gait was listed as an additional contributing factor of disability. No muscle atrophy, ankylosis, recurrent subluxation, lateral instability, recurrent effusion, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, or meniscal condition was found on examination. An October 2018 VA treatment record notes bilateral knee pain that is worse with walking and ascending and descending stairs. The Veteran denied any radicular pain but reported occasional locking. Right knee flexion was limited to 130 degrees while left knee active range of motion was limited to 100 degrees and 130 degrees passively. A January 2019 VA treatment record notes left knee pain following shoveling his driveway. Range of motion testing of the left knee revealed flexion limited to 100 degrees; whereas, right knee range of motion testing revealed flexion to 120 degrees. The January 2019 VA treatment record notes likely left knee medial meniscal tear. A January 2019 radiology report notes mild tibiofemoral joint arthritis of the left knee. A February 2019 radiology report notes horizontal oblique tear of the posterior horn of the medial meniscus, a small joint effusion, and some fluid in the proximal tibiofibular joint. In June 2019, the Veteran reported that he did not hurt his knee after shoveling snow. The Veteran also reported knee instability and a burning feeling in the center of both of his knees. In compliance with the Board’s remand directives, a VA examination was obtained in February 2020. The Veteran reported locking, clicking, swelling, sharp pain, and inability to move or change directions quickly. The Veteran reported flare-ups of the right knee five to seven times a month that are severe such that he is unable to walk steps, hills, and inclines and has weakness and severe pain. Right knee flare-ups are precipitated by kneeling too long, walking, and everyday chores. The Veteran reported left knee flare-ups fourteen to twenty times a month such that he is unable to walk without stretching after sitting for just ten minutes. Left knee flare-ups are precipitated by kneeling, bending, walking, and standing. The Veteran reported regular use of braces. Regarding functional impairment or loss, the Veteran reported pain, locking, instability, and buckling. Objectively, range of motion testing revealed right knee flexion to 140 degrees and left knee flexion to 120 degrees. The Veteran was able to perform repetitive use testing, which resulted in right knee flexion limited to 130 degrees and left knee flexion limited to 100 degrees. The examiner indicated pain significantly limits functional ability with repeated use over a period of time and during a flare-up. The examiner estimated the range of motion due to functional impairment was right knee flexion limited to 90 degrees and left knee flexion limited to 50 degrees. No ankylosis, recurrent subluxation, lateral instability, history of recurrent effusion, joint instability, recurrent patellar dislocation, stress fracture of the lower leg, chronic exertional compartment syndrome, acquired and/or traumatic genu recurvatum with objectively demonstrated weakness and insecurity in weight-bearing, and/or leg discrepancy was found on examination. The examiner noted bilateral shin splints that do not affect range of motion of the knee or ankle. A left knee meniscal tear with frequent episodes of joint locking, joint pain, and joint effusion was also noted. Subsequent treatment records reflect continued complaints and treatment for bilateral knee pain. See, e.g., May 2020 VA treatment record. Based on the foregoing, the Board finds no basis to award a higher rating for right knee patellofemoral syndrome. The currently assigned rating compensates the Veteran for painful, noncompensable limitation of motion. The limitation of motion demonstrated does not meet the criteria for the assignment of a higher rating. A 20 percent rating would require knee flexion limited to at least to 30 degrees or extension limited to at least 15 degrees. The objective and competent evidence in this case shows the Veteran’s right knee limitation of flexion has been, at most, limited to 90 degrees including when additional limitation of motion due to flares and repeated use over time is considered. No limitation of extension has been demonstrated. Therefore, the Board cannot assign a higher rating under Diagnostic Code 5260 or Diagnostic Code 5261. However, after considering the Veteran’s left knee symptomatology, including but not limited to his meniscal tear with frequent episodes of locking, pain, and effusion; the Board finds that a 20 percent rating, but not higher, from February 22, 2019, is warranted for the Veteran’s left knee disability pursuant to Diagnostic Code 5258. See February 2019 VA treatment record. From this date, the Board finds that it would benefit the Veteran to rate his left knee disability under Diagnostic Code 5258 rather than Diagnostic Code 5260. In this case, the Board finds separate ratings under both diagnostic codes would violate the rule against pyramiding. Diagnostic Code 5258 provides for a 20 percent rating for dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint. As the rating under Diagnostic Code 5258 compensates the Veteran for both ‘locking,’ a form of limitation of motion, and pain the Board finds separate ratings would be compensating on duplicative or overlapping symptomatology. Furthermore, the Board has found sufficient basis to award separate 10 percent ratings under Diagnostic Code 5257 for subjective complaints of instability. This rating is assigned due to the Veteran’s subjective reports of instability, buckling, and falling due to his knees. During his 2013 Board hearing, he testified that he falls due to his knees. His VA treatment records reflect ongoing reports of instability. Objectively, the Veteran was provided with knee braces to assist with stability. This evidence supports the assignment of a compensable rating for instability. See English v. Wilkie, 30 Vet. App. 347 (2018). An even higher rating under Diagnostic Code 5257 is not warranted because objective medical evidence, which is probative, fails to establish clinical findings of recurrent subluxation or lateral instability on examination. The VA examination reports of record show testing for lateral instability and recurrent subluxation were normal. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Diagnostic Code 5256 is not applicable because the evidence of record indicates the Veteran does not have ankylosis of the knees or symptoms more nearly approximating ankylosis. Regarding the right knee, Diagnostic Codes 5258 and 5259 are not applicable as the evidence does not reflect dislocated semilunar cartilage or symptomatic removal of the semilunar cartilage. Similarly, as the Veteran has a 20 percent rating under Diagnostic Code 5258 for his left knee semilunar cartilage condition, a separate rating under Diagnostic Code 5259 for consideration of the same symptoms is precluded. Higher and/or separate ratings under Diagnostic Codes 5262 and 5263 are not warranted as the evidence fails to demonstrate impairment of the tibia and fibula or genu recurvatum. Finally, a vague assertion of entitlement to extraschedular consideration is noted in an January 2019 Appellate Brief. To the extent the Veteran’s representative asserts such entitlement, consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the Veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. In regard to the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The Veteran’s bilateral knee disabilities are rated under Diagnostic Codes 5024-5260, 5257, and 5258. The record shows that he has complaints and findings of limitation of motion, pain, locking, and instability. The types of signs and symptoms contemplated by the schedular criteria for musculoskeletal disabilities include functional loss, which may be manifested by decreased or abnormal excursion, strength, speed, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 33-36 (2011). Pain and its effects are also considered as part of the schedular rating criteria. See DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59. Thus, here, the Veteran’s bilateral knee disability manifestations are reasonably contemplated by the assigned diagnostic codes. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent rating for his right knee patellofemoral syndrome. However, separate 10 percent ratings for slight bilateral knee instability are warranted. A rating in excess of 10 percent prior to February 22, 2019, for left knee patellofemoral syndrome is not warranted; however, a 20 percent rating, but no higher, is warranted thereafter. The Board has considered the benefit of the doubt doctrine in this case. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an initial rating in excess of 10 percent for cervical spine strain with degenerative disc disease and spinal stenosis prior to February 5, 2020, and in excess of 20 percent thereafter, is denied. Service connection for the Veteran’s cervical spine disability was granted in an August 2010 rating decision with a noncompensable rating effective January 1, 2009. The current appeal stems from this grant of service connection. A July 2015 rating decision granted a 10 percent rating from January 1, 2009; and a September 2020 rating decision granted a 20 percent rating from February 5, 2020. The Veteran seeks entitlement to a higher initial rating. For the reasons below, the Board finds entitlement to a higher initial rating is not warranted. The Veteran’s cervical spine strain with degenerative disc disease and spinal stenosis is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. It was previously rated under Diagnostic Code 5237. Both diagnostic codes are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted 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. A 20 percent rating is warranted 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. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. 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. Id. at Note 2. The normal combined range of motion of the cervical spine is 340 degrees. Id. The preponderance of the evidence is against a rating in excess of 10 percent for cervical spine strain with degenerative disc disease and spinal stenosis prior to February 5, 2020, and in excess of 20 percent thereafter. As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in June 2010, July 2015, and February 2018; these examinations were not fully compliant with the requirements set forth by Correia, 28 Vet. App. 158 and Sharp, 29 Vet. App. at 33. However, the reports do contain some relevant findings that are included herein. Additionally, as previously discussed in this decision, the Board reiterates its finding that the February 2018 VA examination is not inadequate as it relates to the use of a goniometer. Generally, 2010 VA treatment records note chronic neck pain. See, e.g., December 2010 VA treatment record. A May 2010 VA radiology report notes mild C6 through C7 degenerative changes and a 2.5 centimeter stippled calcification overlying the right anterior lower neck. A November 2010 VA treatment record notes chronic neck pain with complaints of hand numbness. The June 2010 VA examination reflects complaints of pain and stiffness with flare-ups twice a month. No radiculopathy and/or bowel or bladder incontinence were reported. No physician-ordered bed rest or incapacitating episodes were reported. He indicated yard work and heavy lifting will cause increased pain to the cervical spine. Range of motion testing revealed forward flexion to 45 degrees with stiffness and pulling at 45 degrees, backward extension to 45 degrees, lateral flexion to 45 degrees, and rotation to 80 degrees with pulling and stiffness at 80 degrees. The examiner noted no weakness, decreased endurance, pain, or easy fatigability with repetitive range of motion of the cervical spine. Finally, the examiner indicated repetition did not change degrees or increase pain. Generally, 2011 VA treatment records reflect chronic neck pain that is worse on days when he is more active. See, e.g., March 2011 VA treatment record. During his April 2013 Board hearing, the Veteran reported decreased range of motion, headaches, grinding, and muscle spasms. He also reported that it feels like he has rocks in his neck. See April 2013 Board hearing transcript at 17-18. A May 2013 correspondence from the Veteran’s private physician notes physical therapy for chronic cervical pain. The physician noted his posture is mildly kyphotic with a forward head and slightly rounded shoulders. The physician noted that the Veteran reported numbness, tingling, and weakness in the hands, but movement of the neck does not recreate these symptoms. Generally, 2013, 2014, and 2015 VA treatment records note chronic neck pain since about 2005. A March 2013 VA treatment record notes worsened neck pain exacerbated by movement, especially by lateral movement. A June 2014 VA treatment record notes pain associated with reduced range of motion when looking to the right. During the July 2015 VA examination, range of motion testing revealed forward flexion, extension, and bilateral lateral flexion from 0 to 45 degrees; right lateral rotation from 0 to 70 degrees; and left lateral rotation from 0 to 60 degrees. The Veteran reported cervical spine flare-ups that he described as intermittent neck pain with physical labor once a week. He reported no longer being able to ride fast, rough rides in amusement parks, jump on a trampoline, or make quick/sharp turns of the neck. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. The examiner was unable to say whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time. However, the examiner noted pain significantly limits functional ability during a flare up consistent with forward flexion and extension from 0 to 45 degrees; bilateral lateral flexion from 0 to 40 degrees; right lateral rotation from 0 to 75 degrees; and left lateral rotation from 0 to 55 degrees. The examiner noted a normal sensory examination, no ankylosis, no radiculopathy, and no other neurologic abnormalities. Finally, the examiner noted that decreased monofilament findings are consistent with his history of unrelated bilateral carpal tunnel and there is no evidence of cervical radiculopathy. Generally, 2017 VA treatment records reflect chronic neck pain. See, e.g., July 2017 VA treatment record. A February 2017 VA treatment record notes neck with good range of motion. A June 2017 VA treatment record notes associated symptoms are most pronounced whenever he lifts any objects over his head. A July 2017 VA treatment record notes complaints of bilateral hand numbness and tingling with a history of cervical spine stenosis assessed as bilateral carpal tunnel syndrome and suspected bilateral cubital tunnel syndrome. During his February 2018 VA examination, the Veteran reported loss of range of motion, particularly with looking down and looking side to side. He reported flare-ups without functional loss or impairment. Range of motion testing revealed forward flexion to 40 degrees, extension to 15 degrees, right lateral flexion to 30 degrees, left lateral flexion to 40 degrees, right lateral rotation to 50 degrees, and left lateral rotation to 40 degrees. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of range of motion. The examiner was unable to say whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time or during a flare-up without mere speculation. The examiner noted a normal sensory examination and found no radiculopathy, ankylosis, or other neurologic abnormalities. A September 2018 VA treatment record notes full range of motion at neck and ‘5/5’ muscle strength. A September 2019 VA treatment record notes neck pain that is worse with flexion but stable overall. A March 2020 VA treatment records reflect complaints of neck pain. During his February 2020 VA examination, the examiner noted diagnoses of cervical spine strain with degenerative disc disease and spinal stenosis and bilateral upper extremity radiculopathy. The Veteran reported having no range of motion, inability for any type of physical exertion, shooting pain ‘like a lightning bolt’ if he lifts his arms over head, and chronic daily neck pain. He reported flare-ups ten to fifteen times a month where he is unable to lift his head, or he gets headaches. He also reported pain, numbness, and tingling. He indicated functional loss or impairment such that he is unable to stick items on upper shelves and sometimes drops things due to lightning like pain. Range of motion testing revealed forward flexion to 40 degrees, extension to 35 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 60 degrees, and left lateral rotation to 30 degrees. The Veteran was able to perform repetitive use testing without additional loss of range of motion or loss of function. The examiner indicated pain significantly limits functional ability with repeated use over a period of time and during a flare-up. The examiner describes such limitation with repeated use over a period of time as forward flexion to 30 degrees, extension to 30 degrees, bilateral lateral flexion to 25 degrees, right lateral rotation to 50 degrees, and left lateral rotation to 25 degrees. The examiner described such limitation during a flare up as forward flexion to 20 degrees; extension, bilateral lateral flexion, and left lateral rotation to 15 degrees; and right lateral rotation to 30 degrees. The examiner noted decreased sensation to light touch of the bilateral shoulder area and the left inner/outer forearm. Moderate bilateral upper extremity paresthesias and/or dysesthesias and numbness were also found on examination. The examiner indicated involvement of the C5/C6 nerve roots and mild radiculopathy. No ankylosis or other neurologic abnormalities were found. Based on the foregoing, the Board finds no basis to award a higher rating for cervical spine strain with degenerative disc disease and spinal stenosis. The Board acknowledges the Veteran’s lay reports of symptoms that that there was functional loss due to pain, repetitive use over time, and during flare-ups. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the Veteran experiences flare-ups up to 15 times a month and cannot lift his arms without symptoms would not result in limitation of motion more nearly approximating forward flexion to 15 degrees but not greater than 30 degrees or a combined range of motion of the cervical spine not greater than 170 degrees prior to February 5, 2020, or forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine thereafter. Additionally, prior to February 5, 2020, the Veteran did not have muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contours such as scoliosis, reversed lordosis, or abnormal kyphosis. See, e.g., February 2018 VA examination report. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and/or the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating at any time during the appeal period. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See, e.g., July 2015 VA examination. Regarding neurological impairment, the Veteran has already been granted service connection for bilateral upper extremity radiculopathy associated with cervical spine strain with degenerative disc disease and spinal stenosis and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. See, e.g., February 2020 VA examination. Finally, as noted, a vague assertion regarding entitlement to extraschedular consideration was raised in the Appellate Brief. To the extent such consideration is raised, the Board reiterates that consideration of an extraschedular rating requires a three-step inquiry. In regard to the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The cervical spine disability is rated under Diagnostic Code 5242. Although the Veteran has not specified what particular extraschedular symptoms may be present, the record shows that he has complaints and findings of limitation of motion, pain, bilateral arm numbness, and headaches. Diagnostic Code 5242 does not specifically contemplated headache, pain, and bilateral arm numbness, but limitation of motion is specifically contemplated by this Code. The types of signs and symptoms contemplated by the schedular criteria for musculoskeletal disabilities include functional loss, which may be manifested by decreased or abnormal excursion, strength, speed, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 33-36 (2011). Pain and its effects are considered as part of the schedular rating criteria. See DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59 factors, which are incorporated into the schedular rating criteria as applied to the particular diagnostic code in question. Note 1, 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine specifically contemplates associated neurological abnormalities, including radiculopathy. In this case, the Veteran’s symptoms of bilateral arm numbness are already considered in the separate ratings assigned for his service-connected bilateral upper extremity radiculopathy associated with the cervical spine strain with degenerative disc disease and spinal stenosis under Diagnostic Code 8510. Although headaches are not specifically contemplated by DC 5237, Note 1 contemplates associated neurological abnormalities, which reasonably encompasses the Veteran’s headaches. Moreover, he is already service-connected, and receiving compensable rating for, migraine headaches under Diagnostic Code 8100. Thus, here, the Veteran’s cervical spine disability manifestations are reasonably contemplated by the assigned diagnostic codes. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. For the foregoing reasons, the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for cervical spine strain with degenerative disc disease and spinal stenosis prior to February 5, 2020, or in excess of 20 percent thereafter. The benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, 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.