Citation Nr: 21013317 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 06-29 643 DATE: March 9, 2021 ORDER 1. The claim of entitlement to a disability rating greater than 40 percent for service-connected lumbar spine disability, to include on an extra-schedular basis, pursuant to 38 C.F.R. § 3.321, is denied. 2. The claim of entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) prior to August 29, 2006, is denied. FINDINGS OF FACT 1. For the period prior to September 26, 2003, the Veteran’s lumbar spine disability was manifested by subjective complaints of pain and stiffness and flare-ups, objective findings of forward flexion to 40 degrees; however, the preponderance of the evidence is against severe lumbosacral strain with listing of whole spine to opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space or some of the above with abnormal mobility on force motion, unfavorable ankylosis of the entire thoracolumbar spine or intervertebral disc syndrome (IVDS). The Veteran’s symptoms are contemplated by the rating criteria. 2. Since September 26, 2003, the Veteran’s lumbar spine disability has been manifested by subjective complaints of pain and stiffness, flare-ups, objective findings of forward flexion to 30 degrees or less; however, the preponderance of the evidence is against unfavorable ankylosis of the entire lumbar spine or incapacitating episodes of IVDS during any 12-month period; and there is no evidence of a separate neurological manifestation of lumbar spine disability other than the already service-connected radiculopathy of the lower extremities and the assigned effective dates or ratings for those disabilities are not on appeal. The Veteran’s symptoms are contemplated by the rating criteria. 3. For the period prior to August 29, 2006, the Veteran has not been precluded from securing or following a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 40 percent for lumbar spine disability, to include on an extra-schedular basis, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes (DC) 5292, 5293, 5295 (as in effect prior to September 26, 2003); and General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235-5243), and Formula for Rating IVDS Based on Incapacitating Episodes (for DC 5243) (as in effect from September 26, 2003). 2. The criteria for entitlement to a TDIU rating have not been met for the period prior to August 29, 2006. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from October 1984 to July 1985. This appeal to the Board of Veterans’ Appeals (Board) initially arose from a February 2005 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO), inter alia, denied the Veteran’s claim for a rating greater than 20 percent for his service-connected lumbar spine disability. The Veteran timely disagreed with, and perfected an appeal as to, that determination. In January 2009, the Veteran testified during a Board hearing before a Veterans Law Judge at the RO; a transcript of that hearing is of record. On January 6, 2021, the Veteran was informed that the Veterans Law Judge who had conducted his January 2009 Board hearing was no longer employed at the Board. The Veteran was informed that he had a right to an additional hearing before a different Veterans Law Judge and that if he did not respond within 30 days, the Board would assume that he did not want another hearing. As the 30 days to respond has expired and the Veteran has not responded to date, the Board assumes he does not want another hearing and will proceed with the appeal. In March 2009 and March 2011, the Board remanded the claim for a rating greater than 20 percent prior to November 3, 2004, and a rating greater than 30 percent from November 3, 2004, for the lumbar spine disability. In a June 2012 decision, the Board expanded the appeal to include the matter of entitlement to a TDIU rating due to the lumbar spine disability pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009)); denied a disability rating greater than 30 percent for the low lumbar spine disability from the August 25, 2003, the date of receipt of the increased rating claim, to November 9, 2003; but granted a 40 percent rating for the disability, effective November 10, 2003. At that time, the Board also remanded the TDIU claim for additional development. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In March 2013, the Court granted a Joint Motion filed by representatives for both parties, vacating that portion of the March 2013 decision in which the Board denied higher ratings for lumbar spine disability, and remanding the higher rating matters to the Board for further proceedings consistent with the Joint Motion. In in January 2014, the Board remanded the matters of increased ratings for the lumbar spine disability for additional evidentiary development. Subsequently, the RO awarded a TDIU rating, effective August 29, 2006. The Veteran filed an NOD later that month and an SOC was issued in July 2016. In August 2016, the Veteran filed a substantive appeal as to the issue of the effective date for the TDIU award. As to the claim for a TDIU rating, given that 38 C.F.R. § 4.16, requires consideration of all service-connected disabilities, the Board has recharacterized the TDIU claim to include all service-connected disabilities, as claimed by the Veteran and explained in the analysis below. See 38 C.F.R. § 4.16 (requiring consideration of whether the veteran is “unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities.”) (emphasis added). See also Harper v. Wilkie, 30 Vet. App. 356, 359 (2018) (holding that the grant of a TDIU for a portion of the period does not bifurcate the appeal from the underlying disability appeal because it only serves as a partial grant). In a December 2016 rating decision, the RO awarded a 40 percent rating for the lumbar spine disability from August 25, 2003. In September 2017, November 2018, and February 2020, the Board remanded the claims on appeal for further development and the appeal is now returned to the Board for further appellate review. The Board notes that in September 2020, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), under the Appeals Modernization Act (AMA) in response to the June 2020 Supplemental (SOC) regarding the matters on appeal. In November 2020, the Board informed the Veteran that his appeal request could not be processed because the Veteran did not select a Board appeal option, i.e., Direct Review, Evidence Submission, or Hearing request and that a new form must be submitted within sixty days. Here, the September 2020 VA Form 10182 is invalid because he did not choose a Board appeal option and to date, an additional valid appeal under the AMA has not been received. In addition, the September 2020 VA Form 10182 contains contentions regarding the way the Board is handling his appeal, also raised in a January 2020 invalid VA Form 10182. Thus, as there is no indication that the Veteran wishes to withdraw his legacy appeal and given the invalid VA Form 10182, the Board will proceed with the appeal under the legacy system.   Analysis 1. Entitlement to a disability rating greater than 40 percent for service-connected lumbar spine disability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation for distinct periods of time, based on the facts found. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes, at the outset, that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). The provisions of 38 C.F.R. § 4.40 and § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Notably, pain, alone, does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45, but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. Burton v. Shinseki, 25 Vet. App. 1 (2011). The General Rating Formula provides for assignment of a 20 percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). See also 38 C.F.R. § 4.71a, Plate V. 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. Id. at Note (5). The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance for rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Alternatively, disability involving disc disease may be rated under the Formula for Rating IVDS Based on Incapacitating Episodes, pursuant to which ratings from 10 to 60 percent are assigned based on the total duration of incapacitating episodes during a 12-month period. 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. The ratings for the Veteran’s lumbar spine disability have been assigned under Diagnostic Code 5242 (for degenerative arthritis of the spine). However, all spine disabilities are rated pursuant to the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a. Historically, by rating action of October 1987, the RO granted service connection for lumbosacral strain, and assigned an initial noncompensable rating under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5295, effective July 25, 1985. In a statement received by VA on August 25, 2003, the Veteran raised a claim for an increased rating for his service-connected lumbosacral strain. In a rating decision of January 2004, the Veteran’s rating for his lumbosacral strain was increased to 20 percent under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5295, effective August 25, 2003. The Veteran filed a notice of disagreement with the rating assigned in November 2004. In a rating action of July 2006, the Veteran’s rating for his lumbosacral strain was increased to 30 percent under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5295, effective November 3, 2004. In a rating decision of November 2010, the RO awarded the 30 percent rating, effective August 25, 2003, and characterized the disability as lower lumbar spine disability pursuant to the Board’s recharacterization of the issue in March 2009. Effective September 26, 2003 (during the pendency of this appeal), VA revised the criteria for rating all disabilities of the spine, including lumbosacral strain and degenerative arthritis. As there is no indication that the revised criteria are intended to have a retroactive effect, the Board has the duty to adjudicate the claim only under the former criteria for any period prior to the effective date of the new criteria, and to consider the revised criteria for the period beginning on the effective date of the new provisions. See Wanner v. Principi, 17 Vet. App. 4, 9 (2003); DeSouza v. Gober, 10 Vet. App. 461, 467 (1997). See also VAOPGCPREC 3-2000 (2000) and 7-2003 (2003). In this case, the RO considered the claim under both the former and revised applicable criteria, as appropriate, and the RO has given the Veteran notice of the former and revised applicable criteria in the SOC and SSOCs. Hence, there is no due process bar to the Board also considering the claim in light of the former and revised applicable rating criteria, as appropriate. A. Prior to September 26, 2003 Under former Diagnostic Code 5295, a 20 percent rating was warranted for lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position; a 40 percent rating was warranted for severe lumbosacral strain with listing of whole spine to opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space or some of the above with abnormal mobility on force motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). Former DC 5289 also provided for a 50 percent rating for unfavorable ankylosis of the lumbar spine. 38 C.F.R. § 4.71a, DC 5289 (in effect prior to September 26, 2003). [Parenthetically, the Board notes that, as a point of reference, standard or normal ranges of thoracolumbar spine motion are as follows: forward flexion, from 0 to 90 degrees; extension, from 0 to 30 degrees; right and left lateral flexion, each, from 0 to 30 degrees; and right and left lateral rotation, each, from 0 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. See 38 C.F.R. § 4.71a, Plate V.] The Board also notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Considering the pertinent evidence in light of the applicable criteria, the Board finds that a rating in excess of 40 percent for the Veteran’s service-connected lumbar spine disability is not warranted at any point pertinent to the current claim on appeal prior to September 26, 2003. The Board acknowledges that there is little medical evidence of record for the period prior to September 2003. However, the Board has considered the available medical evidence of record (to include medical evidence following this period) to evaluate the severity of the Veteran’s lumbar spine impairment for this period under the former criteria. In August 2003, just prior to filing his claim, the Veteran sought treatment of his feet, at which time symptoms related to the back were also reported, albeit not in detail. It noted that he underwent reconstructive surgery of both feet in 1994 which involved midtarsal joint fusions along with other procedures to better align the component parts of the feet and that the surgeries successfully allowed the Veteran to continue in the line of work that he was trained in for an additional five years. The clinician explained that as time has progressed, however, the physical labor which the Veteran is accustomed to has gradually returned him to his pre-operative state, and that the knees, hips, and lower back are now symptomatic. The clinician determined that in the absence of medical conditions which have been ruled out, the symptoms are related to mechanical malalignment of the lower extremities, beginning at the feet. The initial report of detailed findings as to the severity of the Veteran’s lumbar spine disability during the course of this appeal are shown in the November 2003 VA/QTC examination report. At that time, he reported localized lower back pain that lasts all day. Flare-ups were reported, and he was noted to be able to function during flare-ups. There was no requirement of bed rest reported at the time of this examination. Range of motion was as follows: active flexion limited to 40 degrees, with pain at 30 degrees; active extension limited to 15 degrees, with pain at 15 degrees; active right and left lateral flexion limited to 15 degrees with pain at 15 degrees; and right and left rotation limited to 25 degrees with pain at 25 degrees. The limitations were noted as due to pain, fatigue, weakness, lack of endurance, and incoordination. For this reason, the 30 percent rating was assigned. While this examination occurred after September 26, 2003, the Board finds that it is reasonable to assume that it is an accurate picture of the severity of the Veteran’s lumbar spine disability in August and September 2003. Here, the RO awarded the Veteran a rating of 40 percent disability. Notably, the Board points out that, for the pertinent period prior to September 26, 2003, the 40 percent rating assigned adequately compensates the Veteran for any functional loss due to pain and other factors noted in sections 4.40 and 4.45, and DeLuca, during the period in question. As indicated, the Veteran’s complaints of pain were documented in the November 2003 report. However, the medical evidence does not document, and the Veteran does not specifically allege, any functional loss due to pain greater than that shown objectively during flare-ups or with repeated use. There also is no evidence of a severe level of weakness, excess fatigability, or incoordination associated with the low back at this juncture. As such, the Board finds that the DeLuca factors (noted above) provide no basis for assignment of a rating in excess of 40 percent for the period in question under the former criteria. Further, while some limitation of motion has been documented, the Veteran’s examination report reflects that the Veteran had retained, at the time of examination, significant range of flexion, extension, and rotation based upon the normal ranges of motion of the thoracolumbar spine discussed above. Moreover, the medical evidence does not indicate that the Veteran experienced severe lumbosacral strain with listing of whole spine to opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space or some of the above with abnormal mobility on force motion, or ankylosis of the lumbar spine under former DC 5289. Thus, the Veteran’s has been assigned a rating in excess of what his symptoms warrant under the former rating criteria prior to September 26, 2003. Further, although under former Diagnostic Code 5293, a higher rating was assignable for IVDS on the basis of incapacitating episodes prior to September 26, 2003, the Veteran’s disability was not shown to involve disc disease or any incapacitating episodes at that time. Therefore, a higher rating under former DC 5293 is not warranted for this period of time. Finally, the disability also was not shown to involve any other factor(s) that warrant evaluating the disability under any other former provision(s) of VA’s rating schedule. B. Since September 26, 2003 Effective September 26, 2003, criteria for rating all disabilities of the spine (to include lumbosacral strain, now designated as Diagnostic Code 5237), are set forth in a General Rating Formula for Diseases and Injuries of the Spine. That formula provides that a 40 percent rating is assignable where forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assignable for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assignable for unfavorable ankylosis of the entire spine. These criteria are applied with and 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. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235-5243). Under the rating schedule, forward flexion to 90 degrees, and extension, lateral flexion, and rotation to 30 degrees, each, are considered normal range of motion of the thoracolumbar spine. 38 C.F.R. § 4.71a, General Rating Formula, Note 2, and Plate V. Also, under Note (1) of the General Rating Formula, VA must consider whether combining ratings for orthopedic and neurological manifestations would result in a Considering the pertinent evidence in light of the applicable criteria, the Board finds that a rating in excess of 40 percent for the Veteran’s service-connected lumbar spine disability is not warranted at any point pertinent to this appeal since September 26, 2003. VA/QTC examination conducted on that date reveals active flexion of the thoracolumbar spine limited at 40 degrees, with pain at 30 degrees. x-ray examination revealed minimal spondylosis. On physical examination, tenderness to palpation in the thoracolumbar region was noted, but there was no evidence of radiculopathy. A private examiner submitted a report related to his initial orthopedic evaluation of the Veteran in March 2004. Lower back pain continued, and there were still no reports of associated leg pain, numbness or paresthesias, although pain was noted to radiate occasionally to both groins. It noted that the Veteran did not work for two years because of his surgical feet procedures. Flexion of the spine was to 60 degrees at that time without elaboration as to pain. X-rays of spine showed no fractures; no 1ithesism, moderate decreased disc Space at L5-Sl. The Veteran was again examined by a private physician in July 2004, at which time he reported ongoing low back pain, with some numbness in the left and the right leg. At this time, lumbar range of motion was measured as 50 degrees flexion, 20 degrees extension, 20 degrees lateral bending, along with point tenderness to palpation. The physician noted the Veteran complained mostly of low back pain with occasional pain into the left greater than right lower extremity and has been ongoing for two years. The Veteran stated he has had therapy, consisting of mostly stretching. The Veteran reported that the pain wakes him up at night and he feels some numbness in the left and the right leg in a general distribution without any bladder or bowel dysfunction. The physician noted that if he fails therapy, he will be looking at either living with his symptoms and modifying his work so that he is not lifting or having a relatively large-sized surgery, which the physician indicated is not recommended. An August 2004 private medical letter from a rehabilitation center noted that motion tests were performed and repeated, and that bending at the waist reproduced low back pain. The Veteran reported aggravating factors of the lumbar spine to include, repeated bending, squatting, and sitting greater than ten minutes. He also reported he had severe flare-ups. In June 2006, the Veteran was again afforded VA/QTC examination of his lumbar spine. The symptoms were consistently reported as constant pain throughout the day with radiation to both legs. The examiner noted, per the Veteran’s report, that he is not able to function without medication and that he sometimes requires complete bed rest. There is no evidence, however, that this bed rest was prescribed by a physician. Physical examination reveals active flexion limited to 40 degrees with pain beginning at 20 degrees, extension limited to 0 degrees with pain at 0 degrees, right and left lateral flexion limited to 15 degrees with pain at 15 degrees, and rotation limited to 15 degrees with pain at 15 degrees. The examiner again noted that motion was limited by pain, fatigue, weakness, lack of endurance, and incoordination following repetitive use. Yet, there was no evidence of intervertebral disc syndrome with chronic and permanent nerve root involvement. X-ray revealed minimal spondylosis. Outpatient records document the Veteran’s ongoing back pain but fail to note range of motion measurements, or any prescription of bed rest during the years immediately following the 2006 examination. A May 2007 VA treatment record noted a decrease in motion of the Veteran’s back. In June 2007, the Veteran reported chronic back and feet pain for the past 20 years, as well as progressively worsening pain on neck, ankles and knees. The Veteran experienced generalized tenderness on bilateral lumbar region, flexion of spine severely limited by pain. The Veteran reported his functional capacity includes standing for about 15 minutes in a stretch and possibly off and on for a total of few hours a day, sitting without change in position for about 1/2 hour in a setting and possibly sit for 3 to 4 hours a day total, unable to lift anything heavier than 10 lbs. without pain, and crouching, bending, reaching caused him significant paint, unable to elevate his arms above shoulder without pain. The clinician explained that with the Veteran’s chronic pain and depression, he is not able to be gainfully employed at this time and he did not expect his condition to improve since he is not receptive to medical treatment at that time. November 2007 VA mental health treatment records noted the Veteran’s report of depressive features, including anhedonia, weight change, fatigue, irritability, anger, and restlessness after his pain became unbearable in 1994. The Veteran reported a history of violence, including a justifiable homicide in 1987. He was diagnosed with major depressive disorder and personality traits affecting his medical condition. A January 2008 VA treatment record noted the Veteran cannot return to work full-time, but that he can work part-time provided he does not engage in prolonged standing -- no more than 15 minutes in a stretch, prolonged sitting more than 1/2 hour in a stretch, lifting more than 10 pounds, crouching, bending or reaching to be minimized or avoided whenever possible. He noted a vocational rehabilitation program in an appropriate profession which can meet the above restrictions is possible. In March 2008, the Veteran’s VA primary care physician submitted a note that reflects that he continued to have back pain, but that he refused treatment at VA and wished to continue with a private physician. He reported he is followed by a private physician at Pasadena (via workman’s compensation) and reports that he has been offered surgery of left knee after magnetic resonance imaging (MRI) was completed. At the time of his January 2009 Travel Board hearing, the Veteran again suggested that he has severe and chronic back pain and that the prior VA examiner did not accurately describe its severity. In March 2009, the Board remanded the issue for new examinations, both orthopedic and neurological, by VA physicians. SSA records obtained pursuant to the March 2013 Joint Motion reflect that in a 2008 private treatment record, the Veteran reported he injured his lower back in a work-related accident in 1989 (which is after service discharge), in which he herniated a nucleus pulposus. The Veteran also indicated he was a heavy equipment and crane operator, which required him to lift heavy objects in excess of 50 pounds. The Veteran indicated that he worked full-time. He reported an August 2006 work injury in which he injured his knee. A few days later, he reported he felt lower back pain, as well as pain and stiffness throughout his body. As a result of this injury, he reported that his activities of daily living, recreational activity, and work function were restricted. He missed work from November 2006 to January 2007 and March 2007 to the present time of the examination in February 2008. The Veteran reported his spinal complaints and lower extremity pain and numbness began in August 2006 and he related the pain to his work-related injury. He indicated he was doing well prior to August 2006. Forward flexion of the lumbar spine was to 45 degrees. A 2008 x-ray reveals symmetrical and equal facet joints. Osteoarthrosis was not evident. There was evidence of moderate intervertebral disc space narrowing at L4-L5, L5-S1 levels. There were no signs of generalized osteoporosis. A 2008 MRI notes disc protrusion, loss of disc height, and restriction in motion in flexion. In an April 2008 psychological evaluation, the Veteran reported pain in his back, neck, shoulders, lower arms, hands, lower back, buttocks, lower legs, and feet. He opined the Veteran had a 25 percent chance in going back to work because he had been working a year. A January 2009 Amended Permanent and Stationary Report recounted the August 2006 work injury. It noted the Veteran is still in pain and there has been no relief of his pain. Since the injury, the Veteran has experienced feelings of depression, anxiety, tension, headaches, fatigue, and insomnia. He has also experienced a 43-pound weight gain, which he believes was a direct result of his inactivity since the accident and from the shockwave treatment, which required administration of steroids. The Veteran reported he suffered an injury to his back in 1989 and he was given permanent disability and received benefits for that accident. He also reported that he suffered a thumb injury in 1993 and was temporarily disabled at that time. The Veteran noted there is tenderness and myospasm of the cervical, thoracic, or lumbar paraspinal musculature. The physician concluded the Veteran’s industrial accident that occurred on August 28, 2006, caused a left foot, knee and ankle injury, which continues to plague him through the present. He has had no relief of his pain and uses a cane to walk. The stress of the injury has caused him to suffer various internal medicine complaints including headaches, elevated blood pressure, sleep disorder, weight gain, as well as depression. Based on his examination of the Veteran, the Veteran’s reported history, as well as results of testing, he concluded that the Veteran’s diagnoses of headaches, sleep disorder, and weight gain are 100 percent apportioned to industrial causes, and his aggravated hypertension is related to the stress of his condition as well. Work restrictions included preclusion from working in an environment where the Veteran may be subjected to excessive stress, as it may further aggravate his internal medicine conditions of obesity, hypertension, sleep disorder and headaches. He noted the rating for pain-related impairment due to the Veteran’s headaches and musculoskeletal conditions is 3 percent. An April 2009 neurological and spinal examination noted abnormal moderate spasm, tenderness, and range of motion in the lumbar spine. A November 2009 SSA determination letter notes the Veteran was disabled since August 2006 and although he attempted to work in November 2006 and February 2007 to March 2007, these jobs were unsuccessful work attempts, as the Veteran stopped working within six months of his medical conditions. The adjudicator noted that a private physician opined that the Veteran was temporarily disabled from August 2006. The adjudicator further stated that after the August 2006 work injury, the Veteran experienced feet and knee injuries that made him increasingly bedridden and that his work injury exacerbated his lumbar spine disability as well as other disabilities. The adjudicator concluded he is unable to perform his past duties as a construction electrician, as his past relevant work exceeds the residual functional capacity. A March 2009 MRI revealed disc protrusion. The record reflects that the Veteran had back surgery to include hemilaminectomy and excision of the ruptured disc with a private doctor in June 2009. The physician noted the Veteran experienced severe increasing lumbosacral pain and left leg radicular pain since August 2006, arising from an industrial injury. The pre-operative and post-operative diagnoses were L3-L4 ruptured herniated disk protruded disk, L4-L5 protruded disk, foraminal stenosis, facet arthropathy at L3-L4, moderately at L4- LS, severe advanced left L4 radiculopathy and moderate to severe left L5 radiculopathy. The next VA examination was in June 2010, after the surgery. Continued pain, fatigue and restricted motion was reported. The examiner indicated that the Veteran’s gait was normal at this time. There was no evidence of spasm, atrophy, guarding, pain with motion, tenderness or weakness. Lumbar range of motion was flexion 0 to 30 degrees, extension 0 to 10 degrees, and left and right lateral flexion and rotation 0 to 10 degrees. The examiner indicated that the Veteran experienced motion with pain and that the pain was evidenced with repetitive motion, but that there was no additional loss of motion after repetition. The Veteran again suggested that he experienced incapacitating episodes, but there is no evidence of duration or frequency, and no evidence that bed rest was prescribed by a physician. In fact, the only evidence of the requirement of bed rest is found in the Veteran’s reports to physicians. While he is competent to report his feeling of the need to rest due to back pain, he is not competent to prescribe the medical need for a period of bed rest. Nonetheless, the examiner suggested that the incapacitating episodes are due to IVDS. Peripheral nerve examination at that time also reveals foramina stenosis, and severe advanced left forward radiculopathy and moderate to severe L5 nerve radiculopathy. The Board, in March 2011, found these cursory notations of IVDS and radiculopathy to be inadequate and remanded the issue for a more in-depth examination of the orthopedic and neurological aspects of the Veteran’s disability. As noted in the duty to assist section, above, the Veteran was scheduled for VA examination in April 2011, but he left the facility prior to the examination. The VA examiner wrote a report without the benefit of examination but spoke only to the issue of service connection. As such, the Board finds that this examination report is not pertinent to this rating claim. In September 2011, the Veteran was examined by a VA physician’s assistant and nurse practitioner. Again, the Board is aware of its requirement on remand that a VA physician conduct the examination. However, due to a lack of cooperation on the part of the Veteran, such examination did not occur. Thus, the Board has determined that the VA examinations conducted, albeit not by VA physicians, substantially comply with the March 2011 remand directives, and because the examiners, while not medical doctors, are competent medical professionals, the Board finds that these examinations are indeed adequate for rating purposes. At the time of examination, forward flexion was to 30 degrees, and painful motion began at 20 degrees on flexion. Repetitive testing was not conducted because the Veteran began experiencing severe spasms during the initial range of motion movements. Functional loss due to the back was noted as less movement than normal, weakened movement, pain on movement, interference with sitting, standing and/or weight bearing, and difficulty rising from a seated position. The examiner also observed severe tenderness and spasms on the left lumbar spine, as well as a hesitant gait, wide based with cane, antalgic. The Veteran reported mild constant pain in the right lower extremity, and severe intermittent pain in the left lower extremity. Numbness was also present. The examiner assessed this as involving the femoral nerve on the left, and the sciatic nerve on both sides, left greater than right. No other neurologic abnormalities were described. This examiner also determined that the Veteran did not have IVDS of the thoracolumbar spine and has not had incapacitating episodes in the prior twelve months. Also, in September 2011, the Veteran was examined in a separate peripheral nerve examination. The symptoms were similarly reported as severe back pain causing gait instability and numbness. The examiner performed sensory physical examination and the findings were normal as to the right and left lower extremity tibial and peroneal nerve. The examiner stated that severe collapsing, giving way, and pseudo-weakness made it impossible to fully quantify, but that when the Veteran was able to give good effort, his nerve function was normal. The antalgic gait and imbalance were noted as being due to the severe back pain. The examiner concluded by stating that although the Veteran had radicular symptoms, she was unable to objectify this on examination. Further, she explained radiculopathies involve lower motor neurons and can therefore produce weakness, atrophy, and loss of reflexes in the myotomal distribution. The examiner noted that on examination, none of these factors were found, and, in fact, the Veteran had brisk 3+ reflexes including easily elicited hamstring reflexes (which assess the L5 nerve roots), and his sensory examination was unremarkable. Therefore, the examiner opined that there is no objective evidence on examination of a lumbosacral radiculopathy involving the motor or sensory nerve fibers. An April 2014 private consultation report reflects the Veteran’s lumbar spine had flexion to 60 degrees. An x-ray revealed mild straightening of the normal lordotic curvature and early osteoarthritic changes. The physician noted the Veteran was involved in a motor vehicle accident that resulted in injuries to his lumbar spine while he was in the military. He noted the Veteran continued to have lower back pain but was able to continue working until he suffered a work injury in 2006. He noted that the other orthopedic problem involved the development of plantar fasciitis involving both feet. He concluded that the Veteran suffered subsequent injuries to his lower back, which ultimately required him to undergo lumbar spine surgery, and is permanently disabled as result of his lumbar spine injuries. A May 2016 VA examination report reflects the Veteran rated his pain as a 9/10 that increases with anything he does, even just going to the bathroom. At this point despite past back surgery, the Veteran reported his back pain has not improved and that it is worse. He described flare up episodes described as pain going through his groin and into his penis shooting back up to his neck and feet. He reported functional impairment described as being unable to work, unable to engage in any recreational activity, impairs his sitting, standing, bending and doing menial tasks. Due to the Veteran’s report that he was in a lot of pain and moaning, he was unable to get out of the wheelchair for any physical examination testing during the examination. So, there is no range of motion of his spine conducted. A September 2016 VA examination report reflects he complained of lower back pain that is constant slight with daily activities and worsens to occasional moderate to severe with bending, stooping, heavy lifting, and sneezing. He reported no associated leg pain, numbness or paresthesias. Pain radiated occasionally to both groins. He had no bowel or bladder problems. He complained of paresthesias on his lower back but no leg paresthesias. The examiner provided diagnoses of degenerative disc disease, L3-4-disc herniation. On examination, he had markedly decreased range of motion of the lumbar spine due to pain. The examiner concluded there is no clear evidence of intervertebral disc syndrome. The Veteran stood with straight posture, walked with normal gait, tenderness to palpation diffusely across the lumbar paraspinal muscles and no spasm or trigger points. Flexion was to 60 degrees and extension to 10 degrees with increased pain. There was no ankylosis noted. The examiner also explained that the Veteran’s statements of the circumstances of onset of injury are completely discrepant with the facts documented in multiple areas in his medical records. He opined that his herniated disc and chronic lumbar spine issues are not related to any event in service, namely the motor vehicle accident (MVA) he was involved in. He also opined that his in-service MVA, which resulted in symptoms in his right shoulder and right posterior neck, did not cause any lower back pain and it most certainly did not precipitate any of his chronic lumbar spine issues, including a ruptured herniated disc and foraminal stenosis. He further concluded his lumbar issues are work-related, as documented by his operating surgeon and any complications that may have resulted from this procedure, such as the alleged radiculopathy, must therefore also be work-related. The VA examiner indicated under the section entitled “Indications for Operation,” Dr. Habibi, the operating surgeon, noted in his Operative Report: “‘The patient is a 47 year-old gentleman with a history of severe increasing lumbosacral pain and L leg radicular pain since August 2006, arising from an industrial injury.’” As the Veteran worked as a heavy equipment operator, which the physician indicated is the context of his workplace injury resulting in his chronic back issues. He indicated that the Veteran also struggled with his weight over the last several years. As a result, he explained that the additional mechanical load on the skeleton and that obesity is a well-established and extremely common risk factor to the development and acceleration of arthritis of the spine, hips, knees, and ankles. A December 2016 private treatment record notes bedrest as needed for multilevel disc protrusions cervical spine sprain/strain of lumbar spine, lumbar radiculopathy, plantar fasciitis aggravating lumbar spine injury. Pursuant to the January 2018 remand, the AOJ referred the claim for extra-schedular consideration, and in June 2019, the Director of VA’s Compensation and Pension service (C&P Director) determined that an extra-schedular TDIU due to a lumbar spine disability was not warranted prior to August 29, 2006. In doing so, the Director explained that a consultation report from Workman’s Compensation dated October 23, 2008, noted that the Veteran was injured on the job on August 28, 2006, as a heavy equipment and crane operator and that he was precluded from working in environments where he may be subjected to excessive stress as it would aggravate his obesity, hypertension, sleep disorder, and headaches. He pointed out that the Veteran was working for P&S when he was injured on August 28, 2006. The Director recommended denial of entitlement to TDIU benefits on an extra-schedular basis prior to August 29, 2006, and that the Veteran’s service-connected lumbar spine disability be increased to 50 percent on an extra-schedular basis from May 5, 2016. He explained that because the Veteran was in such pain that he was unable to stand for the examination for x-rays renders the rating schedule standard impractical from May 5, 2016. The Board, however, notes that the Memorandum was not signed, and a subsequent signed Memorandum from the C&P Director was issued. In a September 2019 signed memorandum, the Director determined that the evidence, including VA examinations and VA medical center treatment notes, demonstrates a 40 percent evaluation is appropriate. He explained that the record does not demonstrate that the Veteran’s spinal condition warranted frequent periods of hospitalization. In addition, although there is indication that the Veteran’s combined medical conditions interfere with his ability to maintain employment (as he is now rated unemployable), there is no evidence that the Veteran’s service-connected lumbar spine condition alone presents an unusual disability picture that would render impractical the application of the regular schedular standards. Pursuant to the Board remand, the Director commented on the Board’s request to address whether the Veteran’s pain medications he takes for the Veteran’s lumbar spine condition might have caused several ailments that would be justification for an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1). The Director explained that many of the possible pain-prescription, associated conditions (e.g., allergies, arrhythmia, obesity, gall bladder condition, nausea, etc.) were denied service connection as secondary to the Veteran’s spine condition, as they were not found to be related. He indicated that current VA medical center treatment notes that the Veteran is not currently taking pain medications due to these issues he suffers when taking them. Further, the Director also addressed the Veteran’s VA examination in May 2016 that might be justification for an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1) for his spine condition as he could not be evaluated due to pain when standing. The Director explained that the Veteran also has pain on standing due to his bilateral pes planus with ankle strain and, as there was no evidence to the contrary, pain cannot be solely related to his lumbar spine disability. Therefore, the Director concluded entitlements to extra-schedular evaluations under 38 C.F.R. § 4.16(b) and 38 C.F.R. § 3.321(b)(1) are not warranted. An August 2019 Examination for Housebound Status notes diagnoses of lumbar radiculopathy, prolonged cervical interverbal disc. It noted the Veteran is unable to stand on his feet for long periods due to pain, does a lot of bedrest due to pain, and has problems with urine flow and difficulty with bowel movements. A June 2019 private treatment record noted the Veteran reported he does not engage in a lot of physical activity because of his DDD and he is typically on bedrest. He reported that back pain is contributing to his weight issues and the pain causes him to be sedentary. A January 2020 private neurological consultation obtained pursuant to the February 2020 Board remand notes the Veteran had low back pain for over 10 years. He reported back pain radiating down to his lower legs. The physician indicated an August 2019 MRI notes disc herniation status post left hemilaminectomy, moderate arthrosis, osteoarthritis. The assessment was lumbar spondylosis with radiculopathy, unstable lumbar spondylolisthesis at L5-L6 left hemilaminectomy, microdiscectomy, bilateral SI joint dysfunction, morbid obesity. The physician explained that the dynamic instability in his lower spine is due to significant axial loading due to his body habitus. She further explained he was not a surgical candidate for spinal fusion due to his obesity and it would be reconsidered if the Veteran weighs approximately 200 pounds or below. As noted above, under the General Rating Formula, 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. Here, the findings in the VA/QTC examination report dated November 10, 2003, reflect that the Veteran’s flexion of the thoracolumbar spine was limited to 40 degrees, with pain beginning at 30 degrees. Similarly, in June 2006, flexion was limited to 40 degrees with pain beginning at 20 degrees. In June 2010, flexion was further limited, ending at 30 degrees. In September 2011, flexion ended at 30 degrees, with painful motion beginning at 20 degrees on flexion. In April 2014, flexion was limited to 60 degrees. In September 2016, flexion was limited to 60 degrees. The 40 percent rating currently assigned is the maximum schedular rating for limitation of motion of the thoracolumbar spine under the General Rating Formula, and a rating greater than 40 percent for thoracolumbar spine disability under that formula requires a finding of ankylosis. Here, however, there is no competent evidence of the Veteran’s thoracolumbar spine being ankylosed or fixed in a position at any pertinent point since September 26, 2003. Further, the September 2011, May 2016, and September 2016 VA examiners specifically found no ankylosis. Hence, a rating in excess of 40 percent is not assignable at any point since September 26, 2003. Additionally, the Board notes that no separate rating for any additional neurological manifestation(s) is warranted at any point since the effective date of the award of service connection. The Veteran has already been assigned separate ratings for radiculopathy affecting each lower extremity, and he has not disagreed with the assigned effective dates or ratings for those disabilities. There is also no medical evidence that the Veteran has experienced any separate neurological manifestation of lumbar spine disability other than the radiculopathy. Absent a showing of any other neurological manifestations, no additional rating for associated neurological impairment is warranted. The Board further finds that no other revised criteria provides basis for assignment of a rating in excess of 40 percent at any point since September 26, 2003. The Board notes that while, effective September 26, 2003, the rating schedule provides a Formula for Rating IVDS Based on Incapacitating Episodes, that formula does not appear to be applicable here. Here, the Veteran has not been diagnosed with IVDS. Although the Veteran indicated he needs bedrest and despite the June 2010 VA examiner’s notation that the Veteran had IVDS, the examiners who conducted the September 2011, May 2016, and September 2016 VA examinations, all specifically concluded that the Veteran has not had 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. Although the Veteran was prescribed bed rest in December 2016, it was noted that it was recommended as needed due to multiple service-connected disabilities, as well as non-service-connected disabilities, and not due to IVDS due to his service-connected lumbar spine disability. Even if the Veteran’s service-connected lower lumbar spine disability did involve disc impairment, or, given the comments and assertions of record with respect incapacitating episodes, evaluation of the disability under this formula was appropriate, no higher rating is assignable. Under the Formula a 40 percent rating requires incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a prior 12-month period, and a 60 percent rating requires incapacitating episodes having a total duration of at least 6 weeks during a prior 12-month period. The Board also finds it noteworthy to mention that even the Veteran has not asserted that since September 26, 2003, he has required the extent bed rest required for even a 40 percent rating under this Formula-much less the extent required for the next higher, 60 percent rating. Therefore, a higher rating under the Formula for Rating IVDS based on incapacitating episodes is not warranted for the period since September 26, 2003. See 38 C.F.R. § 4.71a, DC 5243, Note (1). In evaluating the disability under consideration, the Board has certainly considered the lay assertions of record from the Veteran. However, the lay assertions made in support of his claim for higher ratings are not entitled to more weight than the objective findings rendered by trained medical professionals in this case, and which are needed to evaluate the Veteran’s spine disability under relevant rating criteria. Limitation of motion of the thoracolumbar spine is evaluated based upon limitation of motion, and clinical findings addressing the specific ranges of motion of the thoracolumbar spine are more probative to evaluate the level of severity of the service-connected lumbar spine disability. As explained above, in this case, the competent, probative evidence of record does not support a finding that a rating higher than 40 percent is warranted for the service-connected lumbar spine disability during the entire appeal period. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not otherwise for application in this regard. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. As a final point, it is emphasized that the Board has evaluated the Veteran’s lumbar spine disability based on consideration of the higher rating claim on appeal on the basis of the evidence of record, and that, in conjunction with this claim, 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 (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). C. All Periods The Board also points out that, regardless of whether the former or revised criteria are considered, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare- ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion (see Johnson v. Brown, 9 Vet. App. 7 (1996)), to include IVDS (see VAOPGCPREC 36-97, 63 Fed. Reg. 31,262 (1998)). As 40 percent is the highest schedular rating for limitation of motion of the thoracolumbar spine, the Board need not consider whether he is entitled to any even higher disability rating because of functional loss due to pain and other factors under §§ 4.40 and 4.45. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, in Johnston, the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. See id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). For the same reasons, as the Veteran is in receipt of the highest schedular rating for limitation of motion, the Court’s holdings in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (finding orthopedic examination inadequate where the examiner declined to provide an estimate of the degree of additional loss of motion due to flare-ups because such would require resort to speculation) are not applicable here. Under these circumstances, the Board finds that the record presents no basis for assignment of a higher schedular rating under any of the former or revised applicable rating criteria. Additionally, the Board finds that there is no showing that the veteran’s service-connected lumbar spine disability has reflected so exceptional or so unusual a disability picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b). Here, the Veteran asserted that the Veteran experienced weight gain, high blood pressure, arrhythmia, bilateral hip condition, allergies, and side effects caused by medications to treat his low lumbar spine disability. An extra-schedular rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. There must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as “marked interference with employment” and “frequent periods of hospitalization.” Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant’s disability picture requires the assignment of an extra-schedular rating. Id. In this regard, 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. 38 C.F.R. § 4.10. Evaluations are based upon lack of usefulness of these parts or systems, especially in self-support. Id. Furthermore, consideration in applying the rating schedule is to be given to pain on movement, swelling, deformity or atrophy of disuse, plus instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45(f). Moreover, the Diagnostic Codes (DCs) for evaluating the spine, DCs 5235-5243, expressly contemplate limitation of motion, and other aspects including spasm, abnormal gait, spinal contours, fracture, stiffness, aching, radiating pain, associated orthopedic and neurologic abnormalities, and incapacitating episodes. Here, the Veteran’s disability involves functional impairments of the back that cause disturbance of locomotion and other functional limitations under the ordinary conditions of daily life, including difficulty lifting, sitting, and standing. These symptoms, and the resulting functional impairment, are directly contemplated by the rating schedule. 38 C.F.R. § 4.45(f). Initially, although the June 2019 recommendation was not signed and thus not a final memorandum, nevertheless, Board does not agree with the June 2019 memorandum that the Veteran should be granted a 50 percent rating because he could not stand for the May 2016 VA examination. Here, subsequent to the May 2016 VA examination, the Veteran underwent an additional VA examination in September 2016, during which he stood with straight posture, walked with normal gait, tenderness to palpation diffusely across the lumbar paraspinal muscles and no spasm or trigger points. Flexion was to 60 degrees and extension to 10 degrees with increased pain. The examiner also explained that the Veteran’s statements of the circumstances of onset of injury are completely discrepant with the facts documented in multiple areas in his medical records. He opined that the Veteran’s herniated disc and chronic lumbar spine issues are not related to any event in service, and, instead are related to the MVA in which he was involved. He explained that the MVA, which resulted in symptoms in his right shoulder and right posterior neck, did not cause any lower back pain and it did not precipitate any of his chronic lumbar spine issues, including a ruptured herniated disc and foraminal stenosis. He concluded the Veteran’s lumbar issues are work-related, as documented by his operating surgeon and any complications that may have resulted from this procedure, such as the alleged radiculopathy, must therefore also be work-related. Here, as indicated by the September 2019 Director’s findings, as well as medical evidence, including the VA examination reports described above, the Veteran’s weight gain and medications are a direct result of his August 2006 work related injury and subsequent 2009 back surgery, as well as his other service-connected feet and ankle disabilities and non-service-connected disabilities. This conclusion is also consistent with January 2009 Amended Permanent and Stationary Report, which noted he experienced a 43-pound weight gain as a direct result of his inactivity since the August 2006 work accident and from the shockwave treatment, which required administration of steroids. The physician also concluded the Veteran’s industrial accident which occurred on August 28, 2006, caused a left foot, knee and ankle injury which continues to plague him through the present. As previously discussed, pain associated with the Veteran’s back is explicitly considered in the Diagnostic Code. Therefore, such functional effects are indeed contemplated in the DCs under which such service-connected disabilities are evaluated. Overall, given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture associated with his lumbar spine disability. See, e.g., 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, 4.124a. Therefore, the Board finds that, for the entire appeal period, the symptoms associated with the Veteran’s lumbar spine, and their resulting functional impairment, are contemplated by the rating schedule. 38 C.F.R. § 3.321; Thun, supra. Therefore, extra-schedular rating for a rating in excess of 40 percent for the Veteran’s lumbar spine disability is not warranted. 2. Entitlement to a TDIU rating prior to August 29, 2006. Where the schedular rating is less than total, total disability ratings for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more with sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, will be considered as one disability for TDIU purposes. 38 C.F.R. § 4.16(a). In this instance, since the August 25, 2003, date of the claim for increase, and prior to August 29, 2006, the Veteran met the basic eligibility requirements for a TDIU on a schedular basis. The Veteran’s service-connected disabilities, prior to August 28, 2006, include the 40 percent rating for the lumbar spine disability for the entire appeal period, bilateral pes planus with metatarsalgia (10 percent from May 28, 1998, and 50 percent from July 3, 2017), status-post operative left foot hallux valgus with degenerative changes (rated as 10 percent disabling from May 10, 2002), status-post operative right foot hallux valgus with degenerative changes (rated as 10 percent disabling from May 10, 2002), right ankle stain associated with bilateral pes planus with metatarsalgia (rated as 10 percent disabling from May 10, 2002), and left ankle stain associated with bilateral pes planus with metatarsalgia (rated as 10 percent disabling from May 10, 2002). Thus, after consideration of the bilateral factor, the Veteran has at least a combined 70 percent rating for all disabilities since August 25, 2003 (see April 2020 Rating Decision Code Sheet), and thus the percentage requirements for a schedular TDIU are met for the period in question. See 38 C.F.R. § 4.16(a). The central inquiry is “whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The Board has considered the evidence detailed above, as well as the evidence, below, in addressing the claim. An October 2003 letter from a private podiatrist noted that based on the Veteran’s age and evaluation of his podiatric conditions, the Veteran is moderately to severely disabled with regards to his feet. Further, he noted that with advancing age, his podiatric conditions will only worsen with time. Later that month, the podiatrist explained that he underwent surgeries for his bilateral feet deformities and was placed on disability for approximately 2 years. He noted the Veteran’s disability commenced in June 1994 and he was discharged to return to work without restrictions later that month. The November 2003 VA examination noted the Veteran had surgery to both feet in 1994 and 1995 for reconstructive surgery for fallen arches. He also underwent bunionectomy and surgery for a neuroma. The Veteran reported wearing orthotics in his shoes and taking over-the-counter medication as needed for pain. As a result of the foot condition, the clinician noted the Veteran is not able to run and is limited in prolonged walking and standing. The Veteran reported having missed two years of work due to the foot condition, but he is currently not employed. In terms of daily activities, the clinician noted the Veteran is able to brush his teeth, cook, walk, shower, climb stairs, shop, vacuum, dress himself, do the gardening, drive a car, take out the trash, and push a lawnmower. However, the Veteran stated that he performs these activities with excruciating pain. He noted the Veteran’s usual occupation is that of a ground man and truck driver and he was last employed on November 2003, at which time he was laid off. Physical examination of the Veteran’s feet revealed mildly increased callosities on the medial plantar surfaces of both feet, without any breakdown. He noted the Veteran did not use any device, crutches, brace, or cane. Based on the examination, the clinician concluded, the Veteran can provide self-care. The clinician also noted examination of the bilateral lower extremities revealed tenderness to palpation from the hips down to the toes, including the hip joints, knee joints, ankle joints, and feet, as well as the thigh muscles and calf muscles. There was no evidence of acute inflammatory changes involving the joints of the lower extremities, and thus, there was an absence of erythema, warmth, and swelling. The clinician noted the only noticeable deformity was of the feet, in that there is presence of mild flatfeet and hallux valgus. He had a slightly slow gait, but there was no evidence of antalgia or ataxia, or uneven leg lengths. The range of motion of the hip joints, knee joints, and ankle joints were decreased due to pain. X-rays of the knees and ankles revealed no evidence of severe degenerative changes. As to his foot condition, knee condition, and hip condition, the clinician noted the Veteran is limited in running, and frequent kneeling, squatting, and climbing stairs. The March 2004 private orthopedic examination noted the Veteran reported intermittent bilateral feet paresthesias and numbness. The Veteran reported pain is worse with prolonged walking, standing, climbing, kneeling and squatting, and at times has difficulty sleeping because of tingling sensation in his feet with occasional spasms. He complained of bilateral feet pain that was constant and worsened with daily activities to moderate to severe with prolonged walking, standing and climbing. The clinician noted slight to moderate pes planus with no swelling and no effusion. There was no tenderness to palpation, and he had full motion of the ankle with no pain or discomfort. X-rays of both feet revealed previous corrective surgery for bunions with no bony abnormalities. The left foot MRI completed in October 2002 revealed severe hallux valgus deformity with no fluid collection or soft tissue masses in the left foot. X-rays studies revealed no significant findings as to the right and left ankle, and evidence of previous bunionectomy and small plantar calcaneal spur of the right and left feet was noted. The June 2006 VA examination report noted the Veteran’s report of neck pain and the Veteran had limited range of motion due to pain and thereby limited the Veteran’s ability to frequently bend and turn the head and neck and performing overhead work. On foot examination, there was presence of mild bilateral flatfeet, painful motion, and tenderness to palpation throughout the entirety of both feet. There was no evidence of vascular changes or atrophy and also limited range of motion of both ankles as a result of the foot condition. However, the clinician indicated that the Veteran resisted movement of the ankle joints during the range of motion testing. Regarding the foot condition, the clinician concluded that the Veteran is limited in running and performing other repetitive high-impact activities and Veteran appeared to have limited function for standing or walking, in that he ambulates slowly with a wide- based gait, maintaining a crouching position. When asked to perform heel and toe walking, the Veteran declined the testing because of severe pain. The Veteran used shoe inserts, but he does not use any assistive devices for ambulation. With regard to the non-service-connected neck condition, during a severe flare-up, he has difficulty using his neck while performing activities. The Veteran stated that he was told by his physician to have bed rest as needed for the neck flare-ups. A September 2007 panel qualified medical evaluation (QME) related to a worker’s compensation claim noted the Veteran was a machine-operator and that on the date of the injury in August 2006, the Veteran was working in a power line right of way and that due to uneven terrain, a safety apparatus called a landing gear was removed because there was inadequate ground clearance to use it. The Veteran reported that when he tried to and unhook the trailer with a winch, the tongue of the trailer began to sprang up and almost hit his groin, and he was violently jerked 2 to 6 feet off the ground by his right hand because the trailer weighed several tons and it shifted and moved several feet. The Veteran let go of the winch in fear that his hand would get crushed by the cable of the winch, and, as a result, he was jerked off the ground and landed with the full weight of his body on his left ankle, foot, and knee. The Veteran weighed approximately 215 pounds at that time of this accident. The Veteran indicated that he fell 26 feet to the ground on this uneven incline on hillside. The Veteran stated that he immediately developed pain and swelling in his left leg and foot pain and was taken to the hospital and he was having significant problems with left leg swelling and pain, which he complained about and was given pain medication. The Veteran stated that he had had bilateral foot reconstruction in 1994 or 1995 and his private insurance due to fallen arches that had developed as a result of his service in the military. The Veteran had multiple bilateral neuromas and bunionectomy surgeries performed on his feet in 1994 and 1995 on his private insurance, and despite these surgeries in the past, the Veteran had no problems performing his work duties prior to his work injury in August 2006. A February 2008 private initial consultation report noted that due to the Veteran’s August 2006 work injury, his activities of daily living, recreational activity, and work function have been restricted. It noted that he missed work from November 2006 to January 2007; and from March 2007 to present. He reported pain in his neck, to a moderate degree, with dull pain with stiffness and soreness. He reported these symptoms occur intermittently and have progressively worsened. He reported that he experienced a moderate burning, shooting pain with numbness, tingling, stiffness, and swelling in the region of his low back on both sides. He reported that his symptoms occur intermittently and have worsened. The Veteran reported that his headaches began in August 2006, which is the same start date as the spinal complaints. The Veteran further reported that his symptoms began gradually and are consistent in severity throughout the day. He reported that his spinal and upper extremity complaints began on August 30, 2006, while the lower extremity symptoms started August 28, 2006. He also reported that his complaints are the result of a work-related accident/injury. In his 2008 Social Security Administration application for disability benefits, the Veteran reported that his left feet, ankle, knee, back, neck, blood pressure medications, and lower extremity disabilities prevented him from working. He indicated he became unable to work in August 2006 when he incurred a work injury and that he stopped working in March 2007 due to his work injury because he could not stand on his feet for too long. He indicated he worked as a construction electrician from February 1988 to August 2006, November 2006, and January to March 2007. He completed high school and completed one year of college. An October 2008 orthopedic consultation noted the Veteran was being evaluated regarding his industrial injury in August 2006, in which he sustained injuries to his low back. The clinician noted the sources of fact was from the Veteran, as well as physical examination. He indicated that records were not reviewed. The Veteran reported that he started working for P&S as an equipment specialist in 2006, approximately 3 to 4 months before his injury. He was responsible for operating heavy equipment and moving material to work on the line and he worked up to 70 hours per week, 6 to 7 days per week. He reported that he last worked in September 2006, at which time, he was placed on temporary total disability by the company physician, and he was not working. He was noted as temporarily totally disabled and receiving workers’ compensation benefits. The Veteran reported constant pain in his lower back which varied in degree, with pain from a 5 to a 9, on a pain scale of 10 with 10 being the most severe. He reported that the pain is located across his waist and radiates down into his hips and legs his body position, getting up from a sitting position and upon straightening up from a bent over position. He experiences weakness, numbness and tingling in his legs, feet and toes. He also reported experiencing increased back pain upon coughing and sneezing. He ambulated with the aid of a cane. He reported complaints of giving way of his back, as it will pop and then give way, causing him to fall. There was no loss of bowel or bladder control and there was no increased frequency in urination. He denied increased back pain with bowel movements and straining. The Veteran also stated that in 1989, while working for a transportation company, he sustained an injury to the low back. As a result, medical attention was required, and he underwent a course of physical therapy, traction and medications. An MRI was performed, which revealed abnormalities and he was off work for approximately 4 years. He reported that a case was opened and subsequently settled. Physical examination of the Veteran’s lumbosacral spine revealed the pelvis was level. There were no signs of antalgic tilt or loss of the normal lumbar lordosis. There were no signs of scoliosis. Forward flexion was limited to 15 degrees. The diagnosis was lumbosacral spine sprain/strain with multi-level disc bulges. The Veteran reported he was a full-time employee and had worked for his employer for the past month. He reported that he was working 10-hour days, 6 days per week. The Veteran indicated the number of hours the Veteran works per day is adversely affected by his complaints. A February 2009 neurosurgical consultation report noted the evaluation was in connection with neurological spinal musculoskeletal symptoms sustained as result of a work-related injury, dated August 28, 2006. The physician indicated she took a medical history, performed comprehensive neurological spinal musculoskeletal examination and reviewed the Veteran’s lumbosacral spine MRI. The Veteran reported that on August 25, 2006, during the course of his employment with P&S, he was unlocking a trailer and was raised up by the trailer and injured his left knee and left ankle. He had been under the care of an orthopedic surgeon. He indicated that prior to his injury to his left knee and ankle of August 28, 2006, he had sustained an injury to his low back in 1989 and an injury to his neck in 1999. The Veteran indicated that his neck injury was due to a motor vehicle accident and his back injury was due to a work-related injury while employed with a transport company. The Veteran indicated that prior to his left knee and ankle injury, he experienced residual, neck and low back pain, which he would describe as a 2 on a pain scale of 1 to 10 with 10 being the most amount of pain. However, after his left knee and ankle injury, he reported he gradually developed increased neck and low back pain. He stated that he would now describe his low back pain as an 8 or 9 on a pain scale of 1 to 10 with 10 being the most and his neck as a 6 or 7 on a pain scale of 1 to 10 with 10 being the most. At the time of the Veteran’s most recent injury in August 2006 in which he sustained injuries to his left ankle and knee, he had been working P&S on an intermittent basis as an equipment specialist for approximately 3 months over the past 3 years, from 2006 to 2009. A detailed thoracolumbar spine examination could not be performed due to pain. The Veteran declined lying down because it hurt him too much. Range of motion of the lumbar spine were significantly restricted, straight leg raising testing while in the seated position was positive at 70 degrees bilaterally. It noted a February 2008 MRI of the lumbosacral spine revealed 2 to 3.5mm disc protrusion. The physician concluded the degrees of multilevel disc protrusions is not significant. A March 2009 supplemental QME report noted at the current time, the Veteran reported persistent problems with bilateral knee pain, worse on the left. He reported low back pain that radiates into his neck and shoulders and problems particularly with his feet and left ankle. He reported that his knee pain bilaterally makes it difficult for him to walk. He rated his pain as 8 on an analog scale of 10 and reports numbness in the low back that radiates into the lower extremities. He reported weakness of the left knee and ankles, left more than right. There is diffuse lumbar and paralumbar spinous tenderness to palpation. The physician noted flexion, extension, and rotation of the lumbar spine reproduced the Veteran’s intractable tow back pain. There was some lumbar paralumbar spinous tenderness to palpation. He described moderate pain with range of motion activity and physical exertion of the lumbar spine region. He noted the Veteran appeared to be able to perform his job functions without limitation prior to his specific industrial injury in August 2006. He indicated that he would apportion his left knee, ankle and foot injury 100 percent of his injury in August 2006, apportion any exacerbation of his back condition to 50 percent to his previous injury in 1989 and 50 percent to his injury in August 2006. He concluded the Veteran is not permanent and stationary, but remains temporarily totally disabled, as has net reached maximum medical improvement. He explained the work restrictions cannot be assigned at this time since he is not permanent and stationary. He explained the Veteran suffered a specific industrial injury in August 2006, arising from his employment and suffered during his employment. The Veteran reported that his pain is aggravated by prolonged walking, standing, and activities of daily living such as his housework and any physical exertion or range of motion activity of his left lower extremity or low back. The Veteran stated that his pain is somewhat alleviated using analgesic medications. In a May 2009 supplemental private report for reevaluation, the Veteran reported that he has been found to have a 5mm lumbar disc bulge. The Veteran was declared permanent and stationary as of January 2008 on an internal medicine basis. The objective findings were limping gait, ambulates with cane, obesity, and abnormal echocardiogram. In a September 2010 statement, the Veteran reported that his back injury occurred in 1985 and that his back needed surgery because he has had problems over the past 20 years. He stated that the work injury was on his left heel, ankle, and knee, and not his back, and thus his service-connected lumbar spine disability caused the need for surgery and that he cannot work because of this disability. In his April 2011 VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability (TDIU application), the Veteran indicated that his feet, ankle, and back disabilities prevented him from securing gainful employment. He reported his disabilities affected his full-time employment in 1985. He reported he last worked full-time in March 2007 and that he became too disabled to work in 2004. He reported the most he earned in wages was $80,000.00 in seven months in 2003. He indicated he worked as a crane/equipment operator from February 2006 to March 2007 at multiple construction companies, 40 hours per week, and earned $2,500.00 every 2 weeks from February 2006 to March 2006, $5,000.00 every five weeks from July 2006 to November 2006, and $4,000.00 from January 2007 to March 2007 for five weeks. The Veteran indicated that he was on disability for eight months in 2004. In an April 2016 TDIU application, the Veteran essentially implied that he had not worked since July 1985, when he was discharged from service. He did not document any post-service work. While the application was received in April 2016, the Veteran signed the document in March 2016. In a May 2016 TDIU application, the Veteran provided an employment history, in which he indicated he worked 5.5 months in 2002, 6.5 months in 2003, 2.5 months in 2004, 5.5 months in 2005, 16 weeks in 2006 at multiple construction, utility, and electrical companies. In a March 2020 TDIU application, the Veteran reported his service-connected feet, ankles, back, left shoulder, and left elbow disabilities, as well as non-service-connected neck, knees, heart, weight gain, and medicines caused his inability to obtain gainful employment. He reported he became too disabled to work in July 1985 and that he last worked full time in 2006. The Board acknowledges that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. See 38 C.F.R. § 4.16(a). See also Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). However, medical evidence addressing the functional effects of the Veteran’s disability on his ability to perform the mental and/or physical acts required for substantially gainful employment is relevant to the unemployability determination. See 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Here, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran’s service-connected disabilities resulted in an inability to secure or follow a substantially gainful occupation prior to August 29, 2006. Initially, the Board notes that the Veteran’s credibility has been called into question due to the multiple inconsistent facts he has documented within records he has submitted to VA but also what he has documented within VA submissions are inconsistent with what he documented in submission to SSA. The record shows that he had been gainfully employed prior to 2006, as the evidence reflects the Veteran stopped working in August 2006 due to a work-related injury in which he sustained a back injury and consequently received workers’ compensations benefits. Prior to that time, as indicated in his April 2011, May 2016, and March 2020 TDIU applications, including the employment history provided in May 2016, the Veteran worked for numerous companies, earning $2,500.00 for 2 weeks of work from February 2006 to March 2006, $5,000.00 for five weeks of work from July 2006 to August 2006, $5,000.00 from October 2006 to November 2006, $4,000.00 for five weeks of work from January 2007 to February 2007, as well as from February 2007 to March 2007. Although the Veteran indicated that he became too disabled to work in 1985 in the April 2016, May 2016 and March 2020 TDIU applications and listed 2004 as the date he became too disabled to work in the April 2011 TDIU application, the Veteran indicated he stopped working full time in 2006 in the March 2020 TDIU application, which is consistent with the records, to include the employment history provided in May 2016 in which the Veteran specifically listed working for numerous companies from 2003-2006. However, in his application for SSA disability benefits, the Veteran documented he had worked in construction from February 1988 to August 28, 2006 (18 years), where he worked 8 hours a day, five days a week earning $32.00/hour. He also reported working for the month of November 2006 and from January 15, 2007, to March 25, 2007, where he documented he worked 8 hours a day, five days a week earning $32.00/hour. When he was asked in SSA’s application, “When did your illnesses, injuries, or conditions limit your ability to work,” the Veteran responded, “08/28/2006.” In a June 2008 worker’s compensation and orthopaedic surgery consultation, the physician wrote that the Veteran “was functioning and doing well prior to August 28, 2006.” Thus, the Veteran provided numerous, inconsistent facts within his multiple TDIU applications, some of which are also are inconsistent with what he reported to SSA. Above the signature on the VA Form 21-8940, a claimant certifies that “the statements in this application are true and complete to the best of my knowledge,” and the form also notes severe penalties may result in the event the statements provided are false or fraudulent. Making false statements while certifying the truth of such statements damages the Veteran’s overall credibility. Also, in contrast to the Veteran’s report that his service-connected disabilities prevented him from gainful employment since 1985 or 2004, as noted in the October 2003 treatment record, despite noting the Veteran is moderately to severely disabled with regard to his feet, the podiatrist explained that after undergoing surgeries for his bilateral feet deformities, he was placed on disability for approximately two years, but the Veteran’s disability commenced in June 1994 and he was discharged to return to work without restrictions later that month. Thus, despite the Veteran symptoms related to his bilateral feet disabilities, he was able to work without restrictions since June 1994. Also, the Veteran suffered another work-related back injury in 1989 rendering him disabled for four years and during which time he received workers’ compensation and/or a settlement. Subsequently, the Veteran suffered a thumb injury in 1993 which also rendered him disabled temporarily. In addition, the September 2016 VA examiner, as well as other medical evidence of record, indicates that the Veteran’s current complaints were due to his August 2006 work-related injury and the related 2009 back surgery. In this regard, as noted above, the SSA disability adjudication materials also support the conclusion that the Veteran was disabled since August 2006, but not prior to that time, following his work-related injury. In his 2008 Social Security Administration application for disability benefits, the Veteran reported that his left feet, ankle, knee, back, neck, blood pressure medications, and lower extremity disabilities prevented him from working. To reiterate, the Veteran had reported he became unable to work in August 2006 when he incurred a work injury and that he stopped working in March 2007 due to his work injury because he could not stand on his feet for too long. He indicated he worked as a construction electrician from February 1988 to August 2006, November 2006, and January to March 2007. Although Social Security records are not controlling upon the VA, the Board finds these documents probative, as they document the Veteran’s assertion as to when he became unable to obtain substantially gainful employment. Here, in addition to the above, the Veteran again confirmed that his spinal and upper extremity complaints began on August 28, 2006, and that his complaints are the result of the work-related accident/injury, as indicated in the February 2008 private initial consultation. Consistent with this report, the Veteran, again, reported in the February 2009 private neurological consultation that his back pain prior to the August 2006 work injury was a 2 on a pain scale of 1 to 10, however, following the work injury, he gradually developed increased neck and low back pain with pain level of an 8 or 9 on a pain scale of 1 to 10. In the April 2014 private consultation report, the Veteran reported he continued to have lower back pain but was able to continue working until he suffered a work injury in 2006. The Board finds statements made for the purpose of treatment, to include reports of prior medical history pertaining to a current medical issue, tend to be highly reliable, as it is in the patient’s best interest to provide information as accurate as possible to receive the most appropriate treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Notably, in the March 2009 QME report, the physician also apportioned any exacerbation of his back condition to 50 percent to his previous work-related injury in 1989 and 50 percent to his work-related injury in August 2006. The Veteran also indicated his service-connected disabilities, as well as non-service-connected hips, knees, neck, heart, weight gain, and medications, prevented him from working in the March 2020 TDIU application. Therefore, there is insufficient evidence to establish that his service-connected disabilities, alone, would have rendered him unemployable prior to August 29, 2006. Here, the lay and medical evidence, as well as the Veteran’s statements, indicate that he worked full time from February 1988 to August 2006 and that his August 2006 work-related injury rendered him unable to work, as the Veteran made that fact clear in his SSA disability application, where he consistently reported that date (August 28, 2006) as when he became too disabled to work. He consistently documented that date within his SSA application and reported that date to the multiple medical professionals that evaluated him for purposes of SSA disability benefits. Significantly, the Veteran continued to work as a crane/equipment operator until March 2007, despite his allegation that his service-connected disabilities prevented him from obtaining gainful employment since 1985 or 2004. In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term “unable to secure and follow a substantially gainful occupation” as having two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: the Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. As noted in the April 2011 TDIU application, the Veteran earned $80,000.00 in 2003, which is close to 7 times the $12,015.00 poverty threshold for two-person households (the Veteran and his spouse) in 2003 as determined by the U.S. Department of Commerce, Bureau of the Census (Census Bureau). See Faust v. West, 13 Vet. App. 342 (2000). See also Poverty Thresholds, Census Bureau, https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. The Board notes that income for 2004 was not provided, and, notably, the Veteran indicated he was on disability for 8 months during that year. He also did not provide income information for 2005, and because he became disabled due to the August 2006 work injury, the Board cannot utilize the income he provided in the April 2011 TDIU application for 2006. However, based on what the Veteran reported to SSA as to his work history, the Board has some idea of his annual salary for 2004 and 2005. To reiterate, within the SSA disability application, the Veteran reported he worked 8 hours a day, five days a week from February 1988 to August 2006 (18 years), at $32.00/hour, which would have been approximately $66,560/year (40 hours x $32.00 x 52 weeks), which would show that the Veteran was in receipt of an annual salary well above the poverty threshold prior to August 29, 2006, which is evidence that he was securing or following substantially gainful employment during that time period. In addition to considering the Veteran’s ability to obtain substantially gainful employment on an economic basis, the Board has also considered the non-economic components of substantially gainful occupation. The Board emphasizes that the rating assigned for Veteran’s service-connected lumbar spine disability, right and left ankle disabilities, and bilateral feet disabilities, prior to August 29, 2006, contemplate the impact of his disabilities on the Veteran’s activities of daily living, to include employment. As noted above, these disabilities prevent the Veteran from prolonged standing, sitting, or walking, as well as heavy lifting, however, the Board finds that such functional impact could be properly addressed by reasonable work accommodations including the use of intermittent work breaks or alternating physical positions, and limited lifting. Further, despite the Veteran’s limitations, the Veteran was able to work from at least 1995 until he sustained the August 2006 work-related injury, therefore his service-connected disabilities, alone, were not shown to have risen to a level to render him unable to secure and follow a substantively gainful occupation for the period prior to August 29, 2006. When considering the cumulative effects and resulting functional limitations of the Veteran’s service-connected disabilities as a whole, the Board has thoroughly considered the evidence discussed above. The Veteran’s service-connected disabilities have been found to result in no worse than moderate functional limitations without regard to the August 2006 work injury. Specifically, the June 2006 VA examination report showed the Veteran had mild bilateral flatfeet, painful motion, and tenderness to palpation throughout the entirety of both feet, limited range of motion of both ankles as a result of the foot condition, however, the Veteran resisted movement of the ankle joints during the range of motion testing. Regarding the foot condition, the clinician concluded that the Veteran is limited in running and performing other repetitive high-impact activities and Veteran appeared to have limited function for standing or walking, in that he ambulates slowly with a wide-based gait. The September 2007 QME and February 2009 private neurological consultations, April 2014 private consultation explained the Veteran was able to perform his work duties without problems until after the August 2006 work-related injury that also aggravated his current disabilities. Thus, the Board finds that the functional impact of his service-connected disabilities could be properly addressed by reasonable work accommodations including the use of intermittent work breaks or alternating physical positions, as well as limited lifting, prior to the August 2006 work injury. The Board has considered the Veteran’s multiple statements where he indicated that his numerous service-connected disabilities caused him to be unable to be employed; however, the Board does not find these statements credible, as explained in detail above, such statements are inconsistent with his employment history, medical records, SSA disability application, as well as his numerous statements that his August 2006 work-related injury rendered him unable to work. To the extent that the Veteran asserts that he is unable to return to prior employment as crane/equipment driver, the Board notes the Veteran continued to work in this position from 2003 to 2007, which shows that the Veteran would likely have been able to work in the same position had he not suffered the August 2006 work injury. The evidence also shows that the Veteran received a high school diploma and completed one year of college and that his employment for many years involved working as a construction electrician and crane operator. Here, the evidence shows, particularly the SSA records, that the Veteran was working full time and became unable to work due to his August 2006 work-related back injury that required a surgery in 2009. The SSA records show that multiple medical professionals opined that the Veteran was unable to work due to his work-related injury, as well as other non-service-connected disabilities. In sum, the Board finds that the Veteran’s service-connected disabilities, when considered individually and collectively, do not result in functional impairment, which renders the Veteran unable to secure or follow a substantially gainful occupation consistent with his educational and vocational history. Rather, the evidence shows that the Veteran was performing substantially gainful employment prior to August 29, 2006. Therefore, entitlement to TDIU rating is denied for the period prior to August 29, 2006. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski; 1 Vet. App. 49, 53-56 (1990). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, 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.