Citation Nr: 21013337 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 18-30 717 DATE: March 9, 2021 ORDER Entitlement to service connection for a cervical spine disability is denied. Entitlement to an initial rating in excess of 40 percent for lumbar spine disability is denied. Entitlement to an initial compensable evaluation for bilateral paronychia is denied. FINDINGS OF FACT 1. The Veteran’s cervical spine disability is not etiologically related to service and did not manifest within one year of separation from active service. 2. Throughout the period on appeal, the Veteran’s lumbar spine disability has not been productive of unfavorable ankylosis of the entire thoracolumbar spine, he has not experienced incapacitating episodes lasting a total duration of at least 6 weeks during the last 12 months, and there is no evidence of disc herniation with compression and/or irritation of the adjacent nerve root. 3. Throughout the period on appeal, the Veteran’s bilateral paronychia has not affected 5 percent or more of his entire body or exposed areas; nor has it required intermittent systemic therapy. CONCLUSIONS OF LAW 1. The criteria for service connection for cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for an initial rating in excess of 40 percent for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.71a, DC 5242. 3. The criteria for an initial compensable rating for bilateral paronychia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7806-7820. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2002 to November 2006 and May 2008 to May 2011. In September 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. In February 2020, the Board remanded the claim for further development. 1. Entitlement to service connection for a cervical spine disability Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Moreover, certain chronic diseases may be presumed to have been incurred during service if they are established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown by demonstrating “(1) that a condition was ‘noted’ during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.” Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board.”). However, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a), such as arthritis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Analysis The Veteran contends that his cervical spine disability is related to service. The Veteran has a current diagnosis of degenerative arthritis of the cervical spine. As such, element one under Shedden is met. The Veteran’s STRs document a 2006 motor vehicle accident (MVA). As such, element two under Shedden is met. The Veteran’s service treatment records (STRs) do not document complaints, treatments, and/or diagnosis of a cervical spine condition. During his August 2002 Report of Medical Examination: Enlistment exam, the Veteran’s neck was clinically normal. On February 2, 2006, the Veteran was seen at the Naval hospital. He was discharged with a diagnosis of chest pain after an MVA. On February 15, 2006 and in March 2006, the Veteran was seen for chest pain due to the MVA. During his October 2006 Report of Medical Examination, Separation Exam, the examiner noted that the Veteran had a tattoo on his neck. Clinically, his neck was normal. On his separation examination paperwork, the Veteran stated that he experienced lower back issues and knee bruises due to an MVA. However, a neck injury or disability was not noted on separation exam by either the Veteran or the examiner. During his March 2008 Retention exam, the Veteran noted that he was involved in a MVA and experienced chest and lower back pain and anxiety. However, he did not note a neck injury, pain, or disability. During his June 2011 Report of Medical Examination, Separation Exam, the Veteran stated that due to strenuous activities performed during active duty, he had been injured on multiple occasions. He stated that he suffered from an injury or illness, i.e., rheumatoid arthritis, while on active duty for which he did not seek medical care. However, he was receiving treatment for depression; posttraumatic stress disorder; chronic migraines; right shoulder, elbow, and hand issues; left hand issues; sleep apnea; lower back and chest pain; hernia; shin splints; and chronic ingrown toenail. However, he did not mention a neck injury. Additionally, the examiner noted that the Veteran’s neck was clinically normal. In October 2015, the Veteran was seen at the LAOPC CBOC. The examiner noted a history of recurring neck pain. In November 2017, the Veteran was seen at a private facility. He was diagnosed with cervical spondylosis, cervical degenerative disk disease, and cervical radiculitis. During his September 2019 Board hearing, the Veteran stated that he injured his neck during a 2006 MVA and also while playing rugby. He stated that he was placed on profile for about a month or two, then he returned to training. He stated that his condition became chronic and reoccurring. In September 2020, the Veteran was afforded a VA examination to determine the nature and etiology of his cervical spine disability. The Veteran stated that his condition began in 2006 after an MVA. He also injured his neck in 2008 to 2011 during physical fitness training, i.e., while playing Rugby. He stated that, on multiple occasions, he was tackled and had mild concussions. When his neck condition began, his symptoms include headache, pain in the neck, difficulty moving his head in different directions, numbness in the arms, and weakness. He was treated for the condition. He was provided with pain medications throughout his military career and was placed on profile. He took Tramadol, Naproxen, Ibuprofen, Tylenol, Analgesic creams, Lidocaine, and muscle relaxers. At the time of the exam, the Veteran’s symptoms included sharp pain in his neck, difficulty moving his head, weakness, occasional numbness in the arm, stiffness, and pain in the left trapezius. He used analgesic cream, Lidocaine, Cyclobenzaprine, Methocarbamol, Naproxen, TENS unit, ice pack, heat pad, and saw a chiropractor. The examiner diagnosed the Veteran with degenerative arthritis of the cervical spine. The examiner opined that the claimed condition is less likely than not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that there is no documentation of neck pain in the Veteran’s STRs, and no documentation of neck pain on his separation exam. The Veteran requested treatment for neck pain on February 7, 2020, where he reported continued neck pain. Based on the documentation, the examiner stated that the Veteran’s neck pain did not start in service. In December 2020, the September 2020 VA examiner opined that the claimed condition is less likely than not (50 percent or greater probability) incurred in or caused by the claimed inservice injury, event, or illness. The examiner stated that the Veteran’s STRs document a 2006 car accident. However, there was no documentation of neck pain, and no documentation of neck pain in the Veteran’s STRs. During his September 2020 VA examination, the Veteran reported neck pain since the car accident. The examiner stated that whiplash injuries are common in motor vehicle accidents. The examiner stated that the Veteran’s current cervical spine condition, degenerative arthritis, is at least as likely as not related to the 2006 car. The Board notes that although the examiner stated that the Veteran’s current neck condition is at least as likely as not related to the 2006 car accident, the Board finds that reading this statement in context with the rest of the opinion, it is clear that the examiner meant that the Veteran’s current disability is less likely than not related to the 2006 MVA. In a January 2021 opinion, the VA examiner (not the 2020 examiner) opined that the claimed condition is less likely than not (less than 50 percent or greater probability) incurred in or caused by the claimed in service injury, event, or illness. The examiner stated that there is no chronic or recurrent neck condition diagnosis or treatment during the Veteran’s time in service. Additionally, the Veteran’s STRs do not document a diagnosis/treatment for a neck condition following the 2006 MVA. On the Veteran’s August 2006 Separation exam, a lower back condition was listed; however, there was no mention of a neck condition. The Veteran’s medical records do not document treatment for a neck condition until 2017, i.e., many years after service. The examiner stated that that cannot be back dated to service. The examiner also stated that there is no evidence of continuity of care of the neck condition. Therefore, the Veteran’s degenerative arthritis of the spine diagnosed in September 2020 is less likely than not (less than 50 percent probability) a residual of the MVA in 2006. Based on the evidence of record, the Board finds that the preponderance of the evidence is against service connection on a direct and/or presumptive basis. The Board notes that the Veteran’s STRs do not document complaints, treatments, and diagnosis for cervical spine condition. During service, the Veteran was involved in an MVA. However, after the accident, the Veteran complained of back and chest pain. Additionally, the 2020 and 2021 VA examiners opined that the claimed condition is less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The 2020 examiner stated that there is no documentation of neck pain in the Veteran’s STRs, and no documentation of neck pain on his separation exam. The January 2021 examiner stated that there is no chronic or recurrent neck condition diagnosis or treatment during time in service. Additionally, the Veteran’s STRs do not document a diagnosis/treatment for a neck condition following the 2006 MVA. On the Veteran’s August 2006 Separation exam, a lower back condition was listed; however, there was no mention of a neck condition. The examiner stated that the Veteran’s medical records do not documents treatment for a neck condition until 2017, i.e., many years after service, and this cannot be back dated to service. The examiner stated that there is no evidence of continuity of care of the neck condition. Therefore, the Veteran’s degenerative arthritis of the spine diagnosed on the September 2020 is less likely than not a residual of the MVA in 2006. Additionally, the Board notes that the first medical evidence of cervical spine complaint was in 2015, i.e., four years after discharge from service. The fact that there were no records of any complaints or treatments involving the Veteran’s cervical spine disability for many years weighs against the claim. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (it was proper to consider the veteran’s entire medical history, including a lengthy period of absence of complaints). Therefore, the Board finds that element three under Shedden has not been met. The Board also finds that service connection for cervical spine degenerative arthritis on a presumptive basis is not warranted as the record does not show evidence of degenerative arthritis within one year of separation from active duty. The first competent evidence suggestive of degenerative changes was in 2017, i.e., six years after his discharge from service. As there is no competent evidence that the disability manifested to a compensable degree within one year of his active service and was not continuous since service, a presumption of service connection under 38 C.F.R. §§ 3.307, 3.309 is not warranted. The Board acknowledges that the Veteran statements regarding the etiology of his cervical spine disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). However, the Board finds that the Veteran’s STRs are more reliable evidence and have more probative value than the Veteran’s more recent lay statements. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). His STRs are replete with other medical documentation, to include back and chest pain, and it is reasonable to find that a neck injury would have been recorded. In the absence of a nexus, the claim for service connection for cervical spine disability is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). Increased Rating Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran’s condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. 2. Entitlement to an initial rating in excess of 40 percent for a lumbar spine disability The spine is rated under 38 C.F.R. § 4.71a, DCs 5235-5243 according to a General Rating Formula for Disease and Injuries of the Spine (General Formula) unless DC 5243 is evaluated under the Formula for Rating intervertebral disc syndrome (IVDS) based on incapacitating episodes. During the pendency the Veteran’s appeal, VA amended criteria for rating musculoskeletal disabilities. The new regulation applies to claims received on or after February 7, 2021 or previously filed claims that are pending on February 7, 2021 if the new regulation will render more favorable result for the Veteran. As such, the Board will evaluate the Veteran’s disability under both old and new regulations for the entire appeal period and choose the more favorable result. The new regulation revises the rating criteria for DCs 5242 for degenerative arthritis, degenerative disc disease other than IVDS. It notes that the rater should also see either DC 5003 or 5010. Diagnostic code 5243, IVDS, was also revised. The revision states that 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. The Board notes that the other DCs remain unchanged. Under the General Formula, a 50 percent rating contemplates unfavorable ankylosis of the entire thoracolumbar spine. There is no equivalent rating under the IVDS Formula. Under the IVDS Formula, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no equivalent rating under the General Formula. Under the General Formula, a 100 percent rating contemplates unfavorable ankylosis of the entire spine. There is no equivalent rating under the IVDS Formula. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case, the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. Analysis The Veteran contends that his disability is more severe than the rating depicts. In April 2016, the Veteran was seen at the LAOPC CBOC. The Veteran complained of pain in his low back. The Veteran had full range of motion (ROM and normal muscle strength. In August 2016, the Veteran was afforded a VA examination to determine the nature and etiology of his lumbar spine disability. The Veteran stated that his symptoms began in 2004 when he was lifting heavy items and performing physical activities. Since onset, the condition had gotten worse. The examiner diagnosed the Veteran with lumbosacral strain and degenerative arthritis of the spine. The Veteran reported flare- ups, i.e., he stated that when he was performing activities such as prolonged sitting, standing, walking, repetitive bending, and heavy lifting, he was limited by pain. He also reported functional loss or functional impairment, to include impaired prolonged sitting, standing, walking, repetitive bending, and heavy lifting. The Veteran’s initial ROM were all normal. Pain was noted on forward flexion, left and right lateral flexion, extension, and left and right lateral rotation. The pain caused functional loss. The examiner noted evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, i.e., the examiner noted mild TTP, lumbosacral spine and paralumbar soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with at least three repetitions. After repetitive use testing, the Veteran’s forward flexion was from zero to 80 degrees, extension from zero to 20 degrees and left and right lateral flexion, and left and right lateral rotation were all from zero to 25 degrees. Pain was noted on exam and caused functional loss. The Veteran was examined immediately after repetitive use over time. Pain and lack of endurance significantly limited functional ability with repeated use over a period of time. After repetitive use over time, the Veteran’s forward flexion was from zero to 75 degrees, extension from zero to 15 degrees and left and right lateral flexion, and left and right lateral rotation were all from zero to 20 degrees. The examination was not conducted during a flare-up. The examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during flare up. Pain, fatigue, and lack of incoordination significantly limited functional ability with flare ups. The examiner was unable to describe in terms of ROM. The examiner stated that objective determination of whether the Veteran is experiencing a flare-up or not can only be determined by someone like PMD/PCP who has prior acquaintance with the Veteran’s body and has determined a non-flare-up base like for comparison. The examiner stated that the VA exam is a limitation of the revised DBQ’s. The examiner stated that he could neither confirm nor refute flare-up status (in all cases, because he see them once). Therefore, he could not verify if the objective ROM that he was observing after repetitive use represents ROM during flare-up or not without resorting to speculation. The examiner noted localized tenderness, guarding, or muscle spasms of the spine. However, the Veteran’s muscle spasms, guarding, and localized tenderness did not result in abnormal gait or abnormal spinal contour. There were additional contributing factors of disability, to include less movement than normal. Bilateral muscle strength testing was normal, and he did not have muscle atrophy. Reflex and sensory exams were normal. Straight leg raising testing was negative. There were no signs or symptoms due to radiculopathy. He did not have IVDS, ankylosis, or another other neurologic abnormalities or findings related to his back disability. He did not use an assistive device as a normal mode of locomotion, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to the Veteran’s condition. Imaging revealed arthritis/mild degenerative disc disease (DDD), L4-5, FJA, L4-5. The Veteran did not experience thoracolumbar vertebral fracture with loss of 50 percent or more of height. His condition impacted his able to work, i.e., the disability impaired his ability to sit, stand, and walk for prolong periods of time. Additionally, the disability affected his ability to bend repeatedly and left heavy objects. In October 2017, the Veteran was afforded a VA examination to determine the severity of his back disability. The Veteran stated that he had attended physical therapy and was given a TENS unit for back pain. He stated that his pain had gradually worsened. The examiner confirmed the Veteran’s degenerative arthritis of the spine. The Veteran reported flare-ups, to include dull, aching pain that radiated down to his left knee. He also reported functional loss or functional impairment, i.e., the pain prevented prolonged sitting, made it hard to sit up straight, and he was unable to stand or walk for prolong periods of time. The Veteran’s ROM was abnormal. Forward flexion was from zero to 70 degrees; extension from zero to 20; left lateral flexion was from zero to 25 degrees; and right lateral flexion and right and left lateral rotation were all from zero to 30 degrees. The abnormal ROM itself contributed to functional loss, i.e., it affected the Veteran’s bending and lifting. Pain was noted on forward flexion, extension, right lateral flexion, and right and left lateral rotation. The pain caused functional loss. There was evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation, i.e., the examiner noted moderate pain in the lumbar region of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with at least three repetitions. Pain was noted on exam and caused functional loss. After repetitive use testing, the Veteran’s forward flexion was from zero to 70 degrees, extension and left and right lateral flexion were from zero to 30 degrees, and left and right lateral rotation were from zero to 20 degrees. The Veteran was examined immediately after repetitive use over time. Pain and fatigue significantly limited functional ability with repeated use over a period of time. After repetitive use over time, the Veteran’s forward flexion was from zero to 40 degrees, extension and left and right lateral flexion were from zero to 20 degrees, and left and right lateral rotation were from zero to 15 degrees. The examination was not conducted during a flare-up. The examiner stated that the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. Pain, fatigue, weakness, and lack of incoordination significantly limited functional ability with flare ups. The examiner stated that during a flare up, the Veteran’s forward flexion, extension, right and left lateral rotation, and right and left lateral flexion were all from zero to five degrees. The Veteran experienced muscle spasm that resulted in abnormal gait or abnormal spinal contour. There were additional contributing factors of disability, to include disturbance of locomotion, interference with sitting, and interference with standing. Bilateral muscle strength testing was normal. There was no muscle atrophy. Reflex exam was normal. Bilateral sensory exam was normal except the examiner noted decreased sensation in the Veteran’s right foot/toe. Bilateral straight leg raising testing was positive. The examiner noted signs or symptoms due to radiculopathy, i.e., the Veteran experienced moderate intermittent pain in his right lower extremity and severe intermittent pain in his left lower extremity. The Veteran’s radiculopathy was mild on the right side and moderate on the left. The Veteran did not have any other signs or symptoms of radiculopathy. He did not have ankylosis or any other neurologic abnormalities or findings related to his back disability. The examiner noted IVDS. However, the Veteran had not had any episodes of acute signs and symptoms due to IVDS that required bedrest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran used a back brace on a regular basis as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to the Veteran’s condition. The Veteran did not experience thoracolumbar vertebral fracture with loss of 50 percent or more of height. His condition impacted his able to work. He stated that his low back pain prevented extended standing and walking, and the heavy film equipment that he had to carry on his shoulders aggravated the back pain. He further stated that he worked 12-hour days and was in pain at the end of every workday. In September 2020, the Veteran was afforded a VA examination to determine the severity of his lumbar spine disability. At the time of the examination, the Veteran’s symptoms included pain, stiffness, radiculopathy pain in the legs, and numbness in the left leg and loss of mobility. The Veteran was treated with methocarbamol, naproxen, cyclobenzaprine, TENS unit, analgesic cream, lidocaine. He also saw a chiropractor. He stated that his condition hindered and severely limited his ability to stand or sit for long periods. He also had difficulty sleeping due to pain. His condition prevented him from continuing physical fitness and his previous job that required long days of moving around. The examiner confirmed the Veteran’s degenerative arthritis of the spine and degenerative arthritis of the spine with lumbosacral strain diagnoses. The Veteran reported severe flare-ups which occurred daily. The flare-ups could last from several hours up to two days. The back flare-ups were precipitated by moving around, walking, or standing or sitting for long periods. The flare-ups were alleviated by an ice pack, heat pad, pain meds, muscle relaxers, rest, Epsom salt, bath, and fasting. The Veteran reported functional loss or functional impairment, i.e., he stated that the pain prevented him from moving, walking, standing, and sitting. The Veteran’s ROM was abnormal. Forward flexion was from zero to 40 degrees, extension and right and left lateral rotation were from zero to 15 degrees, and left and right lateral flexion were from zero to 20 degrees. The abnormal ROM itself did not contributed to functional loss. Pain was noted on forward flexion, extension, right and lateral flexion, and right and left lateral rotation. The pain caused functional loss. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation, i.e., the Veteran experienced moderate pain in his right lower lumbar paraspinal region, consistent with his diagnosis. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner noted no additional loss of function or ROM after three repetitions. The Veteran was examined immediately after repetitive use over time. However, the examination was not conducted during a flare-up; the examiner stated that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare-up. Pain significantly limited functional ability with repeated use over a period of time and during a flare up. After repetitive use over time and during a flare up, the Veteran’s forward flexion was from zero to 30 degrees, and extension, left and right lateral flexion, and left and right lateral rotation were all from zero to 10 degrees. There was objective evidence of pain on passive ROM testing and objective evidence of pain on non-weight bearing testing. The Veteran did not have guarding and muscle spasms. There were no additional contributing factors of disability. Bilateral muscle strength testing was normal. There was no muscle atrophy. Reflex and sensory exams were normal. Straight leg raising test was negative, and the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. He did not have IVDS, ankylosis or any other neurologic abnormalities or findings (such as bowel or bladder problems/pathologic reflexes) related to his back disability. The Veteran used a back brace on a regular basis as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to the Veteran’s condition. The Veteran did not experience thoracolumbar vertebral fracture with loss of 50 percent or more of height. The Veteran’s condition impacted his ability to work. The Veteran stated that he was unable to run or jump, hike, do yard work, sit, drive or stand for long periods of time. He was also unable to bend or lift more than 20 lbs. In December 2020, VA noted that September 2016 VA examiner opined that the symptom flare-ups could not be determined without resorting to speculation. VA noted that under Sharp v. Shulkin, the examiner should have reviewed the record before determining that a value could not be obtained. VA sort clarification from the September 2020 VA examiner. The September 2020 VA examiner noted that flare up based on exam on September 2020 ROM during flare up were, forward flexion from zero to 30 degrees and extension, right and left lateral flexion, and right and left lateral rotation were all from zero to 10 degrees. Based on the evidence of record, the Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for lumbar spine disability. As previously noted, a 50 percent disability rating is warranted if there is evidence of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, DC 5242. There is no evidence on record that the Veteran suffers from ankylosis, favorable or unfavorable. Therefore, under the General Rating Formula for Diseases and Injuries of the Spine, the Veteran is not entitled to a rating in excess of 40 percent. Under the formula for rating IVDS, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Under the revised regulations, 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root. The Board notes that the 2017 VA examiner noted that the Veteran had IVDS; however, the Veteran did not have incapacitating episodes of IVDS having a total duration of at least 4 weeks but less than 6 weeks during the last 12 months. Additionally, there is no evidence of disc herniation with compression and/or irritation of the adjacent nerve root. See 38 C.F.R. § 4.71a, DC 5235-5243. As such, the Board finds that a rating in excess of 40 percent. The Board has also considered whether an increased evaluation could be assigned based on functional loss due to the Veteran’s subjective complaints of pain. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the Veteran already receives the maximum disability rating available for limited motion in the lumbar spine absent ankylosis. In addition, the medical evidence does not suggest that the severity of the Veteran’s service-connected lumbar spine disability is the functional equivalent of ankylosis. Notably, the VA examinations and medical treatment records have demonstrated that the Veteran had at least some ROM in his lumbar spine. Therefore, the Board finds that the current 40 percent evaluation adequately portrays any functional impairment, pain, and limitation of motion that the Veteran experienced due to his back disability. See DeLuca, 8 Vet. App. 202; 38 C.F.R. §§ 4.40, 4.45, 4.59. As to whether additional compensation for neurological impairment is warranted, the General Rating Formula requires consideration of neurological findings, to include bladder or bowel impairment, separate from orthopedic manifestations. The Board notes that the Veteran is already service connected for radiculopathy of the right and lower extremity. With respect to neurological findings of bladder or bowel impairment, the Veteran did not have any neurologic abnormalities or findings related to a lumbar spine condition. With respect to conducting a rating examination relative to joint dysfunction, the Court held that a VA examination of the joints must, wherever possible, include the results of the ROM testing described in the final sentence of § 4.59 which are tests as to pain on active and passive motion, including weight-bearing and non-weight-bearing and, if possible, with range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168-70. Here, the spine is a single group of joints and, as such, there is no opposite joint, much less an undamaged opposite joint. Thus, the holding in Correia is not applicable. Therefore, the Board finds that the preponderance of the evidence is against finding that the Veteran’s disability picture more nearly approximates a rating in excess of 40 percent. 3. Entitlement to an initial compensable evaluation for bilateral paronychia The Veteran’s skin disorder has been rated under 38 C.F.R. § 4.118, DC 7806-7820. Hyphenated DCs are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. In this case, DC 7820 applies to infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic diseases). It directs that the disability be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending on the predominant disability. The Board notes that VA published a final rule amending its regulations on skin disabilities effective August 13, 2018. The amendment, in pertinent part, added a “General Rating Formula for the Skin” for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended DCs 7801,7802,7817,7819,7825, 7826, 7827,7829. See 83 Fed. Reg. 32,592 (July 13, 2018). The claims pending prior to the effective date will be considered under both old and new rating criteria, and whichever criteria is more favorable to the Veteran will be applied. Under the regulations in effect at the time the Veteran filed his claim in November 2015, DC 7806 provided a 10 percent evaluation of at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas affected, or; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted if the skin condition covers 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted if the skin condition covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Under the new General Rating Formula for the Skin, a 10 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, DC 7806. For the Veteran’s case, the results and pertinent criteria are essentially the same. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. Analysis The Veteran contends that his disability is more severe than the rating depicts. In September 2016, the Veteran was afforded a VA examination to determine the nature and etiology of his bilateral toe condition. The Veteran stated that his symptoms began in January 2003. The condition occurred due to wearing boots. The examiner diagnosed the Veteran with bilateral paronychia. The Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck. He did not have any benign or malignant skin neoplasms (including malignant melanoma) or any systemic manifestations due to any skin diseases (such as fever, weight loss, or hypoproteinemia associated with skin conditions such as erythroderma). The Veteran had not been treated with oral or topical medications in the past 12 months for any skin condition. Additionally, he did not have any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. He did not have any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis or any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The Veteran did not have dermatitis, eczema, bullous disorder, psoriasis, infections of the skin, cutaneous manifestations of collagen-vascular disease, or papulosquamous disorder. Additionally, he did not have acne, chloracne, vitiligo, alopecia, hyperhidrosis or benign or malignant neoplasm or metastasis related to any of the diagnoses. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his condition. The Veteran’s skin condition did not have an impact on his ability to work. During his September 2019 Board hearing, the Veteran, through his representative, stated that from time to time, he used corticosteroid (Clindamycin) for his skin condition. The Veteran stated that the Clindamycin was prescribed for another skin condition; however, it was implied that he could use the Clindamycin for his bilateral paronychia. He used the cream once or twice every couple of months. In September 2020, the Veteran was afforded a VA examination to determine the severity of his bilateral paronychia. At the time of the exam, the Veteran stated that his symptoms included swelling and pain. The Veteran used antiseptic cleaning solution, antibiotic ointment, and Clindamycin. The examiner confirmed the Veteran’s bilateral paronychia diagnosis. The Veteran had not been treated with medication in the past 12 months for his skin condition, and he had not had any treatments or procedures other than systemic or topical medications in the past 12 months. The Veteran’s paronychia covered less than five percent of his exposed area and less than five percent of his total body area. At the time of the exam, he did not have a skin condition without any visible characteristic lesions. Additionally, the Veteran did not have cellulitis; however, he had ingrown toenails on his bilateral big toes. The Veteran did not have acne, chloracne, vitiligo, scarring alopecia, alopecia areata, hyperhidrosis, chronic urticaria, primary cutaneous Vasculitis, erythroderma, or benign or malignant neoplasm or metastases related to his skin condition. The Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his condition. The Veteran’s skin condition impacted his ability to work, i.e., the Veteran stated that he could not walk for long periods when cellulitis occurs. Based on the evidence of record, the Board finds that a compensable rating under DC 7820-7806 is not warranted. In this case, the VA examiners stated that the Veteran’s bilateral paronychia covered less than five percent of exposed area and less than five percent of total body area. Additionally, the Veteran had not been treated with oral or topical medications nor had he had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. The Board notes that during his Board hearing, the Veteran stated that he used a corticosteroid. However, the Veteran also stated that the corticosteroid was not prescribed for his bilateral paronychia but for another skin condition. The Board finds that, in this case, the use of a corticosteroid was not a required treatment for the Veteran’s bilateral paronychia condition. Therefore, based on the evidence, a compensable rating is not warranted based on the old or amended regulation. See 38 C.F.R. § 4.118, DC 7820-7806. The Board also considered whether the Veteran’s bilateral paronychia warrant a higher or separate rating under DCs 7800, 7801, 7802, 7804, or 7805. In this case, the Veteran’s disability did not cause scarring or disfigurement of the neck, head, or face. Therefore, a higher or separate rating is not warranted under DC 7800. The Board notes that the evidence does not reflect that the Veteran has burn scars which are deep and nonlinear in an area of 144 square inches or greater; his scars were not unstable or painful, and were not noted to cause functional loss. As such, a higher or separate rating is not warranted under DCs 7801, 7802, 7804, and 7805. Additionally, the evidence does not reflect that the Veteran has dermatitis, eczema, bullous disorder, psoriasis, benign or malignant neoplasm, infections of the skin, cutaneous manifestations of collagen-vascular disease, or papulosquamous disorder, vitiligo, acne, chloracne, alopecia, or hyperhidrosis. As such, a higher or separate rating is not warranted under DCs 7806, 7815, 7816, 7818, 7819, 7820, 7821, 7822, 7823, 7828,7829, 7831, and 7832. Id. The Board has considered the Veteran and his representative’s statements regarding the severity of the Veteran’s skin condition. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiner’s findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that a compensable rating is not warranted for the Veteran’s bilateral paronychia. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See Gilbert, 1 Vet. App. at 55-56; 38 U.S.C. § 5107(b). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Moore 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.