Citation Nr: 21013389 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-35 295A DATE: March 9, 2021 ORDER Entitlement to disability rating of 20 percent, but not higher, prior to April 16, 2012 for degenerative disc disease (DDD) and degenerative joint disease (DJD) of the lumbosacral spine (hereinafter referred to as a “lumbosacral spine disability”) is granted. Entitlement to disability rating in excess of 20 percent prior to July 14, 2017 for the lumbosacral spine disability is denied. Entitlement to disability rating in excess of 40 percent from July 14, 2017 for a lumbosacral spine disability is denied. Entitlement to a separate rating for right lower extremity radiculopathy of the femoral nerve, evaluated as 10 percent disabling, is granted. Entitlement to a separate rating for left lower extremity radiculopathy of the femoral nerve, evaluated as 10 percent disabling, is granted. Entitlement to a disability rating in excess of 20 percent for a right shoulder disability on an extraschedular basis is denied. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability on an extraschedular basis is denied. Entitlement to a compensable initial rating prior to April 5, 2017 for tension headaches is denied. Entitlement to a rating in excess of 50 percent as of April 5, 2017 for tension headaches is denied. FINDINGS OF FACT 1. The most probative evidence establishes that the Veteran’s service-connected lumbosacral spine disability likely resulted in forward flexion 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, for the entire period on appeal prior to July 14, 2017. During this same period, the Veteran’s service-connected lumbar spine disability did not result in limitation of forward flexion of the thoracolumbar spine of 30 degrees or less or incapacitating episodes. 2. From July 14, 2017 has the Veteran’s lumbosacral spine disability resulted in limitation of forward flexion of the thoracolumbar spine of 30 degrees or less; ankylosis of the entire thoracolumbar spine or of the entire spine, or incapacitating episodes of intervertebral disc syndrome having a total duration less than 6 weeks. During this same period, the Veteran’s lumbosacral spine disability has not resulted in unfavorable ankylosis of the thoracolumbar spine, nor is there a finding of incapacitating episodes of intervertebral disc syndrome having a total duration of at least 6 weeks. 3. The Veteran’s right lower extremity radiculopathy of the femoral nerve resulted in no more than mild incomplete paralysis and has been shown to be present prior to October 17, 2017. 4. The Veteran’s left lower extremity radiculopathy of the femoral nerve resulted in no more than mild incomplete paralysis and has been shown to be present prior to February 24, 2016. 5. The manifestations of the Veteran’s service-connected right shoulder disability are reasonably described by the rating criteria and do not present such an exceptional disability picture with such related factors as frequent periods of hospitalization or marked interference with employment, as to render impractical the application of the regular schedular standards. 6. The manifestations of the Veteran’s service-connected left shoulder disability are reasonably described by the rating criteria and do not present such an exceptional disability picture with such related factors as frequent periods of hospitalization or marked interference with employment, as to render impractical the application of the regular schedular standards. 7. Prior to April 5, 2017, the Veteran did not experience characteristic prostrating headache attacks. 8. Beginning April 5, 2017, the Veteran experienced severe migraines with very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for a rating of 20 percent, but no higher prior to April 16, 2012 for lumbosacral spine disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.13, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5243. 2. The criteria for a rating in excess of 20 percent prior to July 14, 2017 for lumbosacral spine disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.13, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5243. 3. The criteria a rating in excess of 40 percent from July 14, 2017 for lumbosacral spine disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.13, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5243. 4. The criteria for a separate 10 percent schedular rating, and no higher, for right lower extremity radiculopathy of the femoral nerve were met prior to October 17, 2017. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8526. 5. The criteria for a separate 10 percent schedular rating, and no higher, for left lower extremity radiculopathy of the femoral nerve were met prior to February 24, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8526. 6. The criteria for an initial extraschedular evaluation for the Veteran’s service-connected right shoulder disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.321. 7. The criteria for an initial extra-schedular evaluation for the Veteran’s service-connected left shoulder disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.321. 8. Prior to April 5, 2017, the criteria for an initial compensable rating for tension headaches were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 9. Beginning April 5, 2017, the criteria for a disability rating in excess of 50 percent for tension headaches are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1972 to October 1975, from November 1975 to November 1979, and from November 1981 to November 1994. In October 2018, the Board remanded the Veteran’s claims for a disability rating in excess of 10 percent prior to April 16, 2012; in excess of 20 percent from April 16, 2012, to July 13, 2017; and in excess of 40 percent thereafter for the lumbosacral spine disability as well as the increased rating claims for the right and left shoulder disabilities on an extraschedular basis. The Board also denied the claim of entitlement to a compensable initial rating prior to April 5, 2017, and a rating in excess of 50 percent as of April 5, 2017, for tension headaches. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court) which, in a February 2020 Order, vacated and remanded the issues for action consistent with a Joint Motion for Partial Remand (JMPR). To comply with the Court-granted JMPR, the Board, in turn, remanded this claim to the agency of original jurisdiction (AOJ) in July 2020. There has been substantial compliance with October 2018 and July 2020 remand directives. In a November 2017 rating decision, the AOJ granted a separate 10 percent, evaluation for right lower extremity radiculopathy, effective October 17, 2017. The AOJ also granted a separate evaluation for left lower extremity radiculopathy, rated 10 percent, effective February 24, 2016 and 20 percent disabling, effective October 17, 2017. In an April 2020 rating decision, the AOJ reduced the evaluation for left lower extremity radiculopathy to 10 percent, effective July 1, 2020. The Veteran has not appealed the evaluations or the effective date assigned. Hence, these issues are not before the Board. Here, the Veteran’s lumbosacral spine disability rating was reduced, but eventually restored to the 40 percent rating; that rating was effective since July 14, 2017. See April 2020 and October 2020 rating decisions. Thus, addressing the propriety of this rating reduction is unnecessary. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. 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 from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to disability rating of 20 percent prior to April 16, 2012 for a lumbosacral spine disability 2. Entitlement to disability rating in excess of 20 percent prior to July 14, 2017 for a lumbosacral spine disability 3. Entitlement to disability rating in excess of 40 percent from July 14, 2017 for a lumbosacral spine disability The Veteran’s service-connected lumbar spine disability is evaluated under Diagnostic Code 5242 (degenerative arthritis of the spine), which assigns ratings based upon the General Rating Formula for Rating Diseases and Injuries of the Spine (General Formula). 38 C.F.R. § 4.71a. Diagnostic Code 5242 refers the rater to Diagnostic Code 5003, which provides that degenerative arthritis, established by x-ray findings, is to be rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or where there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when 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 where there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted 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 warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for ankylosis of the entire spine. 38 C.F.R. § 4.71a. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees; extension from 0 to 30 degrees; lateral flexion bilaterally from 0 to 30 degrees; and rotation bilaterally from 0 to 30 degrees. 38 C.F.R. § 4.71a, Plate V. Prior to July 14, 2017 The Board finds that the preponderance of the evidence for the period on appeal prior to July 14, 2017 demonstrates that a 20 percent rating is warranted. Private treatment reports dated beginning in 2011 reflect the Veteran’s complaints of pain, tightness, and muscle spasm in his back. Additional private treatment reports dated in April 2012 reflect that the Veteran active thoracolumbar range of motion was decreased by or to 50 percent flexion and 15-20 percent extension and 25 percent in bilateral ration and side bending. The range of motion reported approximates lumbar flexion of 45 degrees. Pain was also reported upon range of motion testing. The Veteran was provided a VA examination in July 2013 wherein he was noted to have DJD and IVDS of the lumbar spine. He reported having flare-ups with pain, stiffness, and inability to do household chores or yardwork. Upon range of motion testing, the Veteran had forward flexion to 80 degrees, and a combined range of motion of at least 205 degrees. Pain was noted upon range of motion testing at 5 degrees prior to the endpoints. The Veteran did not have localized tenderness or pain to palpation of joints or guarding and/or muscle spasm of the lumbar spine. He was not noted to have ankylosis. The Veteran did not have additional limitation of motion following repetitive motion testing. The examiner noted that the Veteran’s functional loss and/or functional impairment to be less movement than normal and pain on movement. The addition limitation of functional ability during flare-ups and repeated use over time included pain, weakness, fatigability, and incoordination. Although the examiner noted that he was unable to provide additional degree of range of motion los, there was no range of motion loss after three repetitions. Additionally, the Veteran was observed to have IVDS of the lumbar spine, however, there were no incapacitating episodes over the prior 12 months. Based on a review of the available evidence, we find that the severity of the Veteran’s lumbosacral spine disability warrants a rating of 20 percent, but no higher for the entire period on appeal prior to July 14, 2017. The Veteran has reported, and the medical records show, the Veteran complained of muscle spasm and back pain which causes reduced range of motion. However, the symptoms associated with the Veteran’s lumbar spine DJD and IVDS did not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine 30 degrees or less or any favorable ankylosis. The Veteran had lumbar spine forward flexion to no less than 45 degrees. Additionally, the Veteran’s IVDS did not result in any incapacitating episodes. Prior to July 14, 2017, the assigned 20 percent evaluation for the Veteran’s lumbar spine disability fully contemplates all muscle spasm and gait symptoms, as well as all motions other than flexion; these need not be further discussed here. The objective evidence of record does not show that the Veteran’s lumbar spine disability was ever manifested by forward flexion of the thoracolumbar spine to 30 degrees or less or by favorable ankylosis of the entire thoracolumbar spine. Additionally, an alternative rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted as the Veteran has not exhibited any incapacitating episodes during the relevant period and, therefore, a rating under the General Rating Formula for Diseases and Injuries of the Spine is more favorable. There accordingly exists no basis for a lumbosacral spine disability rating in excess of 20 percent prior to July 14, 2017. 38 C.F.R. § 4.71, Diagnostic Codes 5242. From July 14, 2017 Since July 14, 2017, the assigned 40 percent evaluation for the Veteran’s lumbar spine disability fully contemplates all muscle spasm and gait symptoms, as well as all motions. The Veteran was afforded a VA examination in October 2017. At that time, he reported having flare ups twice per year and functional impairment consisting of worsening pain, difficulty walking, difficulty completing ADL’s and that he has to rest in bed during flare-ups. Range of motion testing revealed flexion to 30 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees, and right and left lateral rotation 20 degrees, with pain noted in all planes. The examiner also noted that the Veteran’s IVDS required bed rest prescribed by a physician and treatment by a physician with episodes of bed rest having a total duration of at least one week but less than two weeks during the prior 12 months. The October 2017 VA examination did not completely evaluate the Veteran’s flare-ups by ascertaining adequate information, such as frequency, duration, characteristics, severity, or functional loss. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). However, it was noted the Veteran’s reports that his flare-ups consisted of worsening pain, difficulty walking and completing activities of daily living, the inability to do anything, and resting in bed. Thus, the Board remanded the claim for an examiner to fully address the Veteran’s flare-ups and any additional limitations that may result. The Veteran was afforded another VA examination in July 2019. He then reported flare-ups which occur daily, lasting hours and moderate in severity. However, the Veteran denied functional loss or functional impairment. The Veteran’s range of motion testing revealed forward flexion to 75 degrees and extension, lateral flexion, and lateral rotation to 20 degrees each with pain noted in flexion and extension. There was no evidence of pain with weight bearing. The Veteran performed repetitive motion testing with three repetitions without additional loss of function or range of motion after three repetitions. The examiner also reported that the Veteran’s exam was being conducted after repetitive use over time and during a flare-up, and that pain, weakness, fatigability, or incoordination did not significantly limit functional ability. Based on a review of the relevant evidence during this period, the Board finds that a rating in excess of 40 percent is not warranted at any time since July 14, 2017. Specifically, the evidence demonstrates that the Veteran’s lumbar spine disability, at its worst, was manifested by forward flexion of the thoracolumbar spine to 30 degrees or less. See October 2017 VA spine examination report. Moreover, the Veteran’s July 2019 VA spine examination shows forward flexion limited to 75 degrees with no additional loss in range of motion during repetitive use. This evidence would suggest possible improvement in the Veteran’s lumbar spine disability. In any event, the objective evidence of record does not show that the Veteran’s lumbar spine disability was ever manifested by unfavorable ankylosis of the entire lumbar spine. Additionally, an alternative rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted as the Veteran has not exhibited incapacitating episodes with a total duration of at least 4 weeks during the relevant period. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Accordingly exists no basis for a lumbosacral spine disability rating in excess of 40 percent from July 14, 2017. 38 C.F.R. § 4.71, Diagnostic Codes 5242. The Board also acknowledges the reports of constant pain associated with the Veteran’s lumbosacral spine disability during the periods considered above. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. However, as previously noted, the General Formula for disabilities of the spine expressly states that the criteria and ratings apply “with or without symptoms such as pain.” See 38 C.F.R. § 4.71a, General Rating Formula. In other words, the presence of pain is already considered in the formula. 68 Fed.Reg. 51454 -5 (Aug. 27, 2003) (“Pain is often the primary factor limiting motion, for example, and is almost always present when there is muscle spasm. Therefore, the evaluation criteria provided are meant to encompass and consider the presence of pain, stiffness or aching, which are generally present when there is a disability of the spine.”) As such, the Board does not find that any higher rating is warranted based on the Veteran’s reports of low back pain, to include on flare-ups or after repetitive movement. Neither the Veteran nor his representative has identified any other rating criteria that would provide a higher rating or an additional rating. However, the potential applications of various provisions of Title 38 of the Code of Federal Regulations have been considered as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Codes 5242 and 5243, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). These changes to the rating criteria need not be discussed here because they do not affect or allow for a more favorable outcome in this case. The Board has considered whether the Veteran should receive increased initial ratings for the service-connected neurologic abnormalities associated with his lumbar spine disability. The Veteran’s service-connected right lower extremity neuropathy is rated 10 percent disabling under the criteria of 38 C.F.R. § 4.124a, Diagnostic Code 8520 effective October 17, 2017. The service-connected left lower extremity neuropathy is rated 10 percent disabling under the criteria of 38 C.F.R. § 4.124a, Diagnostic Code 8520 effective February 24, 2016 and July 1, 2020 and rated 20 percent disabling from October 17, 2017 to June 30, 2020. Turning to a separate rating or ratings for neurological abnormalities associated with lumbosacral spine disability, as stated at Note (1) above, the Board must evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. Absent organic changes, the maximum rating will be moderate, unless sciatic nerve involvement is shown. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, is usually characterized by a dull and intermittent pain, of typical distribution, so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. For disease of the peripheral nerves, the term “incomplete paralysis” when used with peripheral nerve injuries indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral combine with application of the bilateral factor. Radiculopathy of the femoral nerve is evaluated pursuant to DC 8526. Such provides for a 10 percent rating for mild incomplete paralysis of the femoral nerve; a 20 percent rating for moderate incomplete paralysis of the femoral nerve; and a 30 percent rating for severe incomplete paralysis of the femoral nerve. Further, a 40 percent rating is warranted where there is complete paralysis of the femoral nerve with paralysis of the femoral nerve with paralysis of quadriceps extensor muscles. The words “moderate” and “severe” are not defined in 38 C.F.R. §§ 4.120-4.124 a. In applying the schedular criteria for rating peripheral nerve disabilities, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The RO has already granted a separate rating for left lower extremity radiculopathy, rated as 10 percent disabling from February 24, 2016, 20 percent disabling from October 17, 2017 to July 1, 2020, and 10 percent thereafter. Additionally, a separate 10 percent rating was assigned for the right lower extremity from October 17, 2017, the date of a VA examination report in which right lower extremity radiculopathy or sciatic neuropathy was shown. However, the Board notes that the 2013 VA examination report reflects moderate intermittent pain and paresthesias and/or dysesthesias. Straight leg raising testing was positive bilaterally. Sensory and strength testing was normal. The examiner indicated that the Veteran had moderate radiculopathy involving both femoral nerves. Private treatment reports showing complaints of numbness in his left leg as well as radiating pain. Accordingly, the Board finds that separate 10 percent ratings under Diagnostic Code 8526 should be granted for the period on appeal prior to February 24, 2016 and October 17, 2017, for the left and right lower extremities, respectively. Based upon a review of the record, the Board finds ratings in excess of 10 percent of the femoral nerves are not warranted. When the involvement is wholly sensory, as here, the rating should be for the mild, or at most, the moderate degree. Although the July 2013 VA examiner reported the severity to be moderate, the symptoms reported are primarily sensory with normal strength noted. While the Veteran’s private 2012 treatment record reflect some diminished strength in the left hip and knee, he consistently maintained active movement against gravity. The evidence does not show neurological manifestations, other than bilateral lower extremity radiculopathy, for which separate ratings should be assigned. The Board finds that the Veteran’s service-connected lumbosacral spine disability symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine. Because the preponderance of the evidence is against the Veteran’s claim for any higher ratings, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other 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 veteran or reasonably raised by the evidence of record). 4. Entitlement to a disability rating in excess of 20 percent for a right shoulder disability on an extraschedular basis 5. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability on an extraschedular basis The Veteran was initially assigned a 10 percent rating for his right shoulder disability, effective November 26, 1979. An April 2004 rating decision increased the rating to 20 percent, effective December 22, 2003, under 38 C.F.R. § 4.71a, DC 5003-5201. Additionally, the Veteran was assigned a 10 percent rating for his left shoulder disability, effective November 28, 2011. A September 2017 rating decision increased the rating to 20 percent, effective November 28, 2011, under 38 C.F.R. § 4.71a, DC 5201. The Veteran contends that extraschedular consideration are warranted for his right and left shoulder disabilities. Specifically, in his May 2004 Notice of Disagreement (NOD), he complained of spasms in both shoulders, tight constrictions of his connective tissues that were at times very painful across his shoulder blades, radiating across his back and upper shoulders. Despite substantial effort to control both shoulders, he was able to suppress them for only minutes or hours at times before the “tension buil[t] and the spasms [came] back in a flood.” He stated that the spasms could “last for variable lengths of time, and [were] sometimes uncontrollable.” He reported that his “shoulder shrugging” made social adjustment “terribly problematic,” and interfered with his daily activities. In November 2011, the Veteran reported that his ongoing shoulder pain and discomfort gave him significant problems during prolonged standing, walking, and even sitting at times. In his September 2013 NOD, the Veteran contended that a higher rating was warranted for his left shoulder disability as it had “a lot of painful motion with daily activities” and he did not have full use of his left shoulder because of the discomfort. Additionally, he stated that range of motion (ROM) of the right shoulder varied, and that sometimes he experienced pain if he lifted his arm chest-high. He had limitation of motion of the arm at shoulder level and frequently experienced a lot of aching pain, along with muscle spasm and twitching. In his June 2018 appellate brief, the Veteran contended that increased ratings should be granted. He reported additional symptomatology not reflected in the rating criteria. As such, he asserted that higher evaluations are warranted under 38 C.F.R. §§ 4 and 3.321(b)(1). Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation Service, is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards.” 38 C.F.R. § 3.321(b)(1) (2017). The Board notes that changes were made to § 3.321 effective January 8, 2018, but the changes are not relevant to this case. The amendment clarified that an extraschedular rating is to be applied to an individual service-connected disability and may not be based on the combined effect of more than one service-connected disability. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). 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 considered contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, 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 those provided by the regulation as “governing norms.” 38 C.F.R. § 3.321 (b)(1) (related factors include “marked interference with employment” and “frequent periods of hospitalization”). The Board has jurisdiction to review determinations of the Director of Compensation Service regarding a veteran’s entitlement to an extraschedular rating. Anderson v. Shinseki, 23 Vet. App. 423 (2009). A February 2004 VA examination report reflects the Veteran’s report of chronic muscle spasms, and his ability to function at 100 percent of his usual capacity during flare-ups. However, he stated that his shoulder would twitch and jump, which interfered with his driving and exercising. He had flexion and abduction to 180 degrees without pain; no additional limitation; no fatigue, weakness, lack of endurance, or incoordination; and no ankylosis. X-rays revealed a normal right shoulder. In May 2004, the Veteran’s wife stated that the Veteran had always had uncontrollable twitching, but that it had increased with more pain associated with his right shoulder disability. He experienced an increase in twitching and pain after driving even short distances, discomfort with wearing a seat belt, and pain all the time. An October 2004 VA examination report reflects the Veteran’s report of constant pain in his right shoulder with a tic, as well as weakness, pain, and the inability to control his shoulder well. He denied that he was considered to be incapacitated due to the right shoulder tic, did not claim that he was recommended for bedrest, and did not claim any specific functional impairment resulting from the tic. On examination, the appearance was abnormal on the right due to an obvious constant twitching of the muscles throughout the right shoulder, although the appearance of the left shoulder was within normal limits. His right shoulder had flexion to 140 degrees, at which point pain began; and abduction to 170 degrees, at which point pain began. There was no ankylosis, and ROM was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. X-rays revealed evidence of degenerative, arthritic changes with mild to moderate severity at the acromioclavicular (AC) joint. The diagnosis of chronic muscle spasm with tic of unknown etiology in the right shoulder was changed to chronic muscle spasm with tic of unknown etiology of the right shoulder, and DJD of the right shoulder with probable impingement syndrome (right rotator cuff). A July 2013 VA examination report reflects diagnoses of bilateral shoulder strain, right shoulder DJD, and right AC joint DJD. The Veteran reported constant tics of the right shoulder with flare-ups described as rapid twitching that occurred with prolonged sitting, standing, or walking. ROM testing demonstrated flexion and abduction to 180 degrees with pain beginning at 175 degrees bilaterally, with no additional limitation in ROM following repetitive-use testing. The Veteran did not have ankylosis, an AC joint condition, or any other impairment of the clavicle or scapula. X-rays revealed degenerative changes in the right shoulder and a small osteophyte of the medial humeral head. An August 2013 VA examination report reflects diagnoses of bilateral shoulder strain, left DJD of the AC joint, and left subacromial spur. The Veteran reported flare-ups consisting of twitching that promoted pain and discomfort. His right shoulder had flexion to 180 degrees with no objective evidence of painful motion, and abduction to 180 degrees with pain beginning at 175 degrees. His left shoulder had flexion and abduction to 180 degrees with pain beginning at 175 degrees. He did not have additional limitation in ROM following repetitive-use testing. He did not have ankylosis, any AC joint condition, other impairment of the clavicle or scapula. X-rays of the left shoulder reflect moderate degenerative narrowing of the AC joint and subacromial spur. SSA records reflect that, in May 2015, the Veteran reported that he could lift his right arm out front without any problems, but that it hurt to raise his arm completely overhead. VA treatment records reflect that in October 2015, ROM was significantly limited as the Veteran could not flex or abduct past 90 degrees. He also complained of pain in the shoulders with movement and an involuntary twitch in the bilateral shoulders described as feeling “heavy on [his] shoulders” and as a “shrug of the shoulders,” which occurred either unilaterally or simultaneously and “all the time.” In November 2015, both shoulders had forward flexion to 130 degrees on active motion and to 135 degrees on passive motion, and abduction to 100 degrees on active motion and 120 degrees on passive motion. A February 2016 VA examination report reflects review of the Veteran’s claims file and diagnoses of bilateral shoulder impingement syndrome, bilateral glenohumeral joint osteoarthritis, and bilateral acromioclavicular joint osteoarthritis. The Veteran denied any flare-ups. Both shoulders had flexion and abduction to 90 degrees; pain was noted on examination but did not result in or cause functional loss. Repetitive use testing did not result in additional functional loss or ROM. Neither shoulder had ankylosis. There is no clavicle, scapular, AC, or sternoclavicular joint condition suspected. There is also no condition or impairment of the humerus. DC 5201 reflects that a rating in excess of 20 percent requires that motion be limited to 25 degrees from the side. Although the Veteran has experienced limitation in motion of his arms, there is no indication that it was ever limited to the point that a 30 percent rating is warranted, specifically limited to 25 degrees from his side. Forward flexion and abduction, even after pain is considered, has been limited, at the most severe, to 90 degrees bilaterally. Although the Veteran had pain on examination, the February 2016 VA examiner stated that there was no additional functional loss or ROM. Moreover, the Veteran stated that he experienced pain when he lifted his right arm chest-high in his September 2013 NOD, and that he could lift his right arm out front without any problems but experienced pain when he raised it completely overhead in May 2015. The Veteran reported flare-ups at the February 2004, July 2013, and August 2013 VA examinations although he denied flare-ups at his February 2016 VA examination. Additional limitation in ROM is not indicated during flare-ups. At his February 2004 VA examination, the Veteran stated that he was able to function at 100 percent of his usual capacity during flare-ups. At his July 2013 and August 2013 VA examinations, he reported flare-ups consisting of rapid twitching that resulted in pain and discomfort. In October 2018, the Board remanded the claim for referral to the Director of Compensation Service for consideration of an extraschedular rating, which was referred in December 2019. According to the October 2020 advisory opinion, the Director, after noting the medical evidence set forth above and specifically the reports of twitching, involuntary tics, and muscle spasms associated with the bilateral shoulder disabilities, found that the evidentiary record fails to demonstrate any impairment to earning capacity based on exceptional or unusual factors for bilateral shoulder conditions. Thun v. Peake, 22 Vet. App. 111 (2008). Accordingly, the Director denied entitlement to an extra-schedular evaluation under the provisions of § 3.321(b)(1). The Board finds the weight of the competent evidence demonstrates the Veteran does not meet the criteria for extraschedular ratings in excess of 20 percent for his right and left shoulder disabilities. The Board finds that the Veteran has reported muscle spasms, tics and flare-ups involving twitching during the appeal. However, to the extent that the Veteran’s muscle spasms, tics, and twitching impact the Veteran’s pain and limitation of motion, the rating criteria contemplate these symptoms. See Diagnostic Codes 5010-5201. Even if the rating criteria were considered to not reasonably describe the disability level and symptomatology, the Board does not find that the Veteran’s shoulder disabilities exhibit other related factors such as marked interference with employment and frequent hospitalization. To the extent that the shoulder disabilities affect the Veteran’s employment, the Board notes that the rating schedule contemplates the effects of the disability on the Veteran’s ability to function under the ordinary conditions of daily life, including employment. As the evidentiary record fails to demonstrate any impairment to earning capacity based on exceptional or unusual factors of the bilateral shoulder conditions, the Board finds that extraschedular ratings are not warranted in this case. 6. Entitlement to a compensable initial rating prior to April 5, 2017 for tension headaches The Veteran contends that, for the period prior to April 5, 2017, a compensable rating is warranted for his tension headaches. His headaches are rated as noncompensable from March 8, 2013, to April 5, 2017, under 38 C.F.R. § 4.124a, DC 8199-8100. A diagnostic code ending in “99” and followed by a hyphen connotes a disability which does not exist in the rating schedule and instead has been rated as analogous to a different disability which does exist in the rating schedule. 38 C.F.R. § 4.20. The RO determined that tension headaches are most closely analogous to DC 8100 for migraines. Under DC 8100, a 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating requires characteristic prostrating attacks occurring on an average once a month over the last several months. A 10 percent rating requires characteristic prostrating attacks averaging one in two months over the last several months. A noncompensable rating is applied for less frequent attacks. In this case, an August 2013 VA examination report reflects a diagnosis of tension headaches, which did not require medication. The Veteran reported pulsating or throbbing pain on both sides of the head, which worsened with physical activity, as well as nausea. He did not have characteristic prostrating attacks. Social Security Administration (SSA) records include a May 2015 treatment record reflecting daily headaches. VA treatment records from February 2016 reflect the Veteran’s report of migraines described as light-headed and throbbing pain in the forehead with no radiation, light or sound sensitivity, nausea, or vomiting. They occurred daily and lasted one hour after taking motrin or Tylenol. Prior to April 5, 2017, the relevant evidence reflects that the Veteran did not experience prostrating attacks at all. In fact, the August 2013 VA examination report reflects that he did not require medication and specifically stated that he did not have characteristic prostrating attacks. Subsequently, it was noted that the Veteran had daily headaches. Although they were minimized and only lasted an hour after taking over-the-counter medication, there is no indication of characteristic prostrating attacks during this period of time, which are required in order to warrant a compensable rating. Higher ratings are not warranted, as even when not considering the ameliorative effects of medication, the evidence is not reflective of prostrating attacks averaging once per month. The Board observes that the Veteran’s headaches were alternative characterized as either tension headaches or migraine headaches. Nonetheless, while the Veteran reported daily headaches, he specifically denied experiencing prostrating attacks. As such, a compensable rating is not warranted prior to April 5, 2017. Based on all of the evidence of record, the Board finds that the level of disability of the Veteran’s tension headaches most closely approximates the currently assigned noncompensable evaluation under DC 8100 prior to April 5, 2017, as the evidence of record does not demonstrate that the Veteran suffered from prostrating headaches, which is necessary for a compensable rating. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. 7. Entitlement to a rating in excess of 50 percent as of April 5, 2017 for tension headaches The Veteran’s tension headaches have been rated at a 50 percent rating under DC 8100 as of April 5, 2017. On April 5, 2017, he complained of severe migraines, which occurred twice a week and were frontal in nature. He felt pressure and heaviness in his head, had no vision changes, and had light sensitivity. An October 2017 VA examination report reflects review of the Veteran’s claims file and diagnoses of chronic tension headaches and cervicogenic headaches. The Veteran reported that his headaches had worsened about eight months prior with daily headaches, pressure, throbbing with associated eye strain, dizziness, photophobia, phonophobia, and neck pain. He had pulsating or throbbing pain on both sides of the head along with nausea, and sensory changes (such as feeling of pins and needles in the extremities). He had daily debilitating headaches that lasted for hours, characteristic prostrating attacks once every month, and very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. The Veteran worked as a substitute teacher, but was unable to work in over six months as his headaches were debilitating and relieved by Fioricet and sleep. The Veteran was afforded another VA examination in August 2020 wherein the VA examiner noted that the Veteran’s diagnose of migraine headaches is a progression of the previous diagnosis of tension headaches. The Veteran continued to have characteristic prostrating attacks once every month. The Veteran has been granted the highest rating available for tension headaches under the VA rating schedule as of April 5, 2017. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. This rating compensates the Veteran for the impairment of earning capacity resulting from his frequent, severe tension headaches, to include their impact on his occupational functioning, as specifically noted in the rating criteria. The Board considered whether the Veteran’s service-connected tension headaches presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). The Board compared carefully the level of severity and symptomatology of the Veteran’s service-connected tension headaches with the established criteria found in the rating schedule. The Board finds that the symptoms associated with the service-connected tension headaches addressed in this decision are fully addressed by the rating criteria under which such disability is rated. Indeed, the ratings currently assigned for the disability contemplate the overall functional loss from the symptomatology attributable to the Veteran’s headaches, characterized by whether they cause prostrating attacks and the severity of such, as detailed above.   Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Williams, 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.