Citation Nr: 21014353 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 10-46 671 DATE: March 11, 2021 ORDER A 20 percent (but no higher) rating for service-connected lumbosacral spine degenerative changes (low back disability), based on guarding and spasm with abnormal gait or spinal contour, from December 27, 2006 is granted. A 40 percent rating (but no higher) for service-connected low back disability based on limitation of motion is granted from March 14, 2013. A separate 20 percent rating for left lower extremity nerve involvement associated with low back disability from December 27, 2006 is granted. A 40 percent rating (but no higher) for left lower extremity nerve involvement associated with low back disability from November 25, 2008 is granted. A separate 40 percent rating (but no higher) for right lower extremity nerve involvement associated with low back disability from November 25, 2008 is granted. More than a 10 percent rating for service-connected left wrist fracture residuals (left wrist disability) based on limitation of wrist motion or wrist joint ankylosis is denied. A separate 20 percent rating (but no higher) for service-connected left wrist disability based on pronation impairment is granted from December 27, 2006. A separate 40 percent rating (but no higher) for median nerve impairment associated with service-connected left wrist disability is granted from December 27, 2006. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from December 27, 2006 is granted. Special monthly compensation (SMC) based on effective loss of use of the left hand from December 27, 2006 is granted. REFERRED The issue of service connection for a left elbow condition, claimed as epicondylitis, was raised in a February 2008 statement and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The evidence reasonably shows the Veteran’s low back disability produced guarding and spasm severe enough to cause abnormal gait or spinal contour as early as in August 2006, just four months prior to discharge in December 2006. 2. There is no evidence or allegation showing low back disability caused limitation of flexion to 30 degrees or less or any degree of actual or functional ankylosis prior to October 10, 2008. 3. The evidence reasonably shows the Veteran’s low back disability continued to produce functional limitation of flexion to 30 degrees or less in March 2014 and more recent VA examinations show competent reports of flare-ups causing his back to frequently “lock up,” precluding all motion. 4. However, nothing of record suggests the Veteran’s low back disability has, at any time on appeal, caused unfavorable ankylosis of the thoracolumbar spine (i.e., being fixed in a forwards or backwards bending position). Even his own estimates taken in more recent examinations—the most severe disability pictures of record—indicate no flexion or extension of the spine (i.e., fixation in a neutral position). 5. The evidence reasonably shows the Veteran’s low back disability was accompanied by diagnoses of sciatica and left lower extremity radiating pain rated described in the moderate range of pain prior to discharge in December 2006. 6. Nothing of record suggests similar right lower extremity pathology or complaints or more severe left lower extremity radicular symptoms at that time. 7. However, the evidence is at least in relative equipoise as to whether the Veteran’s low back disability produced moderately severe left and right lower extremity radicular symptoms from November 25, 2008. 8. Nothing of record suggests that the Veteran has ever had actual muscular atrophy associated with his lumbar radiculopathy or more extensive and severe symptoms most closely resembling complete paralysis as depicted by the pertinent rating criteria (e.g., foot dangle or drop, lack of any active movement below the knee, weakened or lost flexion of the knee). 9. The evidence reasonably shows the Veteran’s service-connected (nondominant) left wrist disability has caused actual and functional loss of pronation beyond the last quarter of the pronation arc before discharge that continued post-service without convincing evidence of material improvement. 10. The evidence reasonably shows the Veteran’s service-connected left wrist disability caused significantly reduced grip strength before discharge that continued post-service without convincing evidence of material, sustained improvement. Rather, he has developed additional symptoms associated with left wrist disability (e.g., difficulty fully closing the fist, significant weakness on wrist motion) that, along with the pre-existing grip strength deficits, appear analogous to some of the symptoms contemplated by the rating criteria for severe, incomplete median nerve paralysis. 11. However, at no point does the record suggest the Veteran has experienced bone loss, fusion, or other functional impairment causing the hand to be fixed in supination or hyperpronation, more extensive or totally impairing symptoms resembling complete left median nerve paralysis as described in the rating criteria, actual or functional ankylosis of the left wrist between palmar- or dorsiflexion or in ulnar or radial deviation, or other impairment of the left upper extremity associated with left wrist disability that warrants higher or additional ratings. Moreover, the Board’s awards here yield a combined disability rating for his left upper extremity of 60 percent from the day after discharge and is the maximum rating allowable under 38 C.F.R. § 4.68. See also 38 C.F.R. § 4.71a, Code 5125 (providing for a 60 percent rating for amputation of a nondominant hand). 12. With the instant awards, the Veteran’s service-connected disabilities (depressive disorder, rated 30 percent from March 29, 2017; low back disability, rated 20 percent prior to October 10, 2008 and 40 percent thereafter, left sciatic radiculopathy, rated 20 percent prior to November 25, 2008 and 40 percent thereafter, right sciatic radiculopathy, rated 40 percent from November 25, 2008, left wrist limitation of motion, rated 10 percent from December 27, 2006, left wrist impairment of pronation, rated 20 percent from December 27, 2006, and left wrist median nerve involvement, rated 40 percent from December 27, 2006) satisfy the schedular criteria for TDIU under 38 C.F.R. § 4.16(a) from December 27, 2006 (given left wrist weakness is rated 40 percent with a combined 70 percent disability rating from that date). 13. The evidence reasonably shows the Veteran’s low back disability has caused significant interference with prolonged sitting or walking, running, lifting, or forward bending since November 2006 (before discharge) and his symptoms have worsened in severity, duration, and frequency since. Similarly, the Veteran’s left wrist symptoms throughout the appeal period (e.g., moderate to severe pain, significantly decreased grip strength, or loss of pronation beyond the last quarter arc) have significantly impaired gross and fine manipulation with the left hand, third-party lay confirmation that he “cannot close his fist,” “has no power in his grip,” and cannot hold onto anything, a March 2013 military disability evaluation specifically finding him unable to perform fine manipulation, lifting, grasping, lowering, or carrying more than ten pounds due to back and wrist conditions, an April 2015 SSA evaluation indicating “3/5” left hand weakness with inability to close his fist fully, and more recent March 2017, July 2019, and October 2020 examination reports indicating he should avoid carrying or manipulation anything over five pounds with his left hand. 14. Considering the above, including the fact that the Veteran cannot reliably grasp the cane used to compensate for low back disability, carry moderately heavy objects, and perform fine manipulation with both hands and his limited education and work experience (i.e., high school diploma with work experience in medium or greater strength work), the Board finds the evidence is at least in relative equipoise as to whether the service-connected disabilities, taken together, have precluded any employment in an unsheltered setting consistent with his experience and education throughout the appeal period. 15. Finally, given the left wrist disability picture presented by clinical and competent lay evidence of record, the Board also finds the evidence at least in relative equipoise as to whether this disability has produced a combination of impairments (e.g., significantly decreased grip strength since before discharge with weakness in wrist motion that, during the appeal period, precluded movement against gravity, significant limitation of left hand gross and fine manipulation, significant difficulty rotating the left wrist for simple tasks like opening doors) that effectively robbed him of the use of his left hand such that “no effective function remains other than that which would be equally well served by” amputation thereof throughout the appeal period. 38 C.F.R. § 4.63. In so finding, the Board acknowledges that several VA examiners have opined to the contrary, but finds those opinions lacking probative value because they lack any meaningful rationale and do not suggest adequate consideration of the full disability picture or competent lay reports of record. Considering that and the fact that the Board finds the evidence establishes that the Veteran is entitled to schedular left wrist ratings that combine to the 60 percent warranted for loss of use of a nondominant hand, the Board finds SMC based on loss of use of the left hand is also warranted. CONCLUSIONS OF LAW 1. The criteria for a 20 percent (but no higher) rating for service-connected lumbosacral spine degenerative changes (low back disability) from December 27, 2006 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7,4.71a, Diagnostic Code (Code) 5237 (2020). 2. The criteria for a higher 40 percent (but no higher) rating for service-connected low back disability based on limitation of motion from March 14, 2013 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Code 5237. 3. The criteria for a separate 20 percent rating (but no higher) for left sciatica from December 27, 2006 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7,4.124a, Code 8520 (2020). 4. The criteria for a 40 percent rating (but no higher) for left sciatica from November 25, 2008 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7,4.124a, Code 8520 (2020). 5. The criteria for a separate 40 percent rating (but no higher) for right sciatica from November 25, 2008 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7,4.124a, Code 8520 (2020). 6. The criteria for more than a 10 percent rating for service-connected left wrist disability based on limitation of wrist motion or ankylosis are not met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.7,4.71a, Code 5214-15 (2020). 7. The criteria for a separate 20 percent rating (but no higher) for service-connected left wrist disability, based on pronation impairment, from December 27, 2006 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.68, 4.7,4.71a, Code 5213 (2020). 8. The criteria for a separate 40 percent rating (but no higher) for service-connected left wrist disability, based on median nerve impairment, from December 27, 2006 are met. 38 U.S.C. §§ 1155, 5107(b) (2018); 38 C.F.R. §§ 4.3, 4.68, 4.7,4.124a, Code 8515 (2020). 9. The criteria for TDIU are met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25 (2020). 10. The criteria for SMC based on loss of use of the left hand are met. 38 U.S.C. §§ 1114, 1155, 5107(b) (2018); 38 C.F.R. §§ 3.350(2)(i), 4.63. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from May 1980 to October 1980. These matters are before the Board of Veterans’ Appeals (Board) on appeal from November 2007 and May 2008 rating decisions that granted service connection for left wrist and low back disabilities, respectively. The Veteran then filed February and October 2008 claims for the same. As those claims were received within a year of the rating decisions assigning initial ratings, the Board finds they reasonably raise disagreement with those ratings and are valid notices of disagreement (NODs). This appeal was perfected by a timely November 2010 substantive appeal in response to an October 2010 statement of the case (SOC). The Board remanded these matters in February 2017, June 2018, and September 2020. As TDIU and SMC for loss of use were raised by the record during the pendency of the instant increased rating appeals, the Board will consider them as well. See Rice v. Shinseki, 22 Vet. App. 447, 455 (2009). For the reasons outlined in detail above, the Board grants TDIU and SMC based on loss of use of the left hand from the earliest possible effective date (the day following discharge from active service), obviating any need for further detailed analysis thereof at this time. The below analysis will therefore focus primarily on the low back and left wrist increased rating claims on appeal. VA’s duty to notify in this matter was satisfied by a June 2007 letter sent in conjunction with original service connection claims for the disabilities on appeal. The Veteran’s service treatment records (STRs) and pertinent post-service treatment records are of record. The disabilities on appeal were examined by VA on several occasions during the course of this appeal and, together, the associated reports and clinical findings describe the disabilities in sufficient detail to allow the Board to determine and describe the frequency, severity, type, and course of relevant pathology throughout the period on appeal. Crucially, the Veteran has had ample opportunity to respond and has not alleged that notice or development was inadequate. See 38 U.S.C. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Increased Rating The issue on appeal is whether higher initial ratings are warranted for the Veteran’s service-connected low back and left wrist disabilities Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where, as here, the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration. Separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App, 119 (1999). The Board considers not only the specific physical limitations found on clinical evaluation, but also overall impairment of functioning “under the ordinary conditions of daily life, including employment.” 38 C.F.R. § 4.10. Disability of the musculoskeletal system specifically is considered the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Low Back Disability The Veteran’s low back disability is currently rated 10 percent disabling prior to October 10, 2008, 40 percent from that date to March 14, 2013, 20 percent from that date to July 3, 2019, and 40 percent thereafter under the General Rating Formula for Diseases and Injuries of the Spine, which provides for a 20 percent rating where forward flexion is greater than 30 degrees but not greater than 60, combined range of motion is not greater than 120 degrees, or there is muscle spasm or guarding severe enough to result in abnormal gait or spinal contour. 38 C.F.R. § 4.71a. A higher 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis (i.e., in a neutral position, or zero degrees) of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis (i.e., in flexion or extension and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching) of the entire thoracolumbar spine. A maximum 100 percent rating requires unfavorable ankylosis of the entire spine (thoracolumbar and cervical). Id. The rating criteria also requires the Board to evaluate “any associated objective neurologic abnormalities” separately under the appropriate Code. Id. Although spinal disabilities can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, the Board’s review of the evidence of record shows no sufficiently specific evidence or allegation of such episodes as defined in the rating criteria (i.e., nothing of record allows for even a vague estimation of the total duration of any physician-ordered bedrest). For example, while a July 2007 VA examination note indicating he reported two days where he was unable to walk due to thoracolumbar spine problems in the prior week, nothing at that time suggests any physician-prescribed bedrest. Therefore, there is no evidence to support an award under those criteria. 1. A 20 percent rating (but not higher) for service-connected low back disability prior to October 10, 2008 Service treatment records (STRs) show reports of low back pain with guarded gait and stance favoring the left side in August 2006, just four months before discharge. Subsequent STRs show continued tenderness on palpation of the lumbosacral spine, muscle spasms, and varying degrees of painful motion throughout October 2006. June 2007 post-service VA treatment records show continued bilateral paraspinal muscle spasms. On July 2007 VA examination, he continued to show tenderness to palpation in the lumbar area with abnormal gait (“slow pace with mild limping”). A November 2008 VA examination also notes lumbar spasms and tenderness bilaterally. Though the examiner did not note any abnormal gait or spinal contour at that time, subsequent June 2009 VA treatment records show straightening of lumbar lordosis “as may be seen with muscle spasms versus positioning.” Subsequent May 2011, March 2014, and 2017 examinations continue to show guarding or muscle spasms resulting in abnormal gait or spinal contour. Consequently, the Board finds sufficient evidence to satisfy the criteria for a 20 percent rating from December 27, 2006, the day following discharge. What remains for consideration is whether a still higher rating is warranted during this period. As the 30 percent rating do not consider the thoracolumbar spine at all, a higher rating here would require at least a showing of thoracolumbar spine flexion to 30 or less degrees or favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. Unfortunately, the evidence of record during this period does not show such a dire degree of lumbar spine impairment. There is, firstly, no evidence or allegation of actual or functional lumbar ankylosis, favorable or otherwise. Range of motion data during this period does not show flexion limited to 30 or less degrees. At most, July 2007 VA examination findings show 75 degrees of active forward flexion (i.e., the Veteran moving it without assistance) with pain beginning at 45 degrees. Although the Veteran did report flare-ups and pain at the time, he described the associated limitations as “limitations in exercises, unable to run, unable to walk long distances,” without endorsing additional limitation of motion. Similarly, while October 2006 STRs note low back pain throughout range of motion, there is no indication of resultant limitation of motion or actual range of motion measurements. Notably, subsequent records that month showed normal thoracolumbar and lumbosacral range of motion on October 26, 2006 and 70 degrees of flexion with “minimal” pain on October 31, 2006. Even assuming arguendo that the July 2007 figures suggest functional limitation to 45 degrees of flexion by pain, the preponderance of the evidence is still against finding any additional impairment significant enough to bridge the remaining 15-degree gap to cross the threshold required for a higher 40 percent rating. 2. A 40 percent rating (but not higher) for service-connected low back disability from March 14, 2013 to July 3, 2019 From March 14, 2013 to July 3, 2019, the low back disability is rated 20 percent. However, a March 18, 2013 VA examination report just after the beginning of this period shows the Veteran reported extensive low back symptoms that limited him to half a mile (or 15 minutes) of walking at a time. He also reported stiffness, fatigue, spasms, decreased motion, a history of falls, and aggravation of pain by any physical activity or stress. Although he could function with pain if medicated, his pain was nonetheless constant, decreased his walking speed, and contributed to weakness and further limitation of motion. A physical examination found thoracolumbar forward flexion limited to just 40 degrees with pain that began at 10 degrees. In contrast to the earlier findings on July 2007 VA examination or in service, the Board notes that the Veteran here explicitly endorsed additional limitation of motion with pain and, notably, the upper bound of achievable motion was just ten degrees greater than the 30-degree threshold required for a higher 40 percent rating. An April 2015 Social Security Administration (SSA) evaluation does not address or otherwise account for the effect of pain or other subjective factors, but it does show no improvement in range of motion, with lumbar flexion remaining limited to 40 degrees. Although a March 2017 VA examiner indicated the Veteran denied functional loss or impairment due to low back disability and found no functional loss from pain, they also failed to properly elicit or consider detailed reports of such limitations, including during flare-ups or with repeated use over time, even though the Veteran did endorse those exacerbating circumstances. Notably, however, the same examiner found additional functional loss from “less than normal movement due to ankylosis, adhesions, etc.” Given there was no ankylosis or adhesions found at the time, and the symptoms on examination primarily related to painful motion and radicular complaints, this certainly seems to contradict the prior notations dismissing additional functional loss. Either way, range of motion studies noted flexion was still limited to just 40 degrees (even without accounting for the impact of pain). The Board finds it particularly notable that the July 3, 2019 VA examination report (upon which the Agency of Original Jurisdiction (AOJ) based a subsequent award of a 40 percent rating) also found 40 degrees of lumbar flexion on examination but, this time, elicited competent reports that flare-ups and repeated use over time caused further limitation of flexion to an estimated 20 degrees. Although that examiner also found that painful motion did not cause additional functional loss on examination, they nonetheless conceded that clinical test results—which, as far as flexion is concerned, were essentially identical to the prior March 2017 and March 2014 examination reports—were consistent with the Veteran’s descriptions of functioning with flare-ups or repeated use over time, and accepted his estimates of additional flexion limitations under such conditions. Under the circumstances, the Board finds the evidence is at least in relative equipoise as to whether the Veteran’s low back disability caused functional impairment commensurate with that contemplated by the higher 40 percent rating criteria from March 13, 2014 to July 3, 2019. 3. More than a 40 percent rating for service-connected low back disability at any time from October 10, 2008 onwards With the awards in the prior two sections, the low back disability on appeal is rated 20 percent from December 27, 2006 and 40 percent from October 10, 2008, and the only remaining question with respect to limitation of thoracolumbar motion is whether more than a 40 percent rating is warranted at any time from October 10, 2008. Such ratings would require findings of either unfavorable ankylosis of either the entire thoracolumbar spine or the entire spine, or their functional equivalent. Unfortunately, there is no evidence or allegation of such dire spinal impairment at any time on appeal. Nothing of record suggests any actual ankylosis, favorable or otherwise, and while he reported on July 2019 and October 2020 VA examination that his back low back disability “locks up” on several days a week, precluding any bending, such complaints at most suggest the functional equivalent of favorable ankylosis (i.e., fixation in a neutral position). Consequently, the preponderance of the evidence is against awarding more than a 40 percent rating for low back disability at any time on appeal based on limitation of motion. 4. A 20 percent rating for left sciatic nerve involvement from December 27, 2006 In considering whether separate ratings are warranted for the service-connected low back disability based on associated neurological impairment, the Board notes that 38 C.F.R. § 4.124a, Code 8520 provides for a 10 percent rating when incomplete paralysis of the sciatic nerve is mild, a 20 percent rating when it is moderate, a 40 percent rating when it is moderately severe, and a higher 60 percent rating when it is severe, with marked muscular atrophy. A maximum 80 percent rating under this Code requires complete paralysis, characterized by the foot dangling or dropping, loss of all active movement in muscles below the knee, or weakened (or lost) knee flexion. October 2006 STRs show diagnoses of unspecified sciatica and “radicular symptomatology lower extremities.” Later that month, straight leg raising tests were positive for lower back pain but not leg pain. In November 2006, STRs show complaints of low back pain radiating into the left buttock, aggravated by “sitting, walking [more than] 15-20 minutes,” running, lifting, and forward bending. He described this pain as “3/10” at best and “4-5/10” at worst over the preceding week and said radicular symptoms were reduced by “gentle standing lumbar extension.” The diagnosis at the time included lumbar radiculitis. Subsequent records that month and in early December 2006 show he denied leg or hip radiculopathy, but a December 6, 2006 record (weeks before discharge) again show low back pain radiating into the left buttock aggravated by activity. This time, he rated his pain at least “2-3/10” and at most “5-6/10.” Post-service treatment records show limited treatment for low back problems immediately following active duty discharge and a July 2007 VA examination report does not show any significant neurological findings related to the thoracolumbar spine. Considering the above, the Board finds ample evidence of left lower extremity neurological symptoms associated with low back disability (i.e., radiating pain into the left buttock) and a corresponding diagnosis of sciatica (indicating sciatic nerve involvement) dating back to active service. Moreover, the Veteran’s own descriptions of the pain in the month immediately preceding discharge indicates such pain fell between two and six out of ten on a one to ten scale. Without any other reports or evidence to evaluate the severity of those symptoms at the time, the evidence reasonably suggests the average level of radiating pain just before discharge fell somewhere in the middle of the 10-point spectrum and, therefore, the Board finds the evidence is at least in relative equipoise as to whether a separate 20 percent rating for left sciatica associated with the service-connected low back disability (based on “moderate,” incomplete paralysis of the left sciatic nerve) is warranted from December 27, 2006. 5. A higher 40 percent rating for left sciatic nerve involvement and a separate 40 percent rating for right sciatic nerve involvement from November 25, 2008 The pertinent post-service evidence also reasonably shows that neurological involvement associated with low back disability progressively worsened over the years, with the first notable increase in severity documented in a November 2008 VA examination report. At that time, he said his pain was bilateral and severe (“8/10”), occurred one to six times a week lasting three to seven days, and was accompanied by numbness, weakness, unsteadiness, and clinical confirmation of reduced lower extremity sensation bilaterally and reduced (“4/5”) motor strength in the left lower extremity. Subsequent records show he continued to deal with radicular symptoms with no improvement shown on May 2011 VA examination, when it continued to involve severe, constant, and bilateral “electric type shock” sensations with associated numbness, weakness, and clinically confirmed reductions in sensation bilaterally, but had progressed to occurring on a daily basis since November 2008. March 2013 and March 2017 examination reports indicate the Veteran endorsed “moderate” numbness, pain, and paresthesias or dysesthesias (bilaterally in 2013 and on the right in 2017), such symptoms were reportedly “severe” on the left. Despite those reports, the March 2017 examiner felt there was only moderate involvement of the left sciatic nerve, but failed to explain why or reconcile that finding with the subjective reports on examination. While subsequent July 2019 and October 2020 VA examination reports found no signs of radiculopathy, the latter examination does note decreased sensation bilaterally from the lower legs down. The Board finds the evidence is at least in relative equipoise as to whether the Veteran’s low back disability produced lower extremity symptoms and impairment consistent with moderately severe involvement of the sciatic nerve on both sides from November 25, 2008, based on competent lay descriptions of observable symptoms (e.g., numbness, weakness, radiating “electric” pain, dysesthesias, etc.) that alternated between severe and moderate since the November 2008 VA examination. In particular, the Board is mindful that the frequency of the Veteran’s reported symptoms increased following the November 2008 examination and, although more recent examination reports appear to include minimal notations related to neurological impairment, they do not show such problems have permanently resolved, as the Veteran continued to demonstrate decreased lower extremity sensation as recently as October 2020. Accordingly, the Board finds the criteria for a higher 40 percent rating for left sciatic nerve involvement and a separate 40 percent rating for right sciatic nerve involvement are met from November 25, 2008. 6. More than a 20 percent rating for left sciatic nerve involvement or a separate compensable rating for right sciatic nerve involvement prior to November 25, 2008; or more than a 40 percent rating for either left or right sciatic involvement thereafter What remains for consideration is whether higher or additional evaluations are warranted for neurological involvement associated with low back disability at any time on appeal. First, the Board finds no evidence or allegation prior to November 25, 2008 showing either more severe left-sided radicular or neurological symptoms or any such right-sided symptoms. As noted in the above analysis, the statements and reports upon which the Board has based the 20 percent rating awarded during that period is the only relevant evidence with any bearing on the severity of his sciatic symptoms during this period. Therefore, the preponderance of the evidence is against awarding any additional or higher ratings prior to November 25, 2008. Second, ratings in excess of those awarded for left and right sciatic involvement from November 25, 2008 onwards require either “[s]evere” incomplete paralysis “with marked muscular atrophy” or “[c]omplete” paralysis characterized by dangling or dropping feet, “no active movement possible of muscles below the knee,” or weakened or lost knee flexion, and there is no evidence or allegation suggesting such serious and total neurological impairment of either lower extremity during the period in question. See 38 C.F.R. § 4.124a, Code 8520. In so finding, the Board first notes that there is simply no evidence or allegation that the Veteran has ever had any muscular atrophy, foot dangle, or foot drop associated with his lower extremity neurological symptoms. Furthermore, while there is some evidence of reduced muscle strength on November 2008 VA examination (“4/5” strength on left ankle dorsiflexion and plantar flexion and left great toe extension), April 2015 SSA evaluation (noting “4/5 give away weakness of all limbs”), and March 2017 VA examination (“4/5” reduced strength on knee extension), such findings do not show approximate the “complete” or “total” loss contemplated by the criteria for a maximum rating under Code 8520. The Board acknowledges that the criteria do list “weakened” flexion of the knee as an indicator of complete sciatic nerve paralysis, but none of the aforementioned records specifically notes reduction of strength on knee flexion. The closest is a vague notation of “give away weakness of all limbs” on April 2015 SSA evaluation but, notably, that examiner noted earlier that sentence that there was “[n]o definite weakness, atrophies, or fasciculations.” In addition, “4/5” motor strength findings indicate that active movement is possible against resistance, which certainly does not approach the rather dire picture painted by the maximum rating criteria in Code 8520, particularly insofar as it contemplates “no active movement possible of muscles below the knee.” As a final note, the Board notes that there is no evidence or allegation suggesting symptoms or affirmative finding that might implicate involvement of a different nerve associated with low back disability. Consequently, the Board finds the preponderance of the evidence is also against awarding still higher (or additional) ratings at any time from November 25, 2008 onwards. Left Wrist Disability The Board now turns to the Veteran’s service-connected left wrist disability, which is rated 10 percent from December 27, 2006 under Code 5215.   7. More than a 10 percent rating for service-connected left wrist disability based on limitation of palmar- or dorsiflexion or ankylosis along that plane of motion As an initial matter, the Board notes the Veteran’s right-handedness means his left wrist is evaluated as the nondominant or minor joint under the pertinent rating criteria. The Veteran is currently assigned the maximum schedular rating available under Code 5215. Although wrist disabilities may also be evaluated under Code 5214, such ratings all require ankylosis in dorsiflexion, palmar flexion, elsewhere in that plane of motion, or with ulnar or radial deviation, and there is no evidence or allegation suggesting such ankylosis or its functional equivalent at any time on appeal. See 38 C.F.R. § 4.71a, Code 5214. Although the clinical evidence of record does reflect significant left wrist disability, he has always retained some degree of movement between dorsiflexion and palmar flexion and ulnar and radial deviation, even when considering subjective factors such as pain, and his allegations of record suggesting fixation of wrist motion does not refer to the planes of motion contemplated in Code 5214. Consequently, the preponderance of the evidence is against awarding a higher rating for left wrist disability based on limitation of motion or ankylosis under Codes 5214-15. 8. A separate 20 percent rating (but no higher) for left wrist disability based on limitation of pronation from December 27, 2006 The Veteran has recently reported his left wrist disability limits his ability to rotate the wrist (i.e., supination or pronation), and a recent October 2020 VA opinion explicitly described this impairment as “part and parcel” of the service-connected condition. Consequently, the Board will consider whether a separate, compensable rating is warranted for impairment of a wholly separate plane of motion by analogy under Code 5213 (which evaluates the relevant arc of motion as impairment of supination and pronation). Code 5213 allows for a 10 percent rating for limitation of nondominant supination to 30 degrees or less and a 20 percent rating for loss of nondominant pronation beyond the “last quarter of the arc,” or where “the hand does not approach full pronation.” A 20 percent rating is also warranted for loss of nondominant pronation beyond the middle of the arc. A maximum 30 percent rating is warranted under Code 5213 when the nondominant hand is “fixed in supination or hyperpronation.” 38 C.F.R. § 4.71a, Code 5213. Although there is no specific description of the “arc” of motion in the rating criteria, the Board notes that the language in the criteria for ratings based on fixation of the hand in the arc of motion provides some clarity. Specifically, that section contemplates progressively more serious disability from fixation “near the middle of the arc or moderate pronation” to fixation “in supination or hyperpronation.” Id. Given such language describes impairment that is similar to ankylosis, it would appear the criteria considers “the middle of the arc or moderate pronation” to be most favorable (i.e., closer to a neutral position), suggesting the “middle of the arc” is, in fact, zero degrees of pronation or supination (i.e., where the palm is perpendicular to the ground. Therefore, the last quarter of the arc is roughly between 40 and 80 degrees of pronation, as 38 C.F.R. § 4.71, Plate I provides for 85 degrees of supination followed by 80 degrees of pronation for a total of 165 degrees in the entire arc. With those criteria in mind, the Board finds the evidence reasonably shows loss of left forearm and wrist pronation beyond the last quarter of the arc that began in service and has persisted since. The first supination and pronation measurements of record are in November 2006 STRs that show left forearm active supination to 40 degrees and active pronation to 35 degrees and December 2006 records just before discharge show left wrist pronation and supination to 45 degrees. Two days later, a physical examination found active left forearm supination to 65 degrees and pronation to 50 (roughly ten degrees past the last quarter). Post-service, a July 2007 VA examination showed left forearm pronation to 70 degrees and supination to 45 degrees. However, it also indicates he had pain throughout pronation (and supination) and the Veteran also reported left wrist flare-ups that were moderate in severity but occurred weekly and lasted hours, causing additional “limitations in lifting, carrying, holding things.” A December 2010 neurological evaluation in the Veteran’s SSA records indicates full pronation and supination but includes virtually no discussion of his subjective complaints. Contemporaneous SSA records show the Veteran said on multiple occasions that his left wrist was nearly useless to him, that it was weak, or that he would drop things. More recent records—specifically, a March 2013 Army Medical Center disability evaluation report and July 2019 and October 2020 VA examination reports—indicate the Veteran is unable to rotate his wrist to open doors. Given the above, the Board finds that STRs reasonably show limitation of pronation to the first three quarters of the arc, with the best range of motion data indicting only ten degrees of active motion into the last three quarters of the arc, and certainly not “approaching” a full 80 degrees of pronation. It is worth noting that the Board cannot determine whether the July 2007 and December 2010 measurements showing 70 and 80 degrees of pronation reflect active or passive motion (though other range of motion data in the July 2007 VA examination report does separately record active and passive range of motion). There is also no indication that either evaluation accounted for or considered the impact of flare-ups or subjective complaints. While it is true that the STRs describing left wrist pronation and supination also do not include detailed discussions of flare-ups or other exacerbating conditions, their specific evaluation of active motion still allows for a more nuanced understanding of the practical limitations found at the time than the later examinations that, at least facially, suggest improved pronation. Even assuming—for the sake of argument—that those examinations do indicate improved pronation, the fact that SSA, VA, and military medical center records from at least 2010 onwards show repeated reports that his left wrist was of little to no use to him and, more specifically, could not be rotated enough to even open doorknobs (as recently as October 2020), suggests any potential improvement was not sustained under the ordinary conditions of life. Consequently, the Board finds the evidence is still at least in relative equipoise as to whether the Veteran’s left wrist disability precluded the hand from approaching full pronation, warranting a 20 percent rating under Code 5213. What remains for consideration is whether a still higher rating is warranted for impairment of left wrist rotation at any time on appeal. However, Code 5213 only provides for a higher 30 percent rating for a nondominant hand where there is fixation in either supination or hyperpronation. Here, despite the aforementioned reports suggesting he cannot rotate his left wrist to open doorknobs or that is sometimes “locks up,” at no point does he allege or even suggest that his hand is “fixed in supination or hyperpronation,” and there is no clinical evidence of such an obvious deformity. Therefore, the preponderance of the evidence is against awarding a still higher rating for left wrist pronation impairment under Code 5213 at any time on appeal. 9. A separate 40 percent rating for left wrist disability based on significant strength reduction from December 27, 2006 The Board finds the pertinent evidence of record also reasonably shows a separate evaluation based on significant strength reduction associated with left wrist disability is warranted during the appeal period. As a threshold matter, the Board acknowledges that a July 2019 VA examiner opined that a documented diagnosis of median nerve entrapment at the wrist is unrelated to the service-connected wrist disability. However, that same examiner (and other clinical records in the file, including a more recent October 2020 VA examination) also explicitly attributed left wrist motor strength reductions to the service-connected disability at issue here. Moreover, the record consistently notes symptoms spoken of in the same breath as reduced left wrist motor strength (e.g., difficulty grasping items, reduced left wrist motor strength on flexion and extension, difficulty or inability closing the fist) that are among the many factors considered in determining the severity of median nerve paralysis under 38 C.F.R. § 4.124a, Code 8515. Therefore, even without rating the documented median nerve entrapment directly, the Board finds that rating the left wrist strength reduction symptoms by analogy under Code 8515 is appropriate. Code 8515 assigns a 10 percent rating for a nondominant side when incomplete paralysis is mild, 20 percent when it is moderate, and 40 percent when it is severe. A maximum 60 percent rating is assigned for complete paralysis of a nondominant nerve, characterized by inclination of the hand to the ulnar side, “the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at rights angles to palm; flexion of wrist weakened; [or] pain with trophic disturbances.” 38 C.F.R. § 4.124a, Code 8515 (emphasis added). While the Board does note that “pronation incomplete and defective” is among the salient factors for consideration under Code 8515, the rule against pyramiding here prohibits its consideration in this analysis, as it is already compensated for under the award granted in the prior section. However, there is no indication that the factors listed must all be present for all ratings under this Code and, even excluding consideration of pronation impairment (as such would be prohibited under the rule against pyramiding laid out in 38 C.F.R. § 4.14), there is ample evidence to support a rating under Code 8515. STRs show decreased left hand strength associated with his left wrist injury since as early as August 2006, and December 2006 STRs (just before active discharge) show dramatically decreased left hand grip strength comparatively (55 pounds on the left versus 115 pounds on the right)—roughly half the strength of the opposite hand. A July 2007 VA examination report evaluating the left wrist disability noted “overall decrease” in left hand strength and dexterity associated with “pain upon closing fist” with a half-centimeter gap between all fingers and the proximal transverse crease of the hand on maximal flexion. May 2009 treatment records note left wrist pain with unspecified loss of grip strength. In September 2010, he indicated in an SSA form that hs couldn’t use his left wrist. SSA evaluations found he was limited in gross manipulation (handling large objects). A March 2013 VA examination report notes “decreased motor power” in the left wrist and hand despite normal sensation and reflexes. That same month, a disability evaluation at the Eisenhower Army Medical Center indicated the Veteran was unable to perform most basic soldiering skills due to wrist and back disabilities and specifically found he could not perform fine manipulation, grasping, or grip with the left hand. An April 2015 SSA neurological evaluation found “no definite motor weakness, atrophies, or fasciculations,” but noted “3/5 antalgic weakness” in the left hand, which indicates active movement was not possible against any resistance. It also noted he was “unable to full[y] close a fist.” A March 2017 VA examination noted “2/5” left wrist strength in flexion and extension (indicating movement was not possible against only gravity), and the examiner felt this was entirely due to his service-connected condition. There was no evidence of atrophy or ankylosis. The examiner indicated he should lift no more than five pounds (e.g., a two-liter bottle of soda, standard bag of sugar or flour, etc.) with the left wrist. On July 2019 VA examination, the Veteran said he sometimes has to use both hands and wrists and, when he does, must stop shortly after beginning because his pain would flare as soon as he grasps an object with his left hand. A physical examination found “4/5” left wrist strength on flexion and extension (indicating active movement was possible against some resistance) that was attributed to the service-connected condition. There was no sign of atrophy. The examiner felt the Veteran should was “limited in pushing, pulling, or carrying objects that weigh [five] or more pounds, or doing activities that require rapid wrist movement.” As noted above, he also opined that focal entrapment of the left ulnar nerve at the elbow and median nerve entrapment at the wrist that had been found on February 2018 electrodiagnostic studies was unrelated to the service-connected condition because the trajectory of these nerves were “not proximate to the wrist bone involved in the fracture…or to the wrist tendons involved in Dequervain’s tenosynovitis.” On October 2020 VA examination, the Veteran again had “4/5” left wrist strength on flexion and extension, but no sign of atrophy. The examiner agreed that his condition limited his ability to push, pull, lift, or carry objects weighing over five pounds. The Board finds the evidence of record reasonably shows the Veteran’s left wrist strength impairments have been demonstrably severe on clinical evaluation both during service and in the intervening years since (e.g., having only half the strength of the right hand in December 2006, consistent notations of difficulty or inability to close the left fist in several records spanning the following decade, “3/5” weakness in April 2015, and “2/5” weakness in March 2017). Even in the best documented strength testing of record (on more recent July 2019 and October 2020 examinations), he was unable to move against maximum resistance and, crucially, those evaluations were not conducted during flare-ups, which the Veteran competently described in July 2019 as essentially triggered by any attempt to grasp an object with his left hand and required he stop said grasping. Moreover, both of the most recent examiners still felt he should avoid lifting or manipulating anything weighing over five pounds with the left hand. Consequently, the Board finds the evidence is at least in relative equipoise as to whether the Veteran’s left wrist strength impairment has been sufficiently severe to warrant a 40 percent rating under Code 8515 from the day following discharge, December 27, 2006, particularly as STRs already documented a dramatic 50 percent comparative strength deficit earlier that month. 10. Still higher or additional ratings for left wrist disability at any time on appeal The Board has considered whether there are other rating criteria that might be pertinent to the present appeal, particularly as the wrist joint can affect the hands and the forearms concurrently, but finds no evidence or allegation suggesting additional pathology warranting separate evaluation as a direct consequence of the service-connected left wrist disability on appeal (e.g., impairment of the ulna or radius, impairment of the elbow itself, etc.). While the Board makes no specific findings as to whether he has additional elbow complaints and acknowledges that a February 2008 statement alleged epicondylitis (an elbow condition) in the same breath as claiming a higher left wrist rating, he did not allege that epicondylitis is a symptom of his left wrist condition and there is no medical evidence suggesting such a relationship. Under the circumstances, the Board has referred service connection for a left elbow condition for initial adjudication by the AOJ. The Board also cannot find a basis for awarding a still higher rating for his reduced left hand strength by analogy under Code 8515. Such a rating would require complete paralysis of the median nerve and, while the Board is sympathetic to the Veteran’s claim and certainly finds evidence of significantly disabling pathology here, the reported and documented symptoms only resemble some of the symptoms specifically contemplated by complete median nerve paralysis criteria in Code 8515. There is no evidence or allegation of additional such symptoms or of resultant impairments similar to the completely disabling sort laid out in that Code. There is no evidence any muscle atrophy, let alone any that is “considerable,” extensive impairment of finger motion, or an obvious and extremely disabling deformity like “ape hand.” The Board even considered whether range of motion studies of record consistently showing greater left hand ulnar deviation than radial deviation might be liberally read as constituting inclination of that hand “to the ulnar side.” However, a plain reading of that phrase indicates it likely describes an actual and permanent physical deformity rather than simply a comparative movement advantage in one direction. Even assuming—for the sake of argument—that the Board could consider such pathology and incomplete left wrist pronation documented in the record (in contravention of 38 C.F.R. § 4.14), the fact would remain that the resultant disability picture painted by the Veteran’s left hand strength reduction symptoms alone would still not approach the “complete” disability of the left upper extremity depicted in the 60 percent rating criteria under Code 8515. More importantly, the Board notes that, with the instant awards, the Veteran’s left wrist disability is rated 10 percent under Code 5215, 20 percent under Code 5213, and 40 percent under Code 8515 from December 27, 2006 and, as such, has a combined rating of 60 percent since the day after discharge. See 38 C.F.R. § 4.25 (describing the process for combining disability ratings). This is the maximum allowable schedular rating for such disability under the governing regulations, which preclude the combined rating for disabilities of an extremity to exceed that awarded for amputation thereof—60 percent under Code 5125 for amputation or loss of use of a nondominant hand. See 38 C.F.R. §§ 4.68, 4.124a, Code 5125.   Considering the above, the Board grants the appeals seeking higher ratings for low back and left wrist disabilities in part and denies them in part. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Yuan, 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.