Citation Nr: 21022715 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-14 796 DATE: April 19, 2021 ISSUE Whether entitlement to a disability rating in excess of 10 percent for chronic back pain with Scheuermann’s Disease prior to May 15, 2013, and in excess of 40 percent thereafter, is warranted. ORDER For the period on appeal prior to May 15, 2013, an increased evaluation of 20 percent, but no greater, for the Veteran’s chronic back pain with Scheuermann’s Disease is granted. For the period on appeal from May 15, 2013, an increased evaluation in excess of 40 percent for the Veteran’s chronic back pain with Scheuermann’s Disease is denied. FINDINGS OF FACT 1. For the period on appeal prior to May 15, 2013, the Veteran’s chronic back pain with Scheuermann’s Disease manifested pain, forward flexion of the thoracolumbar spine limited to at most to 60 degrees with painful motion, and a combined range of motion limited to at most to 175 degrees with painful motion, without evidence of other neurological abnormalities, favorable or unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of acute signs and symptoms requiring bed rest and treatment prescribed by a physician having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 2. For the period on appeal from May 15, 2013, the Veteran’s chronic back pain with Scheuermann’s Disease manifested pain, forward flexion of the thoracolumbar spine limited to at most to 15 degrees with painful motion, and a combined range of motion limited to at most to 85 degrees with painful motion, without evidence of other neurological abnormalities, unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of acute signs and symptoms requiring bed rest and treatment prescribed by a physician having a total duration of at least 6 weeks during the past 12 months. CONCLUSIONS OF LAW 1. For the period on appeal prior to May 15, 2013, the criteria for the assignment of an increased evaluation of 20 percent, but no greater, for the Veteran’s chronic back pain with Scheuermann’s Disease have been met. 38 U.S.C. § 1155, 5107, 5110; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5242, 5243. 2. For the period on appeal from May 15, 2013, the criteria for the assignment of an increased evaluation in excess of 40 percent for the Veteran’s chronic back pain with Scheuermann’s Disease, have not been met or approximated. 38 U.S.C. § 1155, 5107, 5110; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5242, 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Air Force from September 1980 to April 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in June 2018; a transcript of that hearing is of record. In September 2018, the Board remanded the Veteran’s low back claim for further development, including the scheduling of another VA spine examination, which occurred in February 2019. Accordingly, the Board hereby finds that substantial compliance with its remand directives has occurred. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that a March 2016 rating decision granted the Veteran’s increased rating claim and awarded an increased evaluation of 20 percent, effective May 15, 2013, and an April 2020 rating decision granted the Veteran’s increased rating claim and awarded an increased evaluation of 40 percent, effective May 15, 2013. However, because these awards amount to less than the maximum benefit available for the Veteran’s low back disability claim, and because the Veteran has not indicated that he is satisfied with either the 20 percent or the 40 percent evaluations effective May 15, 2013, the Veteran’s increased rating claim for his low back disability, to include chronic back pain with Scheuermann’s Disease, remains on appeal before the Board. See Harper v. Wilkie, 30 Vet. App. 356, 359-61 (2018), citing Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). 1. For the period on appeal prior to May 15, 2013, an increased evaluation of 20 percent, but no greater, for the Veteran’s chronic back pain with Scheuermann’s Disease is granted. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1115; 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Disability evaluations are based upon the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable to issues raised in the record and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). 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 required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. §§ 4.7, 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of the veteran’s disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other VA regulations, regardless of whether they were raised by the Veteran, as well as the entire history of the Veteran’s disability. See 38 C.F.R. §§ 4.1, 4.2; see also Schafrath, 1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran’s disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). However, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily 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. See 38 C.F.R. § 4.40. It is essential that the examination on which disability ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. See id. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. See id. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. See id. The evaluation of joint disabilities must involve the following factors: less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination and impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity, or atrophy of disuse. See 38 C.F.R. § 4.45. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing must also be considered. See id. A rating based on painful motion of a joint may be appropriate regardless of whether the painful motion stemmed from joint or periarticular pathology. See Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). Functional loss caused by pain must be rated as though it were caused by another factor, such as deformity, atrophy, adhesions, or any of the other factors cited above. See Schafrath, 1 Vet. App. at 592. In rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See id. Painful motion is an important factor of disability, and facial expressions such as wincing exhibited in the presence of pressure on or manipulation of the affected joints should be carefully noted and definitely related to the affected joints. See 38 C.F.R. § 4.59. Actually painful, unstable, or malaligned joints due to healed injury are at the very least entitled to the minimum compensable rating for the affected joint. See id. Crepitation within the joint structures or the soft tissues, such as the tendons or ligaments, should be noted carefully as points of contact which are diseased, and flexion elicits such manifestations. See id. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint. See id. When adjudicating disabilities evaluated based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment must be applied, and examinations must assess whether the disability at issue manifested weakened movement, excess fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). Such inquiry should not be limited to muscles or nerves, and, if feasible, these determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. See id. In order to constitute functional loss, pain must affect some aspect of the normal working movements of the body, such as excursion, strength, speed, coordination and endurance. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss and is merely one factor to be considered when evaluating functional impairment. See id. However, 38 C.F.R. § 4.40 does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Once the evidence has been assembled in the record, it is the Board’s responsibility to evaluate the evidence. See 38 U.S.C. § 7104(a). The Board shall consider all competent lay and medical evidence of record, analyze the credibility and probative value of the evidence, and provide reasons for rejecting any favorable material evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In addressing lay evidence and determining its probative value, the Board must assess both its competency, a legal concept determining whether testimony may be heard and considered, and its credibility, a factual determination regarding its probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall afford the claimant the benefit of the doubt, see 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, and where the evidence is in relative equipoise, the claimant shall prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must weigh against the claim in order to warrant its denial. See Alemany v. Brown, 9 Vet. App. 518, 519-20 (1996). Diagnostic Codes 5235 through 5243 pertain to disabilities of the spine, and Diagnostic Codes 5237and 5242 provide that evaluations of lumbosacral or cervical strains and arthritis shall be rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a. The General Rating Formula provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, evaluations of the spine apply as follows: (1) a 100 percent evaluation is warranted where there is evidence of unfavorable ankylosis of the entire spine; (2) a 50 percent evaluation is warranted where there is evidence of unfavorable ankylosis of the entire thoracolumbar spine; (3) a 40 percent evaluation is warranted where there is evidence of unfavorable ankylosis of the entire cervical spine; forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; (4) a 30 percent evaluation is warranted where there is evidence of forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine; (5) a 20 percent evaluation is warranted where there is evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; and (6) a 10 percent evaluation is warranted where there is evidence of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; 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. See id. Note 1 requires the evaluation of any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. See id. Note 2 provides that for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note 3 provides that in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note 4 requires that each range of motion measurement be rounded to the nearest five degrees. Note 5 provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disabilities of the thoracolumbar and cervical spine segments, must be evaluated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. If applicable, spinal disabilities manifesting IVDS based on incapacitating episodes (preoperatively or postoperatively) may be rated under either the General Rating Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Rating Formula), whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25. The IVDS Rating Formula provides as follows: (1) a 60 percent evaluation is warranted where there is evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months; (2) a 40 percent evaluation is warranted where there is evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; (3) a 20 percent evaluation is warranted where there is evidence of incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; and (4) a 10 percent evaluation is warranted where there is evidence of incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires treatment by a physician and bed rest prescribed by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula, whichever method results in a higher evaluation for that segment. See id., Note 2. Degenerative arthritis established by X-ray findings must be evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. See id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See id. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, will warrant a 20 percent rating. See id. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups will warrant a 10 percent rating. See id. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. The assignment of a particular diagnostic code depends upon the facts of each particular case, and the Board is authorized to choose an appropriate diagnostic code that is supported by both the evidence of record and a sufficiently articulated rationale. See Butts v. Brown, 5 Vet. App. 532, 538-39 (1993). Moreover, service connection for a disability is not severed when the diagnostic code assigned to that disability is revised in order to more accurately reflect the veteran’s relevant medical history, diagnoses, and demonstrated symptomatology. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). The Board notes that the criteria for the evaluation of musculoskeletal disabilities in the VA Rating Schedule have been amended effective February 7, 2021 (the 2021 Regulations); therefore, claims filed on or after February 7, 2021, must be evaluated under the 2021 Regulations. See 85 Fed. Reg. 76453-76469 (November 30, 2020); 85 Fed. Reg. 85523-85524 (December 29, 2020). In this case, although the Veteran’s low back claims were filed prior to February 7, 2021, to the extent that the periods on appeal relating to such claims extend beyond February 7, 2021, such claims must be evaluated under both the prior regulations and the 2021 Regulations, and the set of criteria most favorable to the Veteran must be applied. See Kuzma v. Principi, 341 F.3d 1327, 1328-29 (Fed. Cir. 2003). Amended Diagnostic Code 5242 governs degenerative arthritis and degenerative disc disease other than IVDS and applies the General Rating Formula, just as the prior Diagnostic Code 5242. Amended Diagnostic Code 5243 governs Intervertebral Disc Syndrome (IVDS) and provides applies only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign Diagnostic Code 5242 for all other disc diagnoses. See 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2021). In this case, the Board finds that the application of either set of criteria does not modify the Board’s analysis of the Veteran’s claim in any appreciable manner, as under either set of regulations, the General Formula, which has not been amended by the 2021 Regulations, still applies to the Veteran’s lumbar spine claims. Thus, the Board finds that the application of the criteria set forth in Diagnostic Codes 5242 and 5243 under either the prior or the 2021 Regulations does not modify the Board’s analysis of the Veteran’s claim in any appreciable manner. See 38 C.F.R. § 4.71a (2021). Effective dates for disability ratings may be established up to one year prior to the date of claim if, based upon all the evidence of record, it can be factually ascertained that an increase in the Veteran’s service-connected disability occurred during that year preceding the claim. See 38 U.S.C. § 5110(b)(3); C.F.R. § 3.400(o)(2); see also Hart, 21 Vet. App. at 509. In this case, the Veteran filed the instant increased rating claim for his low back disability on September 26, 2012; therefore, the Board has considered whether it was factually ascertainable that the Veteran’s chronic back pain with Scheuermann’s Disease exhibited signs of worsening as early as September 26, 2011. In June 1987, the Veteran was awarded service connection for his low back disability, to include chronic back pain with Scheuermann’s Disease, and assigned an initial evaluation of 10 percent effective April 2, 1987. Subsequently, a March 2016 rating decision increased the Veteran’s 10 percent evaluation for his low back disability to 20 percent evaluation, effective May 15, 2013. The Veteran contends that the severity of his chronic back pain with Scheuermann’s Disease warrants an evaluation in excess of these currently awarded based upon evidence of chronic pain, muscle spasms, and limited range of motion. After careful review, the Board finds that for the period on appeal prior to May 15, 2013, the evidence of record demonstrates that the Veteran’s chronic back pain with Scheuermann’s Disease has manifested pain and forward flexion with painful motion limited at most to 60 degrees of forward flexion, as well as muscle spasms and guarding severe enough to result in an abnormal gait or abnormal spinal contour, thereby warranting a 20 percent disability rating under Diagnostic Code 5237-5242, but not greater, as 20 percent is the maximum rating available under Diagnostic Code 5237-5242 without evidence of forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. During the period on appeal prior Mary 15, 2013, the Veteran was afforded a November 2012 VA examination to evaluate his chronic back pain with Scheuermann’s Disease, which culminated in a report diagnosing chronic back strain with Scheuermann's disease and multilevel degenerative disc disease (DDD) of the thoracolumbar spine and indicating objective range of motion as follows: (a) initial forward flexion limited to 80 degrees, unchanged after three repetitions; (b) forward flexion limited to 60 degrees with painful motion; (c) initial combined range of motion limited to 230 degrees, unchanged after three repetitions; and (d) a combined range of motion limited to 175 degrees with painful motion. The November 2012 VA examination report further indicates the following: (1) functional loss to include less movement than normal; excess fatigability; and interference with sitting, standing, or weight-bearing; (2) localized tenderness or pain to palpation for joints and/or soft tissue of the midline thoracic spine; (3) guarding and/or muscle spasm, neither of which resulted in abnormal gait or spinal contour; and (4) x-rays dated November 2012 revealing arthritis and DDD of the lumbar spine at L5-S1. However, the November 2012 VA examination report also noted the following: normal muscle strength; no muscle atrophy; a normal sensory exam; a normal reflex exam; a normal straight leg raising test; no radicular pain or any other signs or symptoms due to radiculopathy; no other neurologic abnormalities or findings related to the low back condition (such as bowel problems, bladder problems, or pathologic reflexes); no incapacitating IVDS episodes over the past 12 months; no assistive devices; and no functional impact, as the Veteran reported he is still employed as a firefighter, still able to exercise, but cannot relax at night or sit in a movie theater for two hours. Accordingly, in consideration of the foregoing evidence, including the November 2012 findings of forward flexion limited to 60 degrees with painful motion, the Board finds that for the period on appeal prior to May 15, 2013, the Veteran’s service-connected chronic back pain with Scheuermann’s Disease warrants a 20 percent evaluation under the General Rating Formula, Diagnostic Code 5237-5242. Generally, as stated above, where a veteran’s claim involves rating the severity of a joint disability based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45 pertaining to functional impairment must be applied in order to determine whether the disability at issue manifested weakened movement, excess fatigability, or incoordination. See DeLuca, 8 Vet. App. at 205-07. Therefore, in this case, because the Board has awarded the Veteran the maximum schedular rating under Diagnostic Code 5237-5242, and the record lacks evidence of unfavorable ankylosis of the entire thoracolumbar spine, consideration of functional loss due to pain under 38 C.F.R. §§ 4.40, 4.45 and accompanying case law is not required, as any further finding of pain on motion could not result in a higher rating. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In addition, because the evidence of record includes x-ray evidence establishing arthritis of the Veteran’s thoracolumbar spine, the Board has considered whether the Veteran’s low back disability is entitled to a higher rating under Diagnostic Codes 5003 for degenerative arthritis. As stated above, degenerative arthritis is evaluated by the criteria enumerated in the General Rating Formula, which provides that in order to warrant a 40 percent rating, forward flexion of the thoracolumbar spine must be limited to 30 degrees or less, or favorable or unfavorable ankylosis of the entire thoracolumbar spine must exist. See 38 C.F.R. § 4.71a. Therefore, as the record in this case does not reflect that the Veteran’s low back disability manifested forward flexion of limited to 30 degrees or less or favorable or unfavorable ankylosis of the entire thoracolumbar spine at any point during any period on appeal, a higher rating of 40 percent is not warranted in this case. Accordingly, the Board finds that, for the period on appeal prior to May 5, 2013 a preponderance of the evidence of record weighs against a finding that the Veteran’s chronic back pain with Scheuermann’s Disease is entitled to a 40 percent rating under Diagnostic Code 5003. Moreover, as outlined above, evaluation of the same disability or the same manifestations under various diagnoses, or pyramiding, is prohibited, see 38 C.F.R. § 4.14, and compensation may not be awarded more than once for the same symptomatology, as such a result would overcompensate a veteran for the actual impairment of his earning capacity. See Brady v. Brown, 4 Vet. App. 203, 206 (1993). However, separate and distinct manifestations attributable to the same injury may be compensated under different diagnostic codes. See Esteban, 6 Vet. App. at 261-62. In this case, the assignment of separate ratings under Diagnostic Code 5242 and Diagnostic Code 5003 would constitute the sort of pyramiding prohibited by 38 C.F.R. § 4.14, as both codes evaluate the flexion of the thoracolumbar spine and therefore overlap. Accordingly, the Veteran may not be evaluated under Diagnostic Code 5237-5242 as well as under Diagnostic Code 5003 without resulting in unlawful pyramiding. See 38 C.F.R. § 4.14. The Board has also considered whether the Veteran’s service-connected chronic back pain with Scheuermann’s Disease warrants the assignment of an additional or a higher rating under other diagnostic codes at any point during the period on appeal. See Schafrath, 1 Vet. App. at 595. However, because the record contains no evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, or of objective neurologic abnormalities, such as bowel or bladder impairment, the Board finds that no additional disability ratings are warranted in this case. See 38 C.F.R. § 4.71a; IVDS Formula. The Veteran has not specifically raised any other issues, nor have any other issues been reasonably raised by the evidence of record. See Doucette v. Shulkin, 28 Vet. App. 366, 370 (2017). Accordingly, resolving all reasonable doubt in the Veteran’s favor, and in consideration of the foregoing evidence, including the November 2012 findings of thoracolumbar forward flexion limited to 60 degrees with painful motion, the Board finds that for the period on appeal prior to May 15, 2013, the Veteran’s service-connected chronic back pain with Scheuermann’s Disease warrants a 20 percent evaluation, but no greater, under the General Rating Formula, Diagnostic Code 5237-5242. 2. For the period on appeal from May 15, 2013, an increased evaluation in excess of 40 percent for the Veteran’s chronic back pain with Scheuermann’s Disease is denied. As stated above, the Veteran contends that, for the period on appeal from May 15, 2013, he is entitled to an evaluation in excess of 40 percent for his service-connected chronic back pain with Scheuermann’s Disease, based upon evidence of chronic low back pain, stiffness, weakness, and limited range of motion. However, after careful review, the Board finds that for the period on appeal from May 15, 2013, the preponderance of the evidence of record demonstrates that an increased evaluation in excess of 40 percent is not warranted, as the Veteran’s chronic back pain with Scheuermann’s Disease does not more closely approximate the criteria enumerated for a 50 percent evaluation under the General Rating Formula or the IVDS Formula due to its manifestations of pain, objectively measured forward flexion of the lumbar spine limited at most to 15 degrees, and an objectively measured combined range of motion of the thoracolumbar spine limited at most to 85 degrees. Moreover, the Board finds that the record contains no evidence of the following: (1) favorable or unfavorable ankylosis of the entire thoracolumbar spine; or (2) IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. In December 2015, the Veteran was afforded a VA examination to evaluate his chronic back pain with Scheuermann’s Disease which culminated in a report diagnosing a lumbosacral strain, degenerative arthritis of the spine, and IVDS, and indicating his objectively measured range of motion as follows: initial forward flexion limited to 75 degrees; and a combined range of motion limited to 215 degrees. The December 2015 VA examination report further notes no further changes to range of motion testing with repetition but indicates the following: (1) abnormal range of motion itself does not contribute to functional loss; (2) pain was noted on exam and causes functional loss with all ranges of motion; (3) evidence of pain with weight bearing; (4) objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine/mid-thoracolumbar area; (5) pain, weakness, fatigability or incoordination do not significantly limit functional ability with repeated use over a period of time; (6) pain, fatigue, weakness, lack of endurance significantly limit functional ability with flare-ups; (7) the Veteran reports he has “zero range of motion” during a flare up due to being “frozen” or incapacitated for minutes to days; (8) guarding, localized tenderness, and muscle spasm of the thoracolumbar spin result in abnormal gait or abnormal spinal contour; (9) additional contributing factors of disability include less movement than normal due to ankylosis, adhesions, etc., weakened movement due to muscle or peripheral nerve injury, etc., disturbance of locomotion, interference with sitting, interference with standing; (10) IVDS with episodes involving “back contractions” and incapacitating back pain that causes the Veteran to freeze and during which he is only able to lie down and do nothing for one to two days; and (10) the Veteran continues to work and function as a firefighter, but his low back condition is “drastically affecting his sleep habits” causing him to be unable to sleep for more than three hours at time due to severe back spasms and pain. In addition, the December 2015 VA examination report also noted the following: normal muscle strength; no muscle atrophy; a normal sensory exam; a normal reflex exam; a normal straight leg raising test; no radicular pain or any other signs or symptoms due to radiculopathy; no ankylosis; no other neurologic abnormalities or findings related to the low back condition (such as bowel problems, bladder problems, or pathologic reflexes); and no use of assistive devices. In February 2019, the Veteran was afforded another VA spine examination to evaluate his low back disability, which culminated in a report diagnosing chronic back pain with Scheuermann’s disease and indicating his objectively measured range of motion as follows: initial forward flexion limited to 90 degrees and a combined range of motion limited to 240 degrees; and forward flexion with painful motion limited to 15 degrees and a combined range of motion limited to 85 degrees with painful motion. In addition, with flareups described as pain, the Veteran subjectively reported that forward flexion during flareups is limited to zero degrees and a combined range of motion is also limited to zero degrees. The February 2019 VA examination report further indicates the following: (1) the Veteran reports that he has had constant discomfort in his low back since his separation from service which feels like a fist that is constantly putting pressure on his back; (2) the Veteran describes his low back pain as an 8 on a scale of 1 to 10; (3) the Veteran reports flareups, to include periods of time when his back will “seize” up and muscles in the upper back will tighten up preventing the Veteran from moving or taking a deep breath due to extreme pain, and during which his pain is described as a 10 on a scale of 1 to 10; (4) during such flareups, the Veteran will press himself up against a wall to get the spasm to resolve; (5) the Veteran reports that flareups can occur a couple of times per week or as infrequently as once per month, and that he does not observe any pattern for such flareups or any obvious triggers; (6) the flareups can last for a couple of hours or a couple of weeks; (7) his last flareup occurred approximately 4 to 5 weeks prior and lasted approximately 8 hours; (8) he is now able to recognize the onset of the flareup and to slow his breathing down to prevent the spasm from going “full course”; (9) the Veteran has worked as a firefighter for 23 years and has been able to lift, push, and pull without weight restrictions; (10) the Veteran suffers from poor sleep as a result of constant pain and has taken approximately 6 vacation days to rest his low back condition in the past year; (11) he does not believe that his job affects his back since his flareups and pain can occur spontaneously without any physical activity, including a sneeze or just sitting; (12) the Veteran reports that his low back pain does not prevent him from working, and that the only functional loss caused by his low back condition involves his sleep impairment as a result of his chronic constant pain; (13) pain was noted on exam on all ranges of motion but does not result in or cause functional loss; (14) no evidence of pain was noted with weight bearing; (15) no change in the level of pain was noted as related to weight bearing versus non-weight bearing; (16) objective evidence was noted of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine; (17) mild tenderness was noted to palpation over the mid-thoracic spine to the lower thoracic spine and midthoracic paraspinal muscles; (18) pain, weakness, fatigability or incoordination do not significantly limit functional ability with repeated use over a period of time; and (19) February 2019 x-rays confirm mild endplate irregularity and vertebral body wedging which appears chronic and may relate to mild Scheuermann’s disease, as well as mild degenerative facet joint disease at L4-L5 and L5-S1. The February 2019 VA examination report further notes that the Veteran was able to demonstrate full range of motion but qualified his range of motion as that which he could do in spite of pain and that which was associated with the onset of pain, to include as follows: forward flexion elicited pain at 15 degrees; extension elicited pain at 15 degrees; left lateral bending elicited pain at 10 degrees; right lateral bending elicited pain at 15 degrees; left rotational twisting elicited pain at 15 degrees; and right rotational twisting elicited pain at 15 degrees. The report further notes that the Veteran’s range of motion has not been measured during a flare-up to verify that he is unable to move, so the estimated range of motion measurements of 0 are based upon subjective data reported by the Veteran. In addition, the February 2019 VA examination report also noted the following: normal muscle strength; no muscle atrophy; a normal sensory exam; a normal reflex exam; a normal straight leg raising test; no radicular pain or any other signs or symptoms due to radiculopathy; no additional contributing factors of disability; no guarding or muscle spasm of the thoracolumbar spine; no ankylosis; no other neurologic abnormalities or findings related to the low back condition (such as bowel problems, bladder problems, or pathologic reflexes; no IVDS; and no use of assistive devices. Accordingly, in consideration of the foregoing evidence, including the February 2019 VA examination report’s findings of forward flexion limited to 15 degrees, the Board finds that for the period on appeal from May 15, 2013, the preponderance of the evidence of record weighs against a finding that the Veteran’s service-connected chronic back pain with Scheuermann’s Disease warrants an evaluation in excess of 40 percent, as 40 percent is the maximum rating available under Diagnostic Codes 5237, 5242, or 5243 absent evidence of unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The Board has also considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also Mitchell, 25 Vet. App. at 37; DeLuca, 8 Vet. App. at 205-07. However, as the evaluation for the Veteran’s chronic back pain with Scheuermann’s Disease under Diagnostic Code 5237-5242 contemplates the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance, even in light of the effects of pain and repetitive motion, the Veteran’s low back functional limitation has never been found, at any time during the period on appeal from May 15, 2013, to manifest unfavorable ankylosis of the entire thoracolumbar spine. Accordingly, the consideration of other functional limitation factors does not warrant a rating in excess of the 40 percent rating assigned herein. See 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, 8 Vet. App. at 205-07. The Board has also considered whether the Veteran’s chronic back pain with Scheuermann’s Disease warrants the assignment of an additional or a higher rating under other diagnostic codes at any point during the period on appeal. See Schafrath, 1 Vet. App. at 595. However, because the record contains no evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, or of objective neurologic abnormalities, such as bowel or bladder impairment, the Board finds that no additional disability ratings are warranted in this case. See 38 C.F.R. § 4.71a; IVDS Formula. (Continued on the next page)   The Veteran has not specifically raised any other issues, nor have any other issues been reasonably raised by the evidence of record. See Doucette, 28 Vet. App. at 370. Accordingly, in consideration of the foregoing, the Board finds that for the period on appeal from May 15, 2013, the preponderance of the evidence of record weighs against the award of an evaluation in excess of 40 percent under any diagnostic code for the Veteran’s chronic back pain with Scheuermann’s Disease. As the preponderance of the evidence weighs against the award of any increased or separate evaluations, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Marsdale 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.