Citation Nr: 21022931 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 14-42 584 DATE: April 19, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for radiculopathy, sciatic nerve left lower extremity prior to October 18, 2019 is denied. Entitlement to a disability rating in excess of 20 percent for radiculopathy, sciatic nerve left lower extremity from October 18, 2019 is denied. Entitlement to a compensable disability rating for right wrist sprain prior to October 18, 2019 is denied. Entitlement to a disability rating in excess of 10 percent for right wrist sprain from October 18, 2019 is denied. Entitlement to an initial disability rating in excess of 10 percent for lumbar spine degenerative disc disease with anterolistheses and spondylolysis (“lumbar spine disorder”) is ¬¬denied. REMANDED Entitlement to an initial disability rating in excess of 10 percent for right foot contusion is remanded Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded FINDINGS OF FACT 1. Prior to October 18, 2019, radiculopathy, sciatic nerve left lower extremity at worst did not manifest as moderate incomplete paralysis of the sciatic nerve. 2. From October 18, 2019, radiculopathy, sciatic nerve left lower extremity at worst does not manifest as moderately severe incomplete paralysis of the sciatic nerve. 3. Prior to October 18, 2019, right wrist sprain did not manifest in dorsiflexion is less than 15 degrees or palmar flexion limited in line with the forearm. 4. From October 18, 2019, right wrist sprain manifests as pain with repetitive use over time and with flare-ups resulting in functional loss—reduced right wrist dorsiflexion and reduced plantar flexion. 5. At worst, lumbar spine disorder does not manifest as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 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. CONCLUSIONS OF LAW 1. Prior to October 18, 2019, the criteria for entitlement to a disability rating in excess of 10 percent for radiculopathy, sciatic nerve left lower extremity have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code 8520 (2019). 2. From October 18, 2019, the criteria for entitlement to a disability rating in excess of 20 percent for radiculopathy, sciatic nerve left lower extremity have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code 8520 (2019). 3. Prior to October 18, 2019, the criteria for entitlement to a compensable disability rating for right wrist sprain have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.40. 4.45, 4.59. 4.124a, Diagnostic Code 5215 (2019). 4. From October 18. 2019, the criteria for entitlement to a disability rating in excess of 10 percent for right wrist sprain have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.40. 4.45, 4.59. 4.124a, Diagnostic Code 5215 (2019). 5. The criteria for entitlement to a disability in excess of 10 percent for lumbar spine disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.40. 4.45, 4.59. 4.124a, Diagnostic Code 5003-5242 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Marine Corps from March 2008 to July 2012 including service in Afghanistan. These matters come to the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision by the Regional Office (RO). In July 2017, the Veteran testified before the undersigned Veterans Law Judge. A transcript of that proceeding has been associated with the Veteran’s claims file. In March 2018, the Board remanded the appeal for further development of the evidence. In a March 2020 rating decision, the RO increased the Veteran’s ratings for radiculopathy, sciatic nerve left lower extremity and right wrist sprain. As the increased benefits do not constitute a full grant of the benefits sought, the issues are still in appellate status. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Increased Disability Ratings Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Radiculopathy, sciatic nerve left lower extremity The Veteran asserts that the respective disability ratings assigned to his service-connected radiculopathy, sciatic nerve left lower extremity do not adequately contemplate the severity of his symptomatology and that higher disability ratings should be assigned. The RO has evaluated this disability under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Codes 8520-8720 address ratings for paralysis of the peripheral nerves affecting the lower extremities, neuritis, and neuralgia. Diagnostic Codes 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is warranted for complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Diagnostic Codes 8526, 8626, and 8726 provide ratings for paralysis, neuritis, and neuralgia of the anterior crural nerve (femoral). A 10 percent disability rating is warranted for mild of the anterior crural nerve, a 20 percent disability rating is warranted for moderate paralysis of the anterior crural nerve, a 30 percent disability rating is warranted for severe paralysis of the anterior crural nerve, and a 40 percent disability rating (the maximum) is warranted for complete paralysis of the anterior crural nerve. 38 C.F.R. § 4.124a. Words such as “severe,” “moderate,” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Code 8620. Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum rating equal to moderate incomplete paralysis. 38 C.F.R. §§ 4.124, 4.124a, Diagnostic Code 8720. In rating diseases of the peripheral nerves, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Prior to October 18, 2019 In June 2012, the Veteran was afforded a VA examination. A clinician reviewed the claims file; considered the Veteran’s accounts; and conducted an appropriate examination. On examination, the clinician indicated moderate left lower extremity intermittent pain and mild left lower extremity paresthesias and/or dysesthesias. There was no evidence of left lower extremity constant pain or numbness. The clinician reported involved of the left sciatic nerve root. As to the overall severity of this disability, the clinician provided a finding of mild. As to overall functional impact on ability to work, to include the Veteran’s lumbar spine disorder, the clinician indicated that these disabilities would be exacerbated by prolonged walking, sitting, bending, and heavy lifting. In an August 2012 VA progress note, a clinician indicated that the Veteran reported chronic back pain that radiates to left leg through symptoms of pain, numbness, and tingling. The Veteran report 3/10 sharp pain upon prolonged sitting and standing. In his November 2012 notice of disagreement (NOD), the Veteran conveyed that he was unable to work for 8 hours standing. In November 2013, the Veteran was afforded a VA general medical examination—disabilities questionnaire. The clinician assessed the Veteran’s present disability status. This clinician indicated that left straight leg testing was negative. The clinician indicated that no left lower extremity symptoms were present. 2012 and 2013 VA physical therapy (PT) records disclose that the Veteran sought therapeutic services for lumbar radiculopathy. A physical therapist noted that the Veteran tolerated weight-bearing. The Veteran was also afforded educational programming related to this disability. At the July 2017 Board hearing the Veteran testified that he experiences pain that shoots down his left side. When he sits, the Veteran testified that it “[feels] like little hands [go] down [his] left foot.” See July 17, 2017 Hearing Transcript, p. 7. The Veteran endorsed that he experiences dull, mild moderate pain, but with flare-ups the pain is constant and sharp. As noted above, to receive a higher disability rating there would need to be a showing of moderate incomplete paralysis of the left sciatic nerve. Upon contemplation of the totality of evidence of record, such is not disclosed. At worst, clinical evidence shows that the Veteran’s radiculopathy, sciatic nerve left lower extremity manifests as mild incomplete paralysis of the left sciatic nerve. While the clinical evidence does reveal that there was a finding in June 2012 as to moderate left lower extremity intermittent pain. Otherwise, the clinical findings disclose mild left lower extremity paresthesias and/or dysesthesias; an absence of left lower extremity constant pain; and an absence of numbness. Thus, the moderate finding is a clinical outlier. The June 2012 clinician indicated that the overall severity of radiculopathy, sciatic nerve left lower extremity was mild, even with involvement of the involvement of the left sciatic nerve root. The Board has considered the Veteran’s testimony and reporting of “little hands” down to his left foot and endorsement that he experiences dull mild moderate pain and sharp constant pain during flare-ups. Indeed, the Veteran is competent to report discernable symptoms such as sharp pain. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board assigns substantial probative weight to the June 2012 clinician’s VA examination report. The medical professional reviewed the claims file; considered the Veteran’s lay accounts; and conducted an appropriate examination. Moreover, this expert assessed the Veteran’s radiculopathy, sciatic nerve left lower extremity through the medical vectors that indicate the clinical severity of this disability. For the reasons articulated above, the Board finds that the Veteran’s disability does not warrant a disability rating in excess of 10 percent prior to October 18, 2019. From October 18, 2019 On October 18, 2019, the Veteran was afforded a VA examination. This clinician indicated that the Veteran was not taking medication to treat radiculopathy, sciatic nerve left lower extremity. The Veteran reported that he has persistent left lower extremity radicular pain, numbness, and tingling. Left lower extremity sensory was decreased as to the left lower leg/ankle and left foot/toes. The clinician indicated that the Veteran has a normal gait. As to clinical severity, the clinician indicated that evaluation disclosed left moderate incomplete paralysis of the sciatic nerve. The clinician did not note the involvement of any other nerve groups. The clinician reported that the Veteran’s radiculopathy, sciatic nerve left lower extremity did not impact the Veteran’s ability to work. Lastly, the clinician noted that the Veteran disability continues with mild lower left extremity with weakness and loss of sensation. Upon the Veteran’s thoracolumbar spines condition examination of the same date, the clinician reported positive left straight leg testing. Left lower extremity shows symptoms of mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. There was no evidence of left lower extremity radiculopathy constant pain. The clinician reported involved of the left sciatic nerve root. As to the overall severity of this disability, the clinician provided a finding of moderate. As to overall functional impact on ability to work, to include the Veteran’s lumbar spine disorder, the clinician indicated that these disabilities limit the ability to perform repetitive heavy lifting, heavy pushing, and heavy pulling. In November 2019, the Veteran’s spouse submitted a lay statement. In pertinent part, she reported that the Veteran’s service-connected disabilities affect the Veteran’s daily routines, to include his interactions with his children and the marital couple’s personal life. In a lay statement of the same month, the Veteran reported that he takes a great deal of medication for his left lower extremity radiculopathy. And, the Veteran conveyed that this disability affects his sleeping, activities, and personal life. The Veteran repeated his contentions in a December 2019 lay statement. In a June 2020 brief, the Veteran’s representative contended that the Veteran’s disability warrants an increased rating, underscoring the Veteran’s lay accounts of painful symptoms. As noted above, to receive a higher disability rating there would need to be a showing of moderately severe paralysis of the left sciatic nerve. Upon contemplation of the totality of evidence of record, such is not disclosed. From October 18, 2019, at worst, radiculopathy, sciatic nerve left lower extremity manifests as moderate incomplete paralysis of the left sciatic nerves. The clinical evidence of record discloses that the symptoms of this disability include mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. There was no evidence of left lower extremity radiculopathy constant pain. The Board has considered the Veteran’s (and his spouse’s) lay statements concerning the ways in which this disability limits sleeping, activities, and personal life. Indeed, the Veteran is competent to report discernable symptoms such as pain during sleep, during activities, and during moments of intimacy. See Jandreau, supra. The Board assigns substantial probative weight to the October 8, 2019 clinician’s VA examination report. This medical professional reviewed the claims file; considered the Veteran’s lay accounts; and conducted an appropriate examination. Moreover, this expert assessed the Veteran’s radiculopathy, sciatic nerve left lower extremity through the medical vectors that indicate the clinical severity of this disability. As such, the Board finds that the Veteran’s disability does not warrant a disability rating in excess of 20 percent from October 18, 2019. Right wrist sprain The Veteran asserts that the respective disability ratings assigned to his service-connected right wrist sprain do not adequately contemplate the severity of his symptomatology and that higher disability ratings should be assigned. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Deluca v. Brown, 8 Vet. App. 202 (1995). 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 enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202, 206-8 (1995). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint.  38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable Diagnostic Code. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and numbness in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. See Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). Musculoskeletal VA examinations, to be adequate, must address particular issues when are where that are practicable and medically possible to include active and passive motion; weight bearing and non-weight bearing; range of motion of an opposing joint; and findings as to loss of motion during flare-ups. See Correia v. McDonald, 28 Vet. App. (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). The RO has evaluated the Veteran’s right wrist strain under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Wrist disabilities are generally evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5215-5215. As of February 7, 2021, the rating criteria for Diagnostic Code 5214 and 5215 have not changed. In instances where there is wrist ankylosis (Diagnostic Code 5214), unfavorable ankylosis, in any degree of palmar flexion, or with ulnar or radial deviation is rated at 50 percent for major and 40 percent for minor. Ankylosis at any other position other than favorable is rated at 40 percent for major and 30 percent for minor. Ankylosis which is favorable on 20 degree-to-30-degree dorsiflexion is rated at 30 percent for major and 20 percent for minor. In a NOTE, extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. Under Diagnostic Code 5215, for both minor and major wrists, a 10 percent disability rating is assigned when dorsiflexion is less than 15 degrees. And, a 10 percent disability rating is assigned when palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a. Prior to October 18, 2019 In June 2012, the Veteran was afforded a VA examination. The Veteran reported that his right wrist sprain, sustained in 2009, results in lack of movement and pain while exercising. At this time, the right wrist grinds while twisting. Also, the Veteran reported morning right wrist stiffness and flare-ups mirroring the same lay accounts. On examination, the Veteran demonstrated palmar flexion to 70 degrees with no pain and right wrist dorsiflexion to 70 degrees with no pain. Right wrist repetitive use testing resulted in palmar flexion to 70 degrees and right wrist dorsiflexion to 60 degrees. As such. The clinician noted that the Veteran has additional losses in ranges of motion on repetitive use (namely 10 degrees in right wrist dorsiflexion). The Veteran retained 5/5 right wrist strength and no evidence of right wrist ankylosis or right wright tenderness. X-ray imaging did not disclose the presence of arthritis. Testing showed that right wrist grip strength was 100,80,80 as per Jamar dynameter. The clinician indicated that the Veteran’s right wrist sprain resulted in functional impact on his ability to work by curtailing his ability to engage in repetitive right wrist twisting. Here, the clinician noted that right wrist ulnar deviation ends at 45 degrees without evidence of painful motion; right wrist radial deviation ends at 20 degrees without evidence of painful motion; right wrist post ulnar deviation ends at 25 degrees without evidence of painful motion; and post radial deviation ends at 20 degrees without evidence of painful motion. In his November 2012 NOD, the Veteran wrote that he could not lift heavy objects or “perform correctly” with his right hand. In the November 2013 VA general medical examination—disabilities questionnaire, the clinician noted that the Veteran injured his right wrist during service but did not sustain a fracture as per x-ray imaging. The Veteran endorsed that his right wrist pops on occasion with movement and evinces pain during flare-ups. On examination, the Veteran demonstrated right wrist palmar flexion to 80 degrees or greater without pain and right wrist dorsiflexion of 70 degrees or greater without pain. There were no additional losses in ranges of motion upon repetitive use testing. And, the clinician opined that the Veteran had no functional loss or functional impairment attributable to the right wrist sprain. The Veteran demonstrated neither tenderness nor pain on palpation of joints/soft tissue of the right wright. The Veteran retained 5/5 right wrist strength and no evidence of right wrist ankylosis. The clinician opined that right wrist sprain did not impact the Veteran’s ability to work. The clinician noted that physical examination only forced cracking, which is not necessarily pathological (just as is the case with finger cracking). X-ray imaging disclosed no right wrist abnormalities. At the July 2017 Board hearing, the Veteran testified that when he turns his right wrist he must “force it” and sees the bone sticking out (as compared to the left wrist). As the clinical evidence of records fails to disclose the presence of any degree of right wrist ankylosis, Diagnostic Code 5214 is not for application. The Veteran believes that his right wrist sprain is more severe than that contemplated by a noncompensable disability rating prior to October 18. 2019. Indeed, the Veteran is competent to report that which is discernable such as right wrist stiffness. See Jandreau, supra. As noted above, to receive a compensable rating, there would need to be a showing of either dorsiflexion to less than 15 degrees or flexion in line with the forearm. Such in not disclosed in the competent clinical evidence of record. The current noncompensable disability rating for right wrist sprain under Diagnostic Code 5215 contemplates dorsiflexion, at worst, to 60 degrees (and, even here, this measurement is upon repetitive use) and flexion limited to 70 degrees (not in line with the right forearm). Imaging studies did not show the presence of arthritis. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Upon contemplation of the totality of evidence, the Board finds that the weight of evidence is against finding that the Veteran’s right wrist sprain manifests in functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, as articulated above. Therefore, the Board finds that the preponderance of the evidence is against the claim for an initial compensable disability rating for the Veteran’s right wrist sprain. From October 18, 2019 On October 18, 2019, the Veteran was afforded a VA examination. The clinician provided diagnoses of chronic right wrist sprain and right wrist tendinitis. The Veteran reported that he experiences persistent right wrist pain, some weakness, and some stiffness. The Veteran expressed that his right wrist looks swollen and had concerns that he may have an occult fracture or torn ligament/cartilage. The Veteran reported moderate right wrist flare-ups that last for up-to-two hours, precipitated by wrist rotation that impaired writing and driving. The Veteran indicated right wrist functional impairment consisting of an inability to rotate, to overuse, to grip, or to pick up objects. On examination, the Veteran demonstrated right wrist palmar flexion to 70 degrees with pain and dorsiflexion to 60 degrees with pain. There was no evidence of pain with weight-bearing. While pain was noted on examination, the clinician opined that it did not result in functional loss. There was no evidence of crepitus. The Veteran showed tenderness at the ulnar and radial sides of the right wrist of moderate severity. Repetitive use testing resulted in no additional limitation in range of motion. The Veteran was not examined immediately after repetitive use in time. The clinician indicated that pain significantly limited functional ability with repeated use over a period of time. In range of motion, such pain was characterized as palmar flexion to 65 degrees and dorsiflexion to 55 degrees. The clinician provided the same findings for flare-ups. The Veteran showed strength of 4/5 and no evidence of right wrist ankylosis whatsoever. The clinician noted that the right wrist appeared swollen when compared to the left wrist. X-ray imaging disclosed no right wrist abnormalities. Magnetic resonance imaging (MRI) showed mild right wrist joint effusion; an intact triangular fibrocartilage complex; and tenosynovitis of the extensor carpi radialis longus and brevis tendons. As to functional impact on the Veteran’s ability to perform any type of occupational task, the clinician indicated that right wrist sprain limits the Veteran’s ability to perform repetitive tasks. There was no pain on passive range of motion or non-weight bearing in with the right wrist or the left wrist. As noted above, in November 2019, the Veteran’s spouse submitted a statement. She reported that the Veteran’s service-connected disabilities affect the Veteran’s daily routines, to include his interactions with his children and the marital couple’s personal life. In his November and December 2019 lay statements, the Veteran noted that he experienced much right wrist pain, which makes every day a challenge. In the June 2020 brief, the Veteran’s representative advanced that the Veteran’s right wrist sprain warrants an increased rating, underscoring the Veteran’s lay accounts of painful symptoms. As the clinical evidence of records fails to disclose the presence of any degree of right wrist ankylosis, Diagnostic Code 5214 is not for application. The Veteran believes that his right wrist sprain is more severe than that contemplated by a 10 percent disability rating from October 18. 2019. The Veteran is competent to report that which is discernable such as right wrist pain. See Jandreau, supra. As noted above, under Diagnostic Code 5215, the maximum schedular rating is 10 percent for dorsiflexion of less than 15 degrees or when palmar flexion is limited in line with the forearm. At worst, the Veteran’s dorsiflexion is 60 degrees and palmar flexion is limited to 70 degrees. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The October 18, 2019 clinician indicated that pain with repetitive use over time and with flare-ups caused functional loss which results in reduced right wrist dorsiflexion and reduced plantar flexion. Indeed, such findings fall clearly within the criteria discussed directly above. As such the Veteran is entitled to the minimum compensable disability of 10 percent for the right wrist under Diagnostic Code 5215. While the Veteran has been shown to experience right wrist, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, supra. Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” to constitute functional loss warranting an increased rating. See 38 C.F.R. § 4.40. These limitations are contemplated by the criteria for the 10 percent disability rating that is assigned. Therefore, the Board finds that the weight of competent and credible evidence is against the claim for a disability rating in excess of 10 percent from October 18, 2019 for the Veteran’s right wrist sprain. Lumbar spine disorder The Veteran asserts that the respective disability rating assigned to his service-connected lumbar spine disorder does not adequately contemplate the severity of his symptomatology and that a higher disability rating should be assigned. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is used under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made 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. 38 C.F.R. § 4.71a. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), unfavorable or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242). Degenerative arthritis of the spine can also be rated using Diagnostic Code 5003. 38 C.F.R. § 4.71a. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or a combined range of motion of the thoracolumbar spine not greater than 120 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. 38 C.F.R. § 4.71a. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal 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. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). 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. Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). 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 (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). Diagnostic Code 5243 provides that intervertebral disc syndrome is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome (IVDS) that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). The RO have evaluated the Veteran’s lumbar spine disorder under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5242. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated Diagnostic Code is rated by analogy for 5242 degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome as well as Diagnostic Code 5003. The rating criteria for Diagnostic Code 5003 was revised effective February 7, 2021. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent disability rating is assigned with involvement of two or more joints and two or more minor joint groups. A 20 percent disability rating is assigned with evidence of involvement of two or more major joints or more minor joint groups, with occasional incapacitating exacerbations. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Evidence and Analysis In June 2012, the Veteran was afforded a VA thoracolumbar spine conditions examination. The Veteran reported that he took muscle relaxers throughout the day to control his lumbar spine disorder symptoms. The Veteran endorsed flare-ups of increased pain during which he cannot stand or sit without pain. On examination, the Veteran demonstrated forward flexion to 65 degrees with pain; extension to 30 degrees or greater with pain; right lateral flexion to 30 degrees or greater with pain; left lateral flexion to 30 degrees or greater with pain; right lateral rotation to 30 degrees or greater with pain; and left lateral rotation to 30 degrees or greater with pain. Repetitive use testing resulted in no additional limitation in range of motion. Pain on movement after repetitive use contributed to functional loss. There was no evidence of muscle spasm, guarding, or muscle atrophy. The Veteran maintained normal 5/5 strength. The Veteran maintained normal sensory acuity. The Veteran had IVDS; however, the Veteran had not experienced any incapacitating episodes over the past 12 months. A May 2012 MRI of the thoracolumbar spine showed lumbar spine degenerative disc disease with anterolistheses and spondylolysis. The clinician indicated that this disability (along with the separately rated radiculopathy, sciatic nerve left lower discussed above)impacted the Veteran’s ability to work, Specifically, the clinician noted that prolonged standing, sitting, walking, bending, and heavy lifting exacerbated the lumbar spine disorder. In an August 2012 VA progress note, a clinician indicated that the Veteran endorsed chronic back pain the radiates to left leg through symptoms of pain, numbness, and tingling. The Veteran report 3/10 sharp pain upon prolonged sitting and standing. In his November 2012 NOD, the Veteran noted that he was unable to work for 8 hours standing. In the November 2013 VA general medical examination—disabilities questionnaire, the clinician noted that the Veteran had a thoracolumbar spine disorder. The Veteran endorsed flare-ups that occur 365 days a year when sitting for more than 30 minutes, the Veteran experience low/back buttock pain of 4-5/10. On examination, the Veteran demonstrated forward flexion to 90 degrees; extension to 30 degrees or greater; right lateral flexion to 30 degrees or greater; left lateral flexion to 30 degrees or greater; right lateral rotation to 30 degrees or greater and left lateral rotation to 30 degrees. Repetitive use testing resulted in no additional limitation in range of motion. The clinician indicated that the Veteran did not show functional impairment after repetitive use. Muscle strength was normal, without atrophy. Reflex testing was normal and was sensory testing and straight leg testing. This clinician opined that the Veteran did not have IVDS. The clinician indicated that the Veteran displayed a symmetrical gait with no apparent distress (NAD). This clinician indicated that this disability did not impact the Veteran’s ability to work. 2012 and 2013 VA physical therapy (PT) records disclose that the Veteran sought therapeutic services for lumbar spine issues. At the July 2017 Board hearing, the Veteran testified that he was receiving on-going treatment for his lumbar spine disorder. The Veteran also stated that he took muscle relaxers and “pain pills”: experienced flare-ups on a weekly basis; and had severe limitations bending and twisting. On October 18, 2019, the Veteran was afforded a VA thoracolumbar spine conditions examination. The Veteran endorsed flare-ups which manifest as lumbar stiffness. On examination, the Veteran demonstrated forward flexion to 80 degrees with pain; extension to 25 degrees with pain; right lateral flexion to 30 degrees; left lateral flexion to 30 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. The pain upon forward flexion and extension did not result in functional loss. The clinician indicated the presence of moderate tenderness at the left lower back (paralumbar muscles) and the left sciatic notch. Repetitive use testing resulted in no additional limitation in range of motion. Pain caused functional losses upon repetitive use over time. The clinician characterized this as forward flexion to 70 degrees; extension to 20 degrees; right lateral flexion to 25 degrees; left lateral flexion to 25 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 25 degrees. The clinician made the same findings as to flare-ups. There was no evidence of muscle spasm or guarding. Muscle strength was normal, without atrophy. There was no evidence of ankylosis. IVDS did not induce any episodes of bed rest over the past 12 months. MRI disclosed severe spinal stenosis and disc herniation at L2-3, L3-4, and L4-5. This clinician indicated that this disability did impact the Veteran’s ability to work, notably placing limitations upon prolonged standing, sitting, walking, bending, and heavy lifting. Passive range of motion testing was inappropriate. There was evidence of pain on weight-bearing and non-weight bearing. In her November 2019 lay statement, the Veteran’s spouse noted that disabilities affected all aspects of the Veteran’s life. In lay statements of November and December 2019, the Veteran noted again that he took much medication, to include for his lumbar spine disorder. The Veteran believes that his lumbar spine disorder is more severe than that contemplated by a 10 percent disability rating. Indeed, the Veteran is competent to report that which is discernable such as right back pain. See Jandreau, supra. Under the General Rating Formula as delineated in 38 C.F.R. § 4.71a, a higher disability rating requires a showing of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 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, an increased disability rating for IVDS requires a showing of incapacitating episodes having a total duration of at least two weeks but less than four weeks over the past 12 months. The competent medical evidence fails to show that the Veteran’s lumbar spine disorder has met any of these criteria. At worst, the Veteran’s lumbar spine disorder manifests in forward flexion limited to 65 degrees, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Indeed, such a degree of disability is contemplated by 10 percent disability rating under the General Rating Formula. 38 C.F.R. § 4.71a. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the minimal compensable rating for lumbar spine disorder is already assigned, and the analysis must turn to whether functional loss warranting a higher than 10 percent disability rating is reasonably shown. The most recent October 18, 2019 clinician indicated that pain with repetitive use and flare-ups caused diminished forward flexion (which at 70 degrees is clearly within the criteria contemplated by the minimal compensable disability rating of 10 percent). Consequently, increased disability ratings based on functional limitations due these factors are not warranted. While the Veteran has been shown to experience back pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, supra. Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” to constitute functional loss warranting an increased rating. See 38 C.F.R. § 4.40. The Veteran’s lumbar spine disorder results in the functional limitations that he has endorsed, as discussed above. These limitations are contemplated by the criteria for the 10 percent disability rating that is assigned. Therefore, the Board finds that the preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for the Veteran’s lumbar spine disorder. REASONS FOR REMAND Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Entitlement to an initial disability rating in excess of 10 percent for right foot contusion Entitlement to a TDIU The Veteran asserts that the disability rating assigned to his service-connected right foot contusion does not adequately contemplate the severity of his symptomatology and that a higher disability rating should be assigned. The Board finds that there has not been substantial compliance with its April 2018 remand directives concerning the Veteran’s right foot contusion. Therefore, this issue must be remanded for further evidentiary development. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the Board’s April 2018 remand directives, the RO was directed to afford the Veteran an appropriate VA examination to determine the current severity of his right foot contusion. Specifically, the Board requested that the RO ensure that the examining clinician, [W]ith respect to range of motion testing, this must be conducted on active and passive motion and in weight-bearing and non-weight-bearing conditions (pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016)) and flare-ups (pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Upon review of the clinician’s findings in the October 8, 2019 examination of the Veteran’s foot contusion, the directed tasks have not been performed. As such a new VA examination is in order. The Board finds that consideration of entitlement to a TDIU must be deferred until the above-noted examination is completed and considered, as the increased rating claim for a foot contusion is intrinsically intertwined with the other issues on appeal within the context of entitlement to a TDIU. See Smith (Daniel) v. Gober, 236 F. 3d 1370, 1373 (Fed, Cir, 2001) (where the facts underlying separate claims are “intimately connected,” the interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together); see also Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Contact the Veteran and his representative to ascertain whether there are any private treatment records outstanding for the Veteran’s right foot contusion. If so identified, prepare releases, obtain the records, and associate them with the Veteran’s claims file. 2. Obtain outstanding relevant VA treatment records and associate them with the claim file. 3. Arrange for a VA right foot contusion examination with an appropriate clinician, other than the clinician who conducted the October 18, 2019 examination. This clinician must review the claims file and indicate such review in the body of the examination report. Request that the examiner ascertain the severity of the right foot contusion. With respect to range of motion testing, this must be conducted on active and passive motion and in weight-bearing and non-weight-bearing conditions, and measurement of the range of motion of the contralateral foot (pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016)) and pain on repetitive use and flare-ups (pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017)). If the clinician is unable to conduct the required testing or concludes that the required testing is not necessary in this case, she/he must clearly explain why this is so. The Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran’s reports, she/he must provide an explanation for such rejection. Complete, clearly-stated rationales for the conclusions reached must be provided. Explanation are required that consider the record and pertinent medical principles and the clinician’s rationale should include citation to pertinent evidence and/or medical principles relied upon to form all opinions. Upon completion of all of the above directed tasks and re-adjudication of the Veteran’s right foot contusion claim, the claim for entitlement to a TDIU must be adjudicated. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.