Citation Nr: 21023518 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-35 529 DATE: April 20, 2021 ORDER Entitlement to a compensable initial rating for limitation of extension of the left femoral head is denied. Entitlement to a compensable initial rating for a for limitation of flexion of the left femoral head is denied. Entitlement to an initial rating in excess of 10 percent for avascular necrosis of left femoral head (a left hip disability), limitation of abduction, is denied. Entitlement to initial ratings in excess of 10 percent prior to November 2, 2016, in excess of 20 percent for lumbar spondylosis, from November 2, 2016 to June 27, 2019, and in excess of 40 percent from that date is denied. Entitlement to an initial rating in excess of 30 percent for migraines is denied. FINDINGS OF FACT 1. The Veteran’s service-connected left hip disability is manifested by complaints of pain and limitation of motion, but has not been productive of flexion limited to 45 degrees or less, abduction limited beyond 10 degrees, extension limited to 5 degrees, abduction limited such that the legs cannot be crossed, or rotation limited so as to be unable to toe-out more than 15 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, ankylosis, fail joint, or impairment of the femur. 2. Prior to November 2, 2016, the Veteran’s service-connected lumbar spine disability was not manifested by forward flexion of 60 degrees or less or a combined range of motion of 120 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; did not cause muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour; and did not result in intervertebral disc syndrome (IVDS) with incapacitating episodes, or associated objective neurological abnormalities other than previously service-connected radiculopathy of the left and right lower extremities. 3. For the appeal period from November 2, 2016 to June 27, 2019, the Veteran’s service-connected lumbar spine disability was not manifested by forward flexion greater than of 30 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; IVDS with incapacitating episodes; or associated objective neurological abnormalities other than previously service-connected radiculopathy of the left and right lower extremities. 4. For the appeal period beginning on June 27, 2019, the Veteran’s service-connected lumbar spine was not manifested by ankylosis of the thoracolumbar spine or incapacitating episodes due to IVDS; and was not associated objective neurological abnormalities other than service-connected radiculopathy of the left and right lower extremities. 5. Throughout the period on appeal, the Veteran's migraine headaches were manifested by very frequent characteristic prostrating attacks; however, there is no evidence of record indicating that same has manifested by prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for limitation of extension of the left femoral head have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 2. The criteria for a compensable rating for limitation of flexion of the left femoral head have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 3. The criteria for a rating in excess of 10 percent for avascular necrosis of left femoral head, limitation of abduction, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 4. The criteria for an increased rating for a back disability, rated as 10 percent disabling prior to November 2, 3016, 20 percent disabling from November 2, 2016, to June 27, 2019, and 40 percent from that date, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.40, 4.59, 4.71a, Diagnostic Code 5242. 5. The criteria for entitlement to a rating in excess of 30 percent for migraines have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1989 to April 1998. This matter is before the Board of Veterans' Appeals (Board) on appeal of January and September 2013 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2017, the Veteran testified at a hearing before a Veterans Law Judge. A transcript of the hearing is associated with the file. In January 2021, VA notified the Veteran that the Veterans Law Judge who conducted that hearing was no longer employed by the Board. The Veteran was given the option to have another Board hearing; however, as he did not respond to the letter within 30 days, the Board has assumed that the Veteran does not want another Board hearing and will proceed accordingly. The issues were remanded by the Board for further development in June 2018. A review of the record reflects substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). VA provided the Veteran adequate VA examinations as to the disabilities at issue on appeal and made appropriate efforts to obtain additional records as directed in that remand. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is 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. 38 C.F.R. § 4.10. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. 1. Entitlement to a compensable initial rating for limitation of extension of the left femoral head. 2. Entitlement to a compensable initial rating for limitation of flexion of the left femoral head. 3. Entitlement to a rating in excess of 10 percent for avascular necrosis of left femoral head, limitation of abduction. The Veteran asserts that his left hip disability is worse than the ratings currently assigned. The Veteran’s left hip disability is currently rated as 10 percent disabling under Diagnostic Code 5253 and noncompensable under Diagnostic Codes 5251 and 5252. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the rating criteria under those diagnostic codes were not changed. Pertinent to rating disabilities of the hip and thigh, Diagnostic Code 5250 provides a 60 percent rating for favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction; a 70 percent rating for intermediate ankylosis; and a 90 percent rating for extremely unfavorable ankylosis, with the foot not reaching the ground, or necessitating crutches. 38 C.F.R. § 4.71a. Under Diagnostic Code 5251, limitation of extension of the thigh, a 10 percent rating is assigned for extension limited to 5 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252, limitation of flexion of the thigh, a 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent disability rating is assigned where flexion is limited to 30 degrees; 30 percent where flexion is limited to 20 degrees; and 40 percent where flexion is limited to 10 degrees. Id. Under Diagnostic Code 5253, impairment of the thigh, a 10 percent rating is assigned for limitation of rotation of the affected leg with an inability to toe-out more than 15 degrees or limitation of adduction where the legs cannot be crossed. 38 C.F.R. § 4.71a. A 20 percent rating is assigned for limitation of abduction with motion lost beyond 10 degrees. Id. The Schedule provides that the normal flexion of the hip is from zero degrees to 125 degrees and normal abduction of the hip is from zero degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Service treatment records include multiple complaints of left hip pain. The Veteran initially complained of left hip pain in August 1990. In a January 1998 Medical Board examination, the examiner noted the Veteran’s left hip had reduced range of motion and indicated his hip was unable to support his weight easily by itself. The Veteran underwent a VA hip examination in November 2012. The Veteran did not report any flare-ups that impact the function of the left hip. Range of motion of the left hip revealed a flexion to 110 degrees, with extension greater than 5 degrees. Adduction was not limited such that the Veteran could not cross his legs. Rotation was not limited such that the Veteran cannot toe-out more than 15 degrees. The Veteran was unable to perform repetitive use testing for the left hip due to pain; however, the examiner noted the Veteran had less movement than normal, weakened movement, and pain on movement in the left hip. Muscle strength was 5/5 in the left hip. No ankylosis was noted. The Veteran stated that he does not use an assistive device. The Veteran underwent an additional VA examination in November 2016. The Veteran reported that multiple times a week the left hip will completely shut down, and some days he cannot walk on the left at all. Getting up in the mornings can be a struggle. He has to sit on the side of the bed before rising to see if he is going to be able to take steps on leg. The Veteran reported flare-ups of the left hip which were described as constant discomfort when lying down to sleep and very difficulty walking occasionally. He stated that his pain can be so severe that he has to hold still just trying to get from room to room and that it has affected his getting around daily. Range of motion testing of the left hip revealed a flexion to 60 degrees, with extension of 30 degrees. Adduction was limited such that the Veteran cannot cross his legs. Abnormal range of motion contributes to difficulty standing. The examiner noted pain on examination that causes functional loss. There was pain with movements and weight bearing. There was tenderness at the lateral frontal hip. The Veteran was able to perform repetitive use testing with three repetitions. There was no change in range of motion post-test. Pain was found to significantly limit functional ability with repeated use over a period of time. However, the examiner indicated that, in terms of range of motion, there was no reduction on repeated use over time or during flare-ups. Additional factors contributing to disability included disturbance of locomotion and interference with standing. Muscle strength was 2/5 in the left hip without evidence of atrophy. No ankylosis was noted. The Veteran stated that does not use an assistive device. During the April 2017 Board hearing, the Veteran testified that he has fallen several times and that he constantly has to look for a bench to sit down. He reported difficulty working as he cannot constantly sit because his hip will stiffen, and he cannot move. He also stated he cannot constantly just move around and walk all the time because there are times where it completely gives out. The Veteran asserted that at times he can actually bend, but then later he will not be able to do anything. It affects him throughout various times. He has tried pills and injections for treatment, but they wear off. The Veteran also reported that he has flare-ups of his hip in which everything tightens up. He stated that there are some days it hurts to walk and others when he is capable of prolonged walking. The Veteran underwent an additional VA examination in June 2019. The Veteran reported his left hip has worsened over the years. His left hip pops and gives out on him, and he has fallen because of the hip. He also has lost flexibility of left hip and sometimes he needs help dressing because he cannot bend. The Veteran denied flare-ups of the left hip. Range of motion of the left hip revealed a flexion to 75 degrees, with extension of 30 degrees. Adduction was limited such that the Veteran cannot cross his legs. The examiner noted pain on examination that contributes to functional loss. There was pain with passive and active movements and weight-bearing and nonweight-bearing. The Veteran was not able to perform repetitive use testing with three repetitions due to fear of pain. The examiner noted that pain and lack of endurance significantly limits functional ability with repeated use over a period of time. The examiner opined that the Veteran would have left hip flexion to 70 degrees and extension to 20 degrees on repetitive use over time. Muscle strength was 3/5 in the left hip without evidence of atrophy. No ankylosis was noted. The Veteran stated that he does not use an assistive device. Further review of the record shows that the Veteran receives VA treatment for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported left hip symptoms that are worse than those noted in the various VA examination reports of record and there are no ranges of motion measurements documented in the VA treatment notes of record. Based on the foregoing, the Board finds that a compensable rating is not warranted for the limitation of flexion of the Veteran’s left hip disability. The Veteran’s left hip disability had, at worst, flexion limited to 60 degrees during the November 2016 VA examination. At no point has the Veteran’s left hip flexion been limited to 45 degrees warranting a 10 percent disability rating. Although pain was noted on flexion in the all of the examinations, such did not result in or cause additional functional loss even in contemplation 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 and 4.45 such that a compensable rating was warranted. See also DeLuca, supra. Although pain may cause functional loss, pain itself does not constitute functional loss. Mitchell, supra. Rather, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Here, the VA treatment records and VA examinations do not reveal additional functional impairment, including additional limitation of motion, on account of pain, weakness, etc., that is not already contemplated by the assigned noncompensable rating. Burton, supra; 38 C.F.R. § 4.59. Thus, a higher rating is not warranted for the Veteran’s service-connected left hip disability based on limitation of flexion even in consideration of painful motion and other factors such as weakness, fatigability, lack of endurance, and incoordination. With regard to extension, the Board finds that a compensable rating is not warranted for the limitation of extension of the Veteran’s left hip disability. The Veteran’s left hip disability had, at worst, extension to 30 degrees during the November 2016 and June 2019 VA examinations. At no point has the Veteran’s left hip extension been limited to 5 degrees warranting a 10 percent disability rating. Although pain was noted on range of motion in the VA examination reports, such did not result in or cause additional 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 and 4.45 such that a compensable rating was warranted. See also DeLuca, supra. Here, the VA treatment records and VA examinations do not reveal additional functional impairment, including additional limitation of motion, on account of pain, weakness, etc., that is not already contemplated by the assigned noncompensable rating. Burton, supra; 38 C.F.R. § 4.59. Thus, a higher rating is not warranted for the Veteran’s service-connected left hip disability based on limitation of extension even in consideration of painful motion and other factors such as weakness, fatigability, lack of endurance, and incoordination. With regard to adduction and rotation, the Board finds that a disability rating in excess of 10 percent is not warranted for the limitation of adduction and rotation of the Veteran’s left hip. At no point during the appeals period did the Veteran’s left hip exhibit limitation of abduction with motion lost beyond 10 degrees. The VA examination reports found the Veteran was unable to cross his legs. The November 2012 VA examination found the Veteran was not unable to toe-out more than 15 degrees. The November 2016 VA examination report showed external rotation to 10 degrees and internal rotation to 20 degrees. The June 2019 VA examination report found external rotation to be to 20 degrees and internal rotation to be to 30 degrees in the left hip. Although pain was noted on range of motion in the VA examination reports, such did not result in or cause additional 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 and 4.45. See also DeLuca, supra. Therefore, a higher rating cannot be granted based on limitation of adduction and rotation. The Board also considered the applicability of 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255. However, a review of the record indicates that at no time during the pendency of the appeal has the Veteran’s residuals of a left hip disability been manifested by ankylosis, hip flail joint, or malunion or nonunion of the femur. Accordingly, these Diagnostic Codes are not applicable. Finally, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court’s holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. In this case, the November 2012 VA examination was conducted prior to Correia and Sharp and provides only partial information as described above. The Board notes that the VA examination did not test passive versus active motion; however, pain was noted on examination. The effect of pain on range of motion is described above. Regarding repeated use over time, the Board notes that November 2016 VA examiner conducted repetitive-use testing and concluded that there was no additional limitation in range of motion. Regarding flare-ups, the Board acknowledges that Veteran denied flare-ups during the November 2012 and June 2019 VA examination. Although the Veteran reported flare-ups during the November 2016 VA examination, the VA examiner provided an opinion finding no additional functional impairment during flare-ups. However, the Board finds that all information required for rating purposes was provided. The Veteran’s belief that he is entitled to higher ratings for his left hip disability is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings on the VA examination reports and treatment records that were recorded following physical examinations of the Veteran, than to the Veteran’s general belief that he is entitled to higher ratings. The Board notes that a stage rating is already assigned for the Veteran’s disability and that a further staged rating is not warranted. See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Furthermore, the Veteran has not raised any other issues, nor has any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, supra. In reaching the foregoing determinations, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor. However, insofar as the Board has denied higher ratings, the preponderance of the evidence is against such aspects of the claim. Therefore, the benefit of the doubt doctrine is not applicable, and the increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to a rating in excess of 10 percent prior to November 2, 2016, in excess of 20 percent from November 2, 2016 to June 27, 2019, and in excess of 40 percent from that date for the service-connected lumbar spine disability The Veteran contends that his current back disability is worse than evaluated. The Veteran’s service-connected lumbar spondylosis is currently evaluated as 10 percent prior to November 2, 2016, 20 percent from November 2, 2016 to June 27, 2019 and 40 percent disabling from that date under Diagnostic Code 5242. VA regulations provide that spine disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS on Incapacitating Episodes, under Diagnostic Code 5243, whichever would result in a higher rating. 38 C.F.R. § 4.71a. The revisions to the rating schedule addressing the musculoskeletal system effective February 7, 2021, did not change the rating criteria under the General Rating Formula for Diseases or Injuries of the Spine or the Formula for Rating IVDS on Incapacitating Episodes. As Diagnostic Code 5242 contain successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’s favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). Under the Formula for Rating IVDS Based on Incapacitating Episodes, it is noted that an incapacitating episode is defined by regulation as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. According to the Veteran’s November 2016 VA examination, the Veteran has been diagnosed with IVDS but has not had required bedrest in the past 12 months. The record does not otherwise show that the Veteran has been prescribed bed rest by a physician due to IVDS. Therefore, the Veteran does not meet the criteria for a rating under IVDS based on Incapacitating Episodes. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, 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 abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 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. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. For VA compensation purposes, 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 thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided are the maximum that can be used for calculation of the combined range of motion. At a November 2012 VA examination, the Veteran reported flare-ups which impact heavy lifting, pushing, and pulling. His forward flexion was up to 85 degrees, his extension to 25 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degree, right lateral rotation to 25 degrees and left lateral rotation to 25 degrees. There was no loss of range of motion upon repetitive use testing. Reflex and muscle strength testing were normal. In addition, the examiner noted there was no IVDS of the thoracolumbar spine and the Veteran did not use an assistive device. He did not have localized tenderness or pain to palpation and did not have guarding or muscle spasm of the thoracolumbar spine. At a November 2016 VA examination, the Veteran reported flare-ups described as difficulty sitting upright more or less stand from day to day. He reported functional limitation as constant pain when trying to walk around. His forward flexion was up to 60 degrees, his extension to 30 degrees, 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 examiner note that bending contributes to functional loss. There was pain noted on all range of motion and with weight-bearing. Upon repetitive use testing, the examiner found no additional loss of function or range of motion. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner found pain did limit functional ability with flare-up. Estimated range of motion during flare up was the same. The examiner reported localized tenderness not resulting in abnormal gait or abnormal spinal contour. Additional contributing factors of disability included disturbance of locomotion and interference with standing. Muscle strength testing was 4/5 at all areas on the right and 2/5 at hip flexion, 3/5 knee extension, and 4/5 with ankle flexion on the left. Reflex examination was normal. In addition, the examiner noted there was IVDS of the thoracolumbar spine, but the Veteran did not have symptoms requiring bedrest by a physician. During the April 2017 Board hearing, the Veteran testified that his back feels uncomfortable. He finds it hard to bend down to tie shoes and at times to reach up to grab things. He stated it has constantly progressed and is worsening. During a June 2019 VA examination, the Veteran reported that his right lower back feels like someone is squeezing when he walks. He has pain that goes from his lumbar spine that goes down to the lower extremities with numbness and tingling. Symptoms are more on the left side. He sleeps in hour and hour-and-a-half increments because of pain. The Veteran denied flare-ups. He reported functional limitation as difficulty walking or standing for long periods of time. He also stated he cannot sit in certain position for long periods of time. His forward flexion was up to 40 degrees, his extension to 15 degrees, right lateral flexion to 10 degrees, left lateral flexion to 15 degree, right lateral rotation to 25 degrees and left lateral rotation to 25 degrees. The examiner noted that pain on movements contributes to functional loss. There was pain noted on all range of motion but not with weight-bearing. Upon repetitive use testing, the examiner found no additional loss of function or range of motion. Pain significantly limits functional ability with repeated use over a period of time, but the estimated range of motion was the unchanged. The examiner reported muscle spasm resulting in abnormal gait or abnormal spine contour. Muscle strength testing was 4/5 at all areas on the right and 3/5 at hip flexion, and 4/5 with at other motions on the left. Reflex examination was normal. In addition, the examiner noted there was no IVDS of the thoracolumbar spine. The Veteran reported he occasionally uses crutches and a cane. Passive ROM of the spine was not performed as it is not feasible to do this in a safe and reasonable manner. There was no objective evidence of pain when the spine is in a non-weight bearing position at rest. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported lumbar spine symptoms that are worse than those noted above. For the appeal period prior to November 2, 2016, the Board finds that a rating in excess of 10 percent under the General Rating Formula is not warranted for the Veteran’s service-connected lumbar spine disability. In this regard, at no time pertinent to the appeal period did such disability result in forward flexion limited to 60 degrees or less, or a combined range of motion limited to 120 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Specifically, as previously noted, the Veteran’s forward flexion was noted at its worst to be limited to 85 degrees during the November 2012 VA examination, and such limitation does not reach the level necessary for a higher rating, even in consideration of the Veteran’s reports of pain under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, supra. Furthermore, his combined range of motion was not limited to 120 degrees or less. Moreover, at no time during the appeal period does the Veteran have muscle spasm or guarding, much less such that is severe enough to result in an abnormal gait or spinal contour. For the appeal period from November 2, 2016 to June 27, 2019, the Board finds that a rating in excess of 20 percent under the General Rating Formula is not warranted for the Veteran’s service-connected lumbar spine disability. In this regard, at no time pertinent to the appeal period did such disability result in forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Specifically, as previously noted, the Veteran’s forward flexion was noted at its worst to be limited to 60 degrees during the November 2016 VA examination, and such limitation does not reach the level necessary for a higher rating, even in consideration of the Veteran’s reports of pain under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, supra. Therefore, a rating in excess of 20 percent for the Veteran’s service-connected lumbar spine disability under the General Rating Formula is not warranted. For the appeal period beginning on June 27, 2019, the Board finds that a rating in excess of 40 percent under the General Rating Formula is not warranted for the Veteran’s service-connected lumbar spine disability. In this regard, the record fails to show that there is unfavorable ankylosis of the entire thoracolumbar spine. The June 2019 VA examination found forward flexion to be 40 degrees. The Veteran’s examinations have been consistently negative for ankylosis and the Veteran has retained range of motion of the lumbar spine. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Therefore, the Board finds that, at no time during the appeal period has the Veteran’s service-connected back disability resulted in ankylosis warranting a higher rating for the apparel period after June 27, 2019. In addition to considering the orthopedic manifestations of a back disability, VA regulations also require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. However, the Veteran has not alleged, and the evidence does not show, that he has bladder impairment or bowel impairment as a result of his service-connected back disability. Moreover, the Veteran is already in receipt of separate ratings for right and left lower extremity radiculopathy. Therefore, the Board finds that, at no time during the appeal period, has the Veteran’s service-connected back disability resulted in neurological impairment of the bowel or bladder warranting an additional separate rating. In reaching its conclusions, the Board acknowledges the Veteran’s belief that his service-connected lumbar spine disability is more severe than is reflected by the currently assigned disability ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria, to include through objective range of motion measurements, to be more probative than his reports regarding the severity of his back disability. The Board notes that a stage rating is already assigned for the Veteran’s disability and that a further staged rating is not warranted. Furthermore, the Veteran has not raised any other issues, nor has any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, supra. In reaching the foregoing determinations, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor. However, insofar as the Board has denied higher ratings, the preponderance of the evidence is against such aspects of the claim. Therefore, the benefit of the doubt doctrine is not applicable, and the increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to an initial rating in excess of 30 percent for migraines is denied. The Veteran is service-connected for migraines, which has been continuously rated at 30 percent under Diagnostic Code 8100. 38 C.F.R. § 4.124a. Under Diagnostic Code 8100, a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Governing case law and regulations have not defined prostrating. For reference, the Board notes that prostration is defined as extreme exhaustion or powerlessness. See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32d. ed. 2012). The use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991); Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive or requirement must be met in order for a higher rating to be assigned). Here, each of the criteria listed in the 50 percent rating must be met in order to warrant a 50 percent rating. Tatum v. Shinseki, 23 Vet. App. 152 (2009). At a February 2013 VA examination, the Veteran reported chronic headaches. The examiner indicated his treatment plan includes medication. His symptoms consisted of pain on both sides of the head. His non-headache symptoms associated with headaches includes nausea. The duration of typical head pain is less than 1 day. The Veteran reported characteristic prostrating attacks of migraine headache pain more frequently than once per month. The examiner noted he had very frequent prostrating and prolonged attacks of migraine headache pain. His prostrating attacks of non-migraine headache pain occur less than once every 2 months. The Veteran reported he stopped working due to his headaches. Of note, the examiner noted that he also has been found to have vision and sinus conditions. These all can contribute to headache. He has not been diagnosed with a migraine disability by a neurologist. During a November 2016 VA examination, the Veteran complained of frontal headache/side headaches with photophobia. The examiner indicated his treatment plan includes medication. His symptoms consisted of headache pain pulsating or throbbing headache pain, pain localised to one side of the head, and pain worsened with physical activity. Non-headache symptoms included nausea, vomiting, sensitivity to light, sensitivity to sound, and changes in vision. The duration of typical head pain is 1 to 2 days. The Veteran reported characteristic prostrating attacks of migraine headache pain more frequently than once per month. The examiner noted he had very frequent prostrating and prolonged attacks of migraine headache pain. The examiner noted that he does not have prostrating attacks of non-migraine headache pain. The Veteran reported difficulty with concentrating with headaches. During an April 2017 Board hearing, the Veteran testified that his migraines affect his work as he has migraines at least two to three times a week. He stated he has had to change his job several times because of this and he had to resign as project manager because of extreme pain. He stated he has headaches that range in severity at least three days a week. When he has a headache, the lights hurt his eyes and he has pain on each side of his head. He stated he isolates and will get to a dark area that is quiet. He stated he does contracting now due to his limitations. They affect his day to day routine, and he cannot tell when they will come. He takes medication for his migraine pain. Based on the foregoing evidence, the Board finds that a rating in excess of 30 percent for his migraine headaches is not warranted. In this regard, a next-higher rating of 50 percent requires migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Here, the evidence does not show that the Veteran experienced headaches to such a degree. To that end, the November 2016 VA examiner noted that the Veteran experienced very prostrating and prolonged attacks of migraine or non-migraine pain and that the Veteran’s headaches impacted his ability to work as he has difficulty concentrating with headaches; however, the there is no evidence that his symptomatology is productive of severe economic inadaptability. An October 2014 VA mental health examination indicates that after service, the Veteran worked in construction, then started working for himself in a cleaning business. He worked for a security company before going back to his cleaning business. He had migraines which made it difficult to work for others. He moved to Houston after divorce and returned to school. He got an associate degree in busines in June 2014 and at that time he was working on his bachelor’s degree in project management. He had a job in project management with a company subcontracting with AT&T for a while but the physical demands of the job, as well as his migraines, made him miss work and eventually quit the job. A November 2018 VA progress note indicates the Veteran is employed with his own business in which he contracts with state facilities to mentor young men with disabilities. The Board remanded the claim for additional development to include a request for the Veteran to provide employment records which support his claims that his headaches have caused him to change or lose jobs. The AOJ sent the Veteran a request for employment records in June 2019. The Veteran did not reply to the records request, which would have provided relevant information regarding his claim of entitlement to an increased rating for migraine headaches. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Thus, although the record does show that the Veteran’s service-connected headaches have caused difficulty with work, they also show that the Veteran has continued to work throughout the relevant period. Complete inability to work need not be shown for there to be severe economic inadaptability. However, the record in this case shows that any economic inadaptability caused by the service-connected headaches has not been severe, as is required for a rating of 50 percent, because he has been able to work throughout the relevant period. The Board acknowledges the Veteran’s statement that his migraine headaches are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran’s statement nor medical evidence demonstrates that the criteria for a rating in excess of 30 percent have been met. The Board also acknowledges that the Veteran’s VA treatment records note complaints of and treatment for migraine headaches. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether a staged rating is warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. See Fenderson, 12 Vet. App. at 126-27. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. In reaching the foregoing determinations, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor. However, insofar as the Board has denied a higher rating, the preponderance of the evidence is against such aspects of the claim. Therefore, the benefit of the doubt doctrine is not applicable, and the increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. T. J. ANTHONY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. M. Donahue Boushehri, 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.