Citation Nr: 21025981 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 12-30 191 DATE: April 29, 2021 ORDER An initial rating in excess of 10 percent for right knee osteochondral injury, patellar maltracking, limitation of flexion (Diagnostic Code (DC) 5010-5260), is denied. Subject to the laws and regulations governing the award of VA benefits, an initial 20 percent rating, but no more, for right knee osteochondral injury, patellar maltracking, meniscal symptoms (DC 5258), is granted. A rating in excess of 20 percent for right knee osteochondral injury, patellar maltracking, limitation of extension (DC 5010-5261), from April 21, 2015, is denied. An initial rating in excess of 10 percent for left knee strain with degenerative changes is denied. An initial rating in excess of 10 percent for low back strain with sciatica and segmental dysfunction of the thoracic spine prior to April 21, 2015, and in excess of 20 percent thereafter, is denied. REMANDED Entitlement to an initial rating in excess of 10 percent prior to April 21, 2015, and in excess of 30 percent thereafter for cervical spine fracture with spondylosis is remanded. FINDINGS OF FACT 1. Throughout the entire appeal period, the Veteran’s right knee disability has resulted in traumatic arthritis with painful limitation of flexion; at no point has flexion been limited to 30 degrees and incapacitating exacerbations have not resulted. 2. Throughout the entire appeal period, the Veteran’s right knee disability has resulted in frequent episodes of pain, locking, and effusion. 3. From April 21, 2015, the Veteran’s right knee disability resulted in traumatic arthritis with painful limitation of extension; at no point has extension been limited to 20 degrees. 4. Throughout the entire appeal period, the Veteran’s left knee disability has resulted in traumatic arthritis with painful limitation of flexion; at no point has flexion been limited to 30 degrees and incapacitating exacerbations have not resulted. 5. Prior to April 21, 2015, the Veteran’s low back disability did not result in forward flexion limited to 60 degrees, combined range of motion of the thoracolumbar spine limited to 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, or incapacitating episodes lasting at least two weeks in duration. 6. From April 21, 2015, the Veteran’s low back disability did not result in forward flexion limited to 30 degrees, favorable ankylosis of the entire thoracolumbar spine or the functional limitation equivalent of ankylosis, or incapacitating episodes lasting at least 4 weeks in duration. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee osteochondral injury, patellar maltracking, limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5010-5260. 2. The criteria for an initial 20 percent rating, but no more, for right knee osteochondral injury, patellar maltracking, meniscal symptoms, have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5258. 3. The criteria for a rating in excess of 20 percent for right knee osteochondral injury, patellar maltracking, limitation of extension, from April 21, 2015, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5010-5261. 4. The criteria for an initial rating in excess of 10 percent for left knee strain with degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5010-5260. 5. The criteria for an initial rating in excess of 10 percent for low back strain with sciatica and segmental dysfunction of the thoracic spine prior to April 21, 2015, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5242-5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1998 to April 1998 and from April 2001 to January 2009. These matters were previously denied by the Board in an August 2017 decision. The Veteran appealed to the Court of Appeals for Veterans Claims (Court) which in March 2019 issued a Memorandum Decision vacating and remanding the claims. In January 2020, the Board remanded the claims for further evidentiary development consistent with the Memorandum Decision. Substantial compliance with the remand requests having been achieved with respect to the increased ratings claims for the low back strain and bilateral knee disabilities, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). During the course of the appeal for an increased rating for the low back strain, service connection for right lower extremity radiculopathy at 20 percent disabling and left lower extremity radiculopathy at 20 percent disabling was granted, effective April 21, 2015, in a September 2015 rating decision. The Veteran did not appeal the radiculopathy ratings at the time of the award, and they were not addressed in the August 2017 Board decision denying the increased ratings claims. The Veteran did not include in his appeal to the Court anything regarding the radiculopathy ratings. As such, the Veteran was on notice that the radiculopathy ratings were not part of the appeal and he would have no expectation that such ratings would be on appeal. Accordingly, the Board declines to take jurisdiction of the radiculopathy ratings herein. Compare Chavis v. McDonough, No. 18-2928 (U.S. Vet. App. April 16, 2021) (finding that in some circumstances radiculopathy ratings are part of the underlying increased rating spine claim even if a separate notice of disagreement was not filed, but the Court specifically declined holding that in “all” cases neurological ratings are part and parcel of increased rating spine claims). The examiner testified on these matters before a Veterans Law Judge (VLJ) in May 2014. A transcript of the proceeding has been associated with the claims file. That VLJ is no longer with the Board. The Veteran was provided an opportunity for a new hearing before a different VLJ in March 2021 but did not request a new hearing. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner’s assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA’s General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claims for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran’s claims under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the AOJ. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran’s claims. 1. Bilateral Knee Disabilities Service connection for the Veteran’s right knee disability was granted at 10 percent disabling under 38 C.F.R. § 4.71a, DC 5260-5010, effective February 1, 2009. A temporary total rating was granted for the right knee from August 4, 2010, to August 4, 2011. The rating was changed to DC 5299-5259. In a September 2020 rating decision, the AOJ again changed the rating to DC 5010-5261 and granted a 20 percent rating, effective April 21, 2015. An additional 10 percent rating for the right knee was granted effective April 21, 2015, under DC 5010-5260. The Board will consider the severity of the right knee disability from February 1, 2009, under all diagnostic codes applicable to the knee. Service connection for the Veteran’s left knee disability was granted at 10 percent disabling under 38 C.F.R. § 4.71a, DC 5260-5010, effective February 1, 2009. The Board will consider the severity of the left knee disability from February 1, 2009, under all diagnostic codes applicable to the knee. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic codes indicate that the left knee disability is rated by analogy based on traumatic arthritis and limitation of flexion. The right knee disability was rated first based on evidence of traumatic arthritis with limited flexion, then symptomatic removal of semilunar cartilage, then traumatic arthritis with limitation of extension. The additional rating was based on traumatic arthritis and limitation of flexion. Under the pre-amended criteria, DC 5010 provides that traumatic arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DC 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 2010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Effective February 7, 2021, DC 5010 was amended to provide that post-traumatic arthritis is to be rated based on limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Also relevant to any discussion of knee disabilities are the criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under the pre-amended criteria, DC 5257 provides that slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. Effective February 7, 2021, DC 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Under the pre-amended criteria, DC 5262 provides that a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Effective February 7, 2021, DC 5262 is amended to provide for a 40 percent rating for nonunion of the tibia and fibula, with loose motion, requiring brace. Malunion of the tibia and fibula are to be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Effective February 7, 2021, separate ratings are also provided for medial tibial stress syndrome (MTSS) or shin splints. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Turning to the evidence of record, the Veteran underwent a VA examination in May 2009. He reported that his bilateral knee pains came and went every day, stairs aggravated both knees, and symptoms were worse on the right than on the left. Walking 30 minutes or longer aggravated both knees and standing for 15 to 20 minutes aggravated his knees. He used no assistive devices. The Veteran reported no additional limitation with flare-ups. The functional impact was interfering with daily activities, especially with walking or standing. Upon observation, there was no deformity, swelling, or palpable tenderness. There was full extension in both knees without pain. Bilateral flexion was 0 to 120 degrees with pains over the patella. There was no laxity or instability bilaterally. Active range of motion did not produce any weakness, fatigue, or incoordination bilaterally. There was no additional loss of range of motion with repetitive use testing. X-rays demonstrated small degenerative spur about the lateral margin of the left patella and early degenerative change with tiny spurs about the lateral joint compartment of the right knee. In February 2010, it was noted that the Veteran had right knee swelling with synovial thickening. The knee was slightly tender. An MRI conducted in March 2010 revealed abnormal morphology along the inferior articular surface of the body of the medial meniscus. A subtle meniscal tear could not be excluded. Severe patellofemoral chondromalacia, milder cartilage loss on the posterior surface of the lateral femoral condyle, joint effusion and synovial hypertrophy were all demonstrated. In a May 2010 VA treatment record, it was noted that the Veteran’s right knee had no effusion and no restriction in range of motion. In June 2010, a VA clinician stated that there was some giving way and swelling in the Veteran’s right knee. He reported that he could not run anymore. Upon observation, there was no effusion but there was tenderness. Range of motion in the bilateral knees was from 0 to 120 degrees. A July 2010 MRI demonstrated lateral compression syndrome with chondral defect antero lateral femoral condyle and anterior horn lateral meniscal tear. The Veteran reported difficulty with stairs, night pain, and swelling after activity but denied buckling. As noted above, the Veteran underwent arthroscopy in August 2010 and received a temporary total 100 percent rating through August 1011. In a September 2011 VA treatment record, the Veteran stated that his right knee was better since his surgery, but he still had pain, mostly when going up and down stairs. There was no effusion and the Veteran demonstrated a normal gait. An x-ray revealed a slight sharpening of the margins of the patella from an early degenerative change; no appreciable joint effusion; sharp tibial spines from degenerative changes; and no joint space narrowing. At the May 2014 hearing, the Veteran reported that his knees buckled and locked up and he had to catch himself from falling, mainly in the right knee. The left knee gave out on occasion, but not nearly as much as the right knee. Pain in the right knee was sharp and constant, on average a 6.5 to 7 out of 10. Flare-ups were described as a lot of pain (9 out of 10) and swelling occurring two to three times a week, depending on how much walking and physical activity he did. He was able to walk about two to three blocks with pain. The Veteran stated that he did not believe that his right knee benefited from surgery at all. He currently wore a knee brace with metal hinges on the right knee daily but did not require a brace for the left knee. Bilateral knee pain was alleviated with icing, elevating, and using over-the-counter medication. A VA examination was conducted in April 2015. The Veteran reported a functional impairment of pain with standing and walking. He denied flare-ups. Range of motion in the right knee was from 15 to 40 degrees in flexion and 40 to 15 degrees in extension. Pain was noted upon examination and resulted in functional loss in that the Veteran was unable to squat and kneel. There was evidence of pain with weight-bearing and anterior tenderness on palpation. There was evidence of crepitus. In the left knee, flexion was from 0 to 90 degrees and extension was from 90 to 0 degrees. Pain was noted on examination and caused functional loss. There was evidence of pain with weight-bearing and anterior tenderness on palpation. There was evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or range of motion. The examiner determined that whether pain, weakness, fatigability, or incoordination would significantly limit functional ability with repeated use over time in the bilateral knees could not be determined as without observing repeated use over time, it would be mere speculation to express additional loss in terms of degrees. In the section of the examination that asked about additional contributing factors of disability, it appeared that the examiner listed all of the possible contributing factors including less movement than normal due to ankylosis, adhesions, etc., disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing was normal and there was no muscle atrophy bilaterally. The examiner indicated that there was no ankylosis in either knee. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed with negative results bilaterally. The examiner indicated that there were no meniscal conditions. The Veteran’s prior right knee patellar surgery was noted with residuals of loss of range of motion and pain. The Veteran constantly used bilateral knee braces for assistance. The examiner determined that the functional impact was an inability to engage in prolonged standing and walking. The Veteran was able to engage in sedentary, sitting employment. An MRI of the left knee conducted in March 2016 demonstrated interval osteochondral autograft transfer to the lateral aspect of the femoral trochlea repairing a previously noted full-thickness cartilage defect at the site; mild residual osteochondral irregularity in the region; mild chondromalacia along the lateral patellar facet; interval development of a full-thickness articular cartilage defect along the weight-bearing surface of the lateral femoral condyle; worsening chondromalacia along the far posterior aspect of the lateral femoral condyle; scarring in the region of the lateral patellar retinaculum and within the infrapatellar fat from prior arthroscopy and lateral release; mild abnormal signal in the fibular collateral ligament and popliteus tendon, likely degenerative; and small joint effusion. An MRI of the right knee revealed degenerative intrasubstance abnormal signal in the anterior horn of the lateral meniscus without a definitive tear; extensive chondromalacia along the lateral patellar facet with adjacent subchondral cysts and marrow edema; patella alta and edema in the superolateral aspect of the infrapatellar fat, raising the possibility of patellar maltracking and/or excessive lateral pressure; mild chondromalacia along the lateral tibial plateau; and small joint effusion. Retrospective opinions were obtained in March 2020 in compliance with the terms of the Memorandum Decision. The examiner was asked to determine at what degree pain began in the bilateral knees during range of motion testing at the May 2009 examination and to discuss functional impairment. She stated that pain began bilaterally at 120 degrees. This would not dramatically impair walking, standing, kneeling, or squatting. Activities of daily living (ADLs) and work activities would be able to be completed without restriction. The examiner also determined that with repeated use over time and during flare-ups, the Veteran’s range of motion would not dramatically impair walking, standing, kneeling, or squatting, and ADLs and work activities would be able to be completed without restriction. The range of motion demonstrated on examination was within normal limits for walking, climbing stairs, and transitioning from sitting to standing. Regarding the fact that ankylosis was listed in the April 2015 examination as a contributing factor to disability but was also specifically denied on the examination report, the examiner stated that it was indicated that ankylosis was not present on the examination. Further, the available medical records were silent for ankylosis. Therefore, her medical opinion was that it was less likely than not that the Veteran had ankylosis in the bilateral knees. During the April 2015 examination, the examiner also determined that with repeated use over time and during flare-ups, the Veteran’s range of motion in the left knee would not dramatically impair walking, standing, kneeling, or squatting, and ADLs and work activities would be able to be completed without restriction. The range of motion demonstrated on examination was within normal limits for walking, climbing stairs, and transitioning from sitting to standing. For the right knee, the examiner stated that the documented range of motion suggested that the Veteran had pain impairing the ability to bring the knee to full flexion of zero degrees and limited extension to 15 degrees of flexion such that he could not fully strengthen his leg. Flexion had pain at 45 degrees, such that the Veteran was prevented from further bringing the knee toward the buttocks. The April 2015 examination was silent for changes in range of motion during flare-ups or repetitive use, but the available evidence did not aid the clinician in providing additional range of motion measurements during a flare-up. It was not possible without mere speculation to state what the Veteran’s range of motion in a flare-up would be as current medical evidence did not support him being able to walk with a range of motion from 15 to 45 degrees. Normal gait and slopes required less than 90 degrees of flexion, stairs and chairs required 90 to 120 degrees of flexion, and a bath required approximately 135 degrees of flexion. His gait was noted to be unsteady and to be changed as he was favoring his knee. The examiner concluded that it was not possible without mere speculation to provide the Veteran’s active range of motion and passive range of motion including with pain on weight-bearing and nonweight-bearing for his right knee and any degree of functional loss during repeated use over a period time and during flare-ups due to a deficiency in the medical records. The April 2015 range of motion measurements were the most current measurements available for the right knee. The examiner pointed to medical treatises in support of her opinion. The Board notes at the outset that the VA examinations of record, taken in conjunction with records of medical treatment and the March 2020 retrospective opinion, provide an adequate basis upon which to determine the extent and severity of the Veteran’s left and right knee disabilities. Although whether there was pain with passive movement and nonweight-bearing was not elicited on examination, the Veteran has indicated that he experienced increased pain with prolonged standing and walking and with going up and down stairs, suggesting increased pain with active and weight-bearing activities. As such, active and weight-bearing motion as captured by all examinations is more likely to represent the most severe limitation of motion caused by the disability. The Veteran denied flare-ups at every examination. At the May hearing, he stated that flare-ups occurred a couple times per week and resulted in increased pain only. The March 2020 examiner determined that additional functional limitation during flare-ups could not be determined given a lack of information in the claims file regarding symptoms during flare-ups. The Board finds this opinion to accurately reflect the medical evidence of record and to provide an adequate medical reason why an estimation could not be provided without speculation. Similarly, the March 2020 examiner found that additional functional loss following repetitive use over time could not be determined without speculation in the right knee given a lack of information in the medical record. The range of motion demonstrated in the left knee indicated that activities would not be further limited with repeated use over time. The Board finds that the examiner provided an adequate medical opinion for the inability to provide additional loss of range of motion in terms of degrees. Further, the Veteran himself has provided statements regarding the limitation of his activities from which to extrapolate the extent and severity of his knee disabilities. Given the totality of the information, including the Veteran’s own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. Additionally, as no relevant medical evidence has been added to the record since February 7, 2021, consideration under the amended criteria is not warranted. As such, the Board will consider the severity of the Veteran’s bilateral knee disabilities under the pre-amended criteria. A. A rating in excess of 10 percent for right knee osteochondral injury, patellar maltracking, limitation of flexion, is denied. As noted above, the Veteran received an initial 10 percent rating under 38 C.F.R. § 4.71a, DC 5260-5010, pertaining to traumatic arthritis and limitation of flexion, effective February 1, 2009. The rating was recharacterized under DC 5299-5259, pertaining to symptomatic removal of cartilage, effective October 1, 2010. The AOJ again changed the rating to DC 5010-5261, pertaining to traumatic arthritis and limitation of extension, and granted a 20 percent rating, effective April 21, 2015. An additional 10 percent rating for the right knee was granted effective April 21, 2015, under DC 5010-5260, pertaining to traumatic arthritis and limitation of flexion. The Court held that evaluation of a knee disability under DC 5257 or DC 5261 (and DC 5260) or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DC 5258 or DC 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Entitlement to a separate evaluation depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different diagnostic code. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. at 202. Id. As such, the prior changing of the Veteran’s right knee rating from a rating based on limitation of motion to a rating based on a meniscal condition and again to a rating based on limitation of motion was not necessary and such manifestations should be rated separately if not overlapping. Therefore, the Board finds that ratings based on limitation of flexion and based on dislocation of semilunar cartilage are warranted throughout the entire appeal period and a rating based on limitation of extension is warranted from April 21, 2015. Since February 1, 2009, the Veteran’s right knee demonstrated traumatic arthritis with painful limited flexion, warranting a 10 percent rating under DC 5010-5260. Flexion was not limited to a compensable degree under DC 5260 prior to April 21, 2015. At the April 2015 examination, flexion was limited to 40 degrees, warranting a 10 percent rating under the criteria of DC 5260. As flexion has not been shown to be limited to 30 degrees, nor has flexion been described by the Veteran as being limited to such a degree, a rating in excess of 10 percent under DC 5260 is not warranted. Further, other than the period for which a temporary total rating has already been awarded, there were no incapacitating exacerbations. As such, an initial 10 percent rating under DC 5010-5260 is warranted throughout the entire appeal period (since February 1, 2009). A rating in excess of 10 percent is not warranted under DC 5010-5260 at any point during the appeal period. B. A 20 percent rating for right knee osteochondral injury, patellar maltracking, meniscal symptoms, is granted. From February 1, 2009, the Veteran’s right knee disability has also resulted in a meniscal condition with associated symptomology which is not encompassed by the DC 5010-5260 rating addressing limitation of motion. Cartilage involvement was demonstrated throughout the entire appeal period, prior to the August 2010 surgery and subsequent to the surgery. Pain was constant and the right knee had frequent episodes of locking and effusions, as demonstrated upon x-ray and as testified to by the Veteran. As such, a 20 rating under DC 5258 is warranted throughout the entire appeal period (since February 1, 2009). As a 20 percent rating is the maximum evaluation available under DC 5258, a rating in excess of 20 percent is not warranted. The Board has considered whether the meniscal involvement of the right knee should be rated under DC 5259. However, the associated symptoms specifically have been noted to be pain, frequent locking/buckling, and recurrent effusions. As the Veteran’s particular symptomology is listed under DC 5258, the meniscal involvement of the right knee is best rated under DC 5258. As the meniscal symptomology is already compensated under DC 5258, an additional rating under DC 5259 would compensate overlapping symptoms. Rating the meniscal symptomology under DC 5258 instead of DC 5259 represents a more advantageous rating for the Veteran. Therefore, an additional or alternative rating under DC 5259 is not warranted. C. A rating in excess of 20 percent for right knee osteochondral injury, patellar maltracking, limitation of extension, from April 21, 2015, is denied. Prior to the April 21, 2015, examination, extension was not demonstrated to be limited on motion or to be painful. At the examination, extension was limited to 15 degrees. As such, as of the date of the examination, but no earlier, a 20 percent rating is warranted under the criteria of DC 5261. Extension was not limited to 20 degrees at any point, and therefore, a rating in excess of 20 percent is not warranted. The Board has considered whether additional or alternative ratings are warranted for the right knee. Ankylosis or the functional limitation equivalence of ankylosis has not been demonstrated. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App. April 16, 2021). Although the April 2015 examiner listed ankylosis with other types of functional impairment, he specifically stated that there was no ankylosis in the right knee. The March 2020 examiner found ankylosis was less likely than not present in the right knee, based on the examination results and other medical evidence in the claims file. As such, the preponderance of the evidence is against a rating under DC 5256. Further, although the Veteran described locking and buckling causing falls or near-falls at the May 2014 hearing, there was no evidence of lateral instability in the right knee upon clinical evaluation. Locking and buckling is compensated under the rating granted herein under DC 5258. Without evidence of recurrent subluxation or lateral instability, rating the right knee under DC 5257 is not indicated. Finally, there was no evidence of nonunion or malunion of the tibia and fibula nor genu recurvatum warranting ratings under DC 5262 or DC 5263. As such, the evidence does not support additional or alternative ratings for the right knee disability throughout the appeal period. The Veteran’s representative has contended (see July 2018 Appellant’s Brief, February 2021 Informal Hearing Presentation ) that extraschedular ratings may be warranted for the right knee disability including due to his use of assistive devices. Therefore, the Board has considered whether referral for extraschedular consideration is warranted. See 38 C.F.R. § 3.321(b)(1); see Thun v. Peake, 22 Vet. App. 111 (2008). The Court has set out a three-part test (based on the language of 38 C.F.R. § 3.321(b)(1)) for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. at 111. The Veteran’s relevant right knee symptoms include pain, limited range of motion, locking/buckling, and effusions/swelling. These symptoms result in difficulty with prolonged walking, standing, bending, climbing stairs, and squatting, and an inability to run. Such symptoms and their functional impact are specifically contemplated by the 10 percent criteria of DC 5260, the 20 percent criteria of DC 5258, and the 10 percent criteria of DC 5261. Further, the Veteran’s use of an assistive device such as a right knee brace is due to symptoms related to impairment of range of motion and locking. As impairment of range of motion and locking are contemplated by the schedular rating criteria and the ratings applied to the Veteran’s right knee disability, the use of a knee brace does not satisfy the first part of Thun’s first element. See Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018) (“All the symptoms for which a cane or walker could serve as a proxy are contemplated by § 4.120 as impairments of motor and sensory function. In other words, the symptoms of sciatica that cause the Appellant to use assistive devices such as a cane or walker are contemplated by the schedular rating criteria and therefore do not satisfy the first part of Thun’s first element.”). Based on the foregoing, the Board finds that the established schedular criteria are adequate to describe the severity and symptoms of the Veteran’s right knee disability. Therefore, the first prong of the Thun analysis is not met and referral for extraschedular consideration is not warranted. D. An initial rating in excess of 10 percent for left knee strain with degenerative changes is denied. The Board finds that a rating in excess of 10 percent for the Veteran’s left knee under 38 C.F.R. § 4.71a, DC 5010-5260, is not warranted at any point during the appeal period. Since February 1, 2009, the Veteran’s left knee demonstrated traumatic arthritis with painful limited flexion, warranting a 10 percent rating under DC 5010-5260. Flexion was not limited to a compensable degree under DC 5260. At worst, flexion has been limited to 90 degrees on clinical examination. The Veteran has not described limitation of flexion to a greater degree. Further, there is no evidence of incapacitating exacerbations. As such, a rating in excess of 10 percent is not warranted under DC 5010-5260. The Board has considered whether additional or alternative ratings are warranted for the left knee. Ankylosis or the functional limitation equivalence of ankylosis has not been demonstrated. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App. April 16, 2021). Although the April 2015 examiner listed ankylosis with other types of functional impairment, he specifically stated that there was no ankylosis in the left knee. The March 2020 examiner found ankylosis was less likely than not present in the left knee, based on the examination results and other medical evidence in the claims file. As such, the preponderance of the evidence is against a rating under DC 5256. Further, although the Veteran described occasional locking and buckling causing falls or near-falls at the May 2014 hearing, there was no evidence of lateral instability in the left knee upon clinical evaluation and he has not been prescribed any canes or other assistive devices due to stability concerns. Without evidence of recurrent subluxation or lateral instability, rating the right knee under DC 5257 is not indicated. Further, there is no indication that the Veteran has had semilunar cartilage dislocation or removal during the appeal period warranting rating under DC 5258 and DC 5259. Extension has not been shown to be limited to a compensable degree warranting rating under DC 5261. Finally, there was no evidence of nonunion or malunion of the tibia and fibula nor genu recurvatum warranting ratings under DC 5262 or DC 5263. As such, the evidence does not support additional or alternative ratings for the left knee disability throughout the appeal period. The Veteran’s representative has contended (see July 2018 Appellant’s Brief, February 2021 Informal Hearing Presentation) that extraschedular ratings may be warranted for the Veteran’s disability including due to his use of assistive devices. Therefore, the Board has considered whether referral for extraschedular consideration is warranted. See 38 C.F.R. § 3.321(b)(1); see Thun v. Peake, 22 Vet. App. at 111. The Veteran’s relevant left knee symptoms include pain and limited range of motion. These symptoms result in difficulty with prolonged walking, standing, bending, climbing stairs, and squatting, and an inability to run. Such symptoms and their functional impact are specifically contemplated by the 10 percent criteria of DC 5260. Further, the Veteran’s use of an assistive device such as a left knee brace is due to symptoms related to impairment of range of motion. As impairment of range of motion is contemplated by the schedular rating criteria and the rating applied to the Veteran’s left knee disability, the use of a knee brace does not satisfy the first part of Thun’s first element. See Spellers v. Wilkie, 30 Vet. App. at 218. Based on the foregoing, the Board finds that the established schedular criteria are adequate to describe the severity and symptoms of the Veteran’s left knee disability. Therefore, the first prong of the Thun analysis is not met and referral for extraschedular consideration is not warranted. 2. Low Back Strain Service connection for the Veteran’s low back strain was granted at 10 percent disabling under 38 C.F.R. § 4.71a, DC 5237, pertaining to lumbosacral strain, effective February 1, 2009. In a September 2015 rating decision, the AOJ increased the rating to 20 percent, effective April 21, 2015, under DC 5242-5237. The hyphenated diagnostic code indicated that the disability is rated by analogy based on degenerative arthritis of the spine and lumbosacral strain. 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 evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). Ratings under the General Rating Formula 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. Prior to February 7, 2021, DC 5242 was assigned for degenerative arthritis of the spine and DC 5243 for IVDS. As of February 7, 2021, DC 5242 is assigned for degenerative arthritis and DDD other than IVDS. It also amends DC 5243 for IVDS, allowing the diagnostic code to be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; otherwise DC 5242 must be used for all other disc diagnoses. Although the amended criteria for 5242 and 5243 separated DDD from IVDS, the rating formula under each diagnostic code was unchanged. The General Rating Formula provides for assignment of a 10 percent rating when forward flexion of the thoracolumbar spine is 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 requires forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating requires unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, DC 5242, General Rating Formula for Diseases and Injuries of the 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 is zero to 30 degrees, and left and right lateral rotation is 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 in this note are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine at Note (2); see also 38 C.F.R. § 4.71a, Plate V. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under the appropriate diagnostic code. Note (1). Alternatively, disability involving disc disease may be rated under the Formula for Rating IVDS Based on Incapacitating Episodes. That formula provides a 10 percent disability rating for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). Turning to the evidence of record, a May 2009 VA treatment record reflected that the Veteran had normal thoracic and lumbar curvatures, the spine was non-tender, and he had full active range of motion. The Veteran underwent a VA examination in May 2009. He described daily low back pain which came and went. Pain was usually a stabbing type of pain averaging at 6 out of 10 and increasing to 8 out of 10 with bending only. He took no medications and had had no incapacitating episodes in the past year. He denied any urinary or fecal incontinence and had no additional limitation with flare-ups. Upon observation, the spine was normal with no deformity or swelling. Tenderness was noted at L4-L5. Forward flexion was 0 to 70 degrees with pain at the L4-L5 vertebrae. Extension was 0 to 20 degrees with pain at L3, L4, and L5. Right and left lateral rotation and flexion were 0 to 20 degrees with pain at L3, L4, and L5. There was normal pinprick and strength in the lower extremities. Deep tendon reflexes were normal and equal. The Veteran’s gait was normal. There was no muscle atrophy or muscle spasm present. Active range of motion did not produce any weakness, fatigue or incoordination. There was no additional loss of range of motion with repetitive use testing. The straight leg raise on the left was to 60 degrees with pain and 70 degrees on the right with pain. In June 2009, VA clinicians noted that the Veteran had a stable gait, good forward flexion of the spine, mild tenderness to palpation in the lumbar spine, and no incontinence of stool or urine. An x-ray revealed moderate degenerative joint disease (DJD) with anterior and lateral osteophytes at L3-S1. Mild L3-L4 degenerative disc disease (DDD) with narrowing and anterior and posterior osteophytes. In August 2009, it was noted that the Veteran’s range of motion was limited with flexion. A lumbar brace was prescribed. An MRI conducted in July 2010 revealed bilateral hypoplastic twelfth rib; moderate DDD changes at L3-L4 for anterior marginal osteophytes; preserved alignment; no acute compression deformity of the lumbar vertebral bodies; no aggressive osseous lesions; and the sacroiliac joints were unremarkable. There was no subluxation of the lumbar vertebrae. An x-ray was conducted in September 2010 which demonstrated multifactorial spinal stenosis at L3-L4 and L4-L5. Spinal stenosis was severe at L3-L4 with mild to moderate right and mild left neural foramen stenosis. The Veteran received a lumbar epidural spinal injection in October 2010. In November 2010, VA clinicians noted that the Veteran’s lumbar range of motion was normal with pain on flexion but not on extension. There was tenderness over the mid-lumbar region, as well. The Veteran had a normal gait. Another steroid injection was administered. In February 2011, the Veteran underwent a surgical lumbar decompression of spinal stenosis. At the May 2014 hearing, the Veteran stated that his low back condition had worsened since his surgery. He had good days and bad days, but the bad days outweighed the good days. He experienced pain weekly or a couple times a week. He might turn the wrong way and pain would shoot down his legs. The Veteran described a pain level of 8 out of 10, constant and mostly sharp and stabbing. He currently took no medications or muscle relaxers to treat his lumbar spine disability. When he sat for too long, he would have to get up or change positions to relieve symptoms. When he stood for too long, he had to sit down to relieve symptoms. The Veteran had previously tried physical therapy and chiropractic therapy without relief. His wife had observed him resting in the fetal position to relieve his pain. They had also tried different types of beds and chairs to assist in relieving his pain, as well. The Veteran’s wife also stated that his pain disturbed his sleep. He pushed himself through the pain and would try to rest on his days off. A VA examination was conducted in April 2015. The Veteran reported continued chronic lumbar pain bilaterally, increased with bending, prolonged standing, and walking. He denied flare-ups. Forward flexion was 0 to 80 degrees, extension was 0 degrees, right and left lateral flexion were to 10 degrees, right lateral rotation was to 15 degrees, and left lateral rotation was to 25 degrees. Functional loss resulting from restricted range of motion was that the Veteran was unable to bend and lift. Pain was noted on all planes of motion and with weight-bearing. There was bilateral lumbar muscular tenderness, as well. The Veteran was able to perform repetitive use testing without additional functional loss. The examiner was unable to determine whether pain, weakness, fatigability, or incoordination would significantly limit functional ability with repeated use over time as it would be mere speculation to provide limitation in degrees of range of motion without observing movement after repeated use over time. Muscle spasm, tenderness, and guarding were observed which resulted in abnormal gait or spinal contour. In the section of the examination that asked about additional contributing factors of disability, it appeared that the examiner listed all of the possible contributing factors including less movement than normal due to ankylosis, adhesions, etc., disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing was normal and there was no muscle atrophy. A reflex examination yielded normal results. A sensory examination was normal bilaterally but decreased at the thigh/knee (L3-L4) and lower leg/ankle (L4-L5-S1) bilaterally. The straight leg test was positive on both sides. Moderate radiculopathy involving the sciatic nerve was demonstrated in both lower extremities. There was no ankylosis of the spine and no other neurologic abnormalities. The Veteran had IVDS but had not had any incapacitating episodes in the past year. He required no assistive devices to aid in locomotion. The examiner determined that the functional impact was that the Veteran was unable to engage in manual labor and prolonged standing or walking. He was however able to engage in sedentary, sitting employment. An MRI was conducted in October 2017 which demonstrated mild dextroscoliosis; moderate degenerative changes at L3-5, advanced for age; and status post posterior decompression L2-L5 with mild residual circumferential canal narrowing at L2-L4. A lumbar CT was performed in September 2018 which revealed status post laminectomies from L2-L4; mild dextroscoliotic curvature; maintained vertebral body heights and alignment; no fractures or subluxations; and multilevel lumbar spondylosis. In December 2018, the Veteran reported continued lumbar pain that was not as severe following the February 2011 decompression and laminectomy. Pain was constantly a 7 out of 10. Pain was better with changing positions, a short pace walk, and the fetal position and worse with prolonged walking, standing, and sitting. In February 2019, the Veteran underwent several sessions of acupuncture. He described his pain usually dull but sometimes sharp, stiffness especially in the morning and with cold weather, and improved symptoms with a hot shower. All lower back ranges of motion were limited due to pain and stiffness and tenderness to palpation was observed in the paraspinal muscles. In April 2019, all lower back ranges of motion were again limited due to pain and stiffness and the Veteran had moderate tenderness to palpation in the lumbar paraspinal muscles. A retrospective opinion was obtained in March 2020. The examiner was asked when pain began during motion at the May 2009 examination and how that affected functional ability. The examiner stated that during that examination, the Veteran was unable to bend at the hips more than 70 degrees. This would have prevented him from picking things up off the ground, tying his shoes, and putting on his pants without pain. The Veteran demonstrated an impaired ability to lean back from the lower back, twisting side to side, and reaching down bilaterally. That range of motion would impact his ability to pick things up off of the ground and twisting to look around. Regarding additional limitation during flare-ups or with repeated use over time, there was no increased limitation with flare-ups and no incapacitating episodes. The medical records around the time of the examination were silent for flare-ups, as well. The examiner’s opinion was that decreased range of motion from flare-ups or with repetitive use over time was less likely than not. The examiner was asked to reconcile the listing of ankylosis in the additional factors section and the notation that the Veteran did not have ankylosis of the spine at the April 2015 examination. The examiner stated that the range of motion in extension to 0 degrees could suggest ankylosis, but the April 2015 examiner specifically denied ankylosis and the medical records were silent for ankylosis. The contemporaneous MRI did not show fused bones or other hard tissues in the lumbar spine. As such, it was the examiner’s opinion that ankylosis was less likely than not. The examiner was also asked to additional limitations during flare-ups or with repeated use over time. She stated that the available records were silent for decreasing range of motion from flare-ups. The April 2015 examination stated that the Veteran had increased pain with bending, standing, and walking. She determined that it was less likely than not there was decreased range of motion from repetitive use over time or during flare-ups. The range of motion demonstrated at the April 2015 examination would impair the Veteran’s bending, lifting, twisting, and carrying. He would still be able to perform sedentary work. The Board notes at the outset that the VA examinations of record, taken in conjunction with records of medical treatment and the March 2020 retrospective opinion, provide an adequate basis upon which to determine the extent and severity of the Veteran’s low back disability. Although whether there was pain with passive movement and nonweight-bearing was not elicited on examination, the Veteran has indicated that he experienced increased pain with prolonged standing, walking, and sitting, suggesting increased pain with active and weight-bearing activities. As such, active and weight-bearing motion as captured by all examinations is more likely to represent the most severe limitation of motion caused by the disability. The Veteran denied flare-ups at every examination. The March 2020 examiner determined that there would be no additional functional limitation during flare-ups. She however described the specific types of movements that increased pain would limit or prohibit. Similarly, the March 2020 examiner found that additional functional loss following repetitive use over time would not result, based on the prior examination ranges of motion and the Veteran’s descriptions of his symptoms. The Board finds that the examiner provided an adequate medical opinion for the inability to provide additional loss of range of motion in terms of degrees. Further, the Veteran himself has provided statements regarding the limitation of his activities from which to extrapolate the extent and severity of his low back disability. Given the totality of the information, including the Veteran’s own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. Additionally, as no relevant medical evidence has been added to the record since February 7, 2021, consideration under the amended criteria is not warranted. As such, the Board will consider the severity of the Veteran’s low back disability under the pre-amended criteria. A. An initial rating in excess of 10 percent for low back strain with sciatica and segmental dysfunction of the thoracic spine prior to April 21, 2015, and in excess of 20 percent thereafter, is denied. Prior to April 21, 2015, the Veteran’s lumbar spine range of motion did not demonstrate forward flexion limited to 60 degrees or combined range of motion limited to 120 degrees. Further, there was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour. Additionally, there was no evidence of incapacitating episodes lasting at least 2 weeks in a 12-month period. As such, the criteria for a rating in excess of 10 percent prior to April 21, 2015, were not met. At the April 21, 2015, examination, the Veteran’s lumbar spine demonstrated muscle spasm and guarding severe enough to result in abnormal gait or spinal contour. Subsequent VA treatment records reflected an abnormal spinal contour (dextroscoliosis). As the April 21, 2015, examination is the first medical evidence demonstrating such symptomology, a 20 percent rating is warranted as of that date. At no point was forward flexion limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine demonstrated. Although the April 2015 examiner noted contradictory information regarding ankylosis, as determined by the March 2020 examiner, nowhere in the medical record was there a diagnosis of ankylosis or MRI evidence of the type of condition that would result in ankylosis. Further, although the Veteran had limitation of motion, he was able to engage in the types of movement that would be prevented by ankylosis of the spine. As such, the preponderance of the evidence is against a finding that the Veteran’s low back disability resulted in ankylosis or the functional limitation equivalence of ankylosis. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App. April 16, 2021). Further, there was no evidence of incapacitating episodes lasting at least 4 weeks in a 12-month period. Accordingly, a rating in excess of 20 percent from April 21, 2015, is not warranted. The Board has considered whether additional ratings are warranted for the Veteran’s service-connected low back disability based on any associated objective neurologic abnormalities. See General Rating Formula for Disease and Injuries of the Spine, Note (1). However, the Veteran is already in receipt of ratings for associated bilateral lower extremity radiculopathy. Further, the evidence as outlined above does not identify any other neurological abnormalities associated with the Veteran’s low back disability. Thus, the Board finds no basis to award any further separate ratings pursuant to Note (1). The Veteran’s representative has contended (see July 2018 Appellant’s Brief, February 2021 Informal Hearing Presentation) that extraschedular ratings may be warranted for the Veteran’s disability. Therefore, the Board has considered whether referral for extraschedular consideration is warranted. See 38 C.F.R. § 3.321(b)(1); see Thun v. Peake, 22 Vet. App. at 111. The Veteran’s relevant low back symptoms include pain, limited range of motion, and guarding and muscle spasm resulting in abnormal gait or spinal contour. These symptoms result in difficulty with prolonged walking, standing, bending, lifting, and sitting. Such symptoms and their functional impact are specifically contemplated by the criteria of DC 5242-5237. Extraschedular evaluations are not available where a disability is capable of evaluation under the rating schedule. See Long v. Wilkie, 33 Vet. App. 167 (2020). Based on the foregoing, the Board finds that the evidentiary record does not reasonably raise the prospect that the Veteran’s disability is not and cannot be adequately rated under the rating schedule. Therefore, referral for extraschedular consideration is not warranted. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent prior to April 21, 2015, and in excess of 30 percent thereafter for cervical spine fracture with spondylosis is remanded. In compliance with the Memorandum Decision, in the January 2020 Board remand, a retrospective VA medical opinion was requested which would determine at which degree pain began for the Veteran’s cervical spine disability, range of motion on active and passive motion and during weight-bearing and nonweight-bearing, and whether additional limitation occurred with flare-ups or after repeated use over time at the May 2009 examination. Also requested was a reconciliation regarding whether there was ankylosis at the April 2015 examination and a discussion of range of motion on active and passive motion and during weight-bearing and nonweight-bearing, and whether additional limitation occurred with flare-ups or after repeated use over time at the April 2015 examination. An opinion was obtained in September 2020. The clinician merely stated that the 2009 examiner noted the ranges of motion and where pain occurred. Specifically, no pain was noted for any planes of motion, other than right and left rotation, which occurred, more likely than not at 60 degrees for each. The Board finds that the retrospective opinion does not adequately address the Board remand requests based on the Court’s guidance. As such, remand is needed to obtain a new retrospective opinion. The prior remand requests are replicated below. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the following: (a.) Provide a retrospective opinion, to the extent possible, based on the May 2009 examination report, as to what degree, in terms of range of motion, the Veteran’s pain began for his cervical spine disability and how this pain affected his functional loss for this disability as to any inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, including on repeated use and during flare-ups. (b.) Provide a retrospective opinion, to the extent possible, based on the May 2009 examination report, as to the Veteran’s range of active motion and passive motion, including with pain, on weight-bearing and nonweight-bearing, for his cervical spine disability. In this regard, the examiner should provide an estimate, if at all possible, of any additional impairment on repeated use and during flare-ups based on the evidence of record and the Veteran’s statements. If it is not possible to provide a specific finding without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). (c.) Provide a retrospective opinion, to the extent possible in order to reconcile the contradictory findings of the April 2015 examination report regarding if the Veteran had ankylosis in the cervical spine. (d.) Provide a retrospective opinion to the extent possible, based on the April 2015 examination report, as to the Veteran’s range of active motion and passive motion, including with pain, on weight-bearing and nonweight-bearing, for his cervical spine disability and any degree of functional loss during repeated use over a period of time and on flare-ups. In this regard, the examiner should provide an estimate, if at all possible, of any additional impairment based on the evidence of record and the Veteran’s statements. If it is not possible to provide a specific finding without speculation, the examiner should state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, Associate 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.