Citation Nr: 21028737 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 11-33 164 DATE: May 11, 2021 ORDER Prior to September 28, 2017, entitlement to a rating of 20 percent, but no higher, for a lumbar spine disability is granted subject to the laws and regulations governing monetary benefits. From September 28, 2017, entitlement to a rating in excess of 20 percent for a lumbar spine disability is denied. FINDING OF FACT Throughout the period on appeal, the Veteran's lumbar spine disability was not manifested by forward flexion limited to 30 degrees or less, ankylosis, or by IVDS with incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months. CONCLUSIONS OF LAW 1. Prior to September 28, 2017, the criteria for a rating of 20 percent, but no higher, for a lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5242-5243. 2. From September 28, 2017, the criteria for a rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DC 5242-5243. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from February 1989 to February 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2016, the Veteran testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, the Veteran's claims were initially before the Board in June 2017, when they were remanded for additional development. See June 2017 BVA Decision. Thereafter, in a September 2018 decision, the Board denied the Veteran's claims for entitlement to a rating in excess of 10 percent for the lumbar spine prior to September 28, 2017, and to a rating in excess of 20 percent thereafter. The September 2018 Board decision also denied entitlement to a rating in excess of 20 percent for radiculopathy of the right lower extremity from December 16, 2008, and to an initial compensable rating for radiculopathy of the left lower extremity prior to April 19, 2016, and to a rating in excess of 10 percent thereafter. See September 2018 BVA Decision. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In June 2019, the Court granted the parties' Joint Motion for Partial Remand (JMPR), which in pertinent part, vacated and remanded the portions of the September 2018 Board decision that denied entitlement to a disability rating in excess of 10 percent for the Veteran's service-connected lumbar spine disability prior to September 28, 2017, and to a rating in excess of 20 percent thereafter. However, the Court did not disturb the portions of the September 2018 Board decision that denied entitlement to a disability rating in excess of 10 percent for the Veteran's service-connected radiculopathy of the right lower extremity from December 16, 2008, or to a disability rating in excess of 10 percent for his service-connected radiculopathy of the left lower extremity from April 19, 2016, and as a result, those claims were deemed abandoned. See June 2019 CAVC Decision. The Veteran's claims were last before the Board in January 2020, when they were remanded for additional development. See January 2020 BVA Decision. Lastly, in a January 2021 rating decision, the RO granted increased 20 percent ratings for the Veteran's service-connected lumbar radiculopathy of the right and left lower extremities, effective September 28, 2017. See January 2021 Rating Decision Narrative. The Veteran has not expressed disagreement with the rating or effective date assigned for his lumbar radiculopathy of the bilateral lower extremities; therefore, those issues are not before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997); Waddell v. Wilkie, No. 17-0438, 2018 U.S. App. Vet. Claims LEXIS 1463 (Nov. 1, 2018) (unpublished single-judge disposition); John v. Shulkin, No. 16-2487, 2018 U.S. App. Vet. Claims LEXIS 116 (Jan. 31, 2018) (unpublished single-judge disposition); see also Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (a non-precedential decision may be cited for any persuasiveness or reasoning it contains). Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings 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. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. Prior to September 28, 2017, entitlement to a rating of 20 percent, but no higher, for a lumbar spine disability is granted subject to the laws and regulations governing monetary benefits. 2. From September 28, 2017, entitlement to a rating in excess of 20 percent for a lumbar spine disability is denied. As an initial matter, the Veteran filed his claim for entitlement to a rating in excess of 10 percent for chronic lumbosacral strain, degenerative disc disease of the lumbar spine on December 16, 2008. See December 2008 VA Form 119 Report of Contact. During the pendency of the appeal, an April 2018 rating decision granted an increased 20 percent rating for IVDS of the lumbar spine, effective September 28, 2017. See April 2018 Rating Decision Narrative. The Veteran contends that he should be entitled to a disability rating in excess of 10 percent for his service-connected lumbar spine disability, prior to September 28, 2017, and to a rating in excess of 20 percent thereafter. From February 13, 1993 to September 28, 2017, the Veteran's lumbar spine disability was assigned a 10 percent disability rating under 38 C.F.R. § 4.71a, DC 5242-5237. Thereafter, for the period on appeal from September 28, 2017, the Veteran's lumbar spine disability has been rated as 20 percent disabling pursuant to 38 C.F.R. § 4.71a, DC 5242-5243. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a. The Board notes that the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. Prior to February 7, 2021, the General Rating Formula for Diseases or Injuries of the Spine pertained to diagnostic codes 5235 to 5243. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine. Under the General Rating Formula for Diseases or Injuries of the Spine, the diagnostic criteria pertinent to thoracolumbar spine disabilities provides that a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; and muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, 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 limited to 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. Under the General Rating Formula, a maximum 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. Id. at Note 2. 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 lateral rotation, with the normal combined range of motion of the thoracolumbar spine being 240 degrees. See also Plate V; 38 C.F.R. § 4.71a. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (5). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is assigned where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, and a 60 percent rating is assigned where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is defined as 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. 38 C.F.R. § 4.71a; Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). Effective February 7, 2021, DC 5242, applies to degenerative arthritis and degenerative disc disease other than IVDS. DC 5243 applies to IVDS and directs the rater to assign that diagnostic code only when there is disc herniation with compression of the adjacent nerve root, and to assign DC 5242 for all other disc diagnoses. As discussed more fully below, throughout the period on appeal, the Veteran's lumbar spine disability has not been shown to be manifested by IVDS that satisfies the rating criteria for a 40 percent evaluation. Accordingly, the rating criteria pertaining to the Veteran's service-connected lumbar spine disability has not substantially changed as a result of the February 7, 2021 amendments. Turning to the evidence of record, a February 2008 private treatment record shows that the Veteran underwent a lumbar spine MRI for lower back pain. The impression included some very mild degeneration involving L4-L5 and L5-S1 with a suggestion of annular fissures dorsally at both lumbar levels. However, the private physician found no abnormal enhancement at either location and noted that only the slightest shallow degree of broad protrusions were present. In addition, no evidence of root compression was found. See March 2009 Medical Treatment Record Non-Government Facility. The Veteran underwent a VA spine examination in January 2009. The examiner diagnosed the Veteran with degenerative joint disease of the lumbosacral spine associated with lumbosacral strain. During the examination, the Veteran endorsed daily moderate pain with intermittent stiffness, accompanied by spasms, and pain that radiated down his right leg. He also endorsed severe pain with flare-ups, which occurred two to three times per week and resulted in an additional 50 percent reduction in motion. Range of motion (ROM) testing revealed forward flexion to 65 degrees, extension to 20 degrees, and bilateral lateral flexion and rotation to 25 degrees. The examiner noted objective evidence of pain on active ROM testing, but no objective evidence of pain or further limitations were found following three repetitions of movement. However, the examiner did not state whether they performed passive ROM testing or ROM testing with and without weightbearing or discuss the functional impact of the Veteran's flare-ups. The examiner further noted that the Veteran's gait was antalgic and found evidence of pain with motion and guarding, which was not severe enough to result in an abnormal gait or spinal contour. Motor strength, sensory, and reflex testing were normal, and the examiner found that the Veteran's service-connected lumbar spine disability was not manifested by incapacitating episodes of spine disease, ankylosis, scoliosis, lumbar or reverse lordosis, or by abnormal kyphosis. The examiner further acknowledged that the Veteran experienced nocturia two times per night, numbness, paresthesias, and falls, but stated that the etiology of such symptoms was unrelated to his low back disability. In addition, the examiner found no evidence of urinary or fecal incontinence, or of urinary urgency or retention. Following the examination, the examiner found that the Veteran's service-connected lumbar spine disability significantly affected his usual occupation as a corrections officer and resulted in increased absenteeism, mildly affected his ability to do chores and travel, moderately affected his ability to exercise, and imposed severe restrictions on his ability to participate in sports. See March 2016 CAPRI. A June 2010 primary care initial evaluation note shows that the Veteran reported that his lower back pain had been bothering him a lot for the preceding two years. Specifically, the Veteran described a burning, sharp pain that radiated to his right leg and foot, which was aggravated on walking and bending for long periods of time. However, he also indicated that he walked four miles every day and denied urine and stool incontinence. On examination, the examiner found deferred range of motion secondary to pain, but did not note any point tenderness to palpation or deformities. The assessment included chronic backache secondary to degenerative disc disease. The following month, the Veteran reported a four-day exacerbation of lower back pain and was treated with gabapentin. See October 2011 Medical Treatment Record Government Facility; August 2017 CAPRI. In November 2010, the Veteran reported exacerbation of lower back pain of four days duration. He also reported that he had been experiencing increased frequency and urgency of urine for six weeks but denied a history of polydipsia and hematuria. The assessment was lumbar radiculopathy and a urinary tract infection/prostatitis. The Veteran also reported increased lower back pain in June 2011. Specifically, he endorsed tingling in the "thoracic" and pain, which radiated to his legs and thighs and caused limited flexibility or ROM of the back. The Veteran further reported that his lower back pain caused occupational impairment. On examination, the examiner found restricted ROM of the Veteran's trunk on flexion and extension but did not describe ROM in terms of degrees. The examiner further reported that the Veteran's bowels and bladder were intact. The assessment was worsening of chronic back pain. See August 2017 CAPRI. In his December 2011 substantive appeal, the Veteran endorsed chronic pain and middle thoracic pain. See December 2011 VA Form 9. The Veteran was afforded a VA examination for back conditions in April 2016. The examiner diagnosed the Veteran with lumbosacral strain and lumbar spine degenerative disc disease. During the examination, the Veteran endorsed flare-ups, which were manifested by sharp, shooting pain from his lower back that radiated down to his toes on the left side to his thigh. He further reported that his pain increased with walking and using stairs. The Veteran also endorsed functional loss, to include inability to do some activities with his family, incontinence, pain, and difficulty bending over. ROM testing revealed forward flexion to 65 degrees, extension to 30 degrees, and bilateral lateral flexion and rotation to 30 degrees. However, the medical examiner did not indicate whether ROM testing was done on active or passive motion or with or without weightbearing. Pain that caused functional loss was noted on forward flexion and extension ROM testing, but repetitive use testing did not result in further loss of ROM or function. In this regard, the examiner noted that the examination was being conducted during a flare-up but found that the Veteran's functional ability was not significantly limited by pain, weakness, fatigability, or incoordination. Muscle strength and reflex testing were normal, the examiner found no evidence of muscle spasm or localized tenderness, and guarding was not found to result in abnormal gait or spinal contour. In addition, the Veteran's lumbar spine disability was not found to be manifested by ankylosis or IVDS. Following the examination, the examiner opined that, although the Veteran reported urinary incontinency with back pain, urgency, and a sensation of incomplete emptying of bladder, it was more likely that the Veteran's urinary symptoms were related to his prostate and not attributable to his lumbar spine disability. However, the examiner found that the Veteran's service-connected lumbar spine disability caused functional impairment, to include limiting his ability to perform repetitive, prolonged heavy lifting. See April 2016 C&P examination. During his October 2016 Board hearing, the Veteran testified that he experienced tension and constant pain in his lower back, walked with a limp, and had limited ROM in his lumbar spine, which prevented him from bending over to pick things up. He endorsed urinary incontinence and urgency, which he believed were related to his service-connected degenerative disc disease and associated nerve damage. In addition, the Veteran reported that he was unable to take prescription medications to manage his back pain due to his job as a corrections worker and indicated that he missed approximately 12 to 15 days of work per year due solely to back pain. The Veteran further acknowledged that he had not been prescribed bedrest for his lumbar spine disability but testified that he was essentially confined to his home and unable to assist with household chores during flare-ups. See October 2016 Hearing Transcript, pages 15-22. In November 2016, the Veteran endorsed muscle aches, weakness, spasms, arthralgias/joint pain, and back pain. However, he denied incontinence, increased frequency, and difficulty urinating. On examination, a private physician noted tenderness of the Veteran's illolumbar region, and his active ROM was found to be limited. However, the private physician did not describe ROM in terms of degrees and found that passive ROM testing and the Veteran's gait were normal. The assessment included mild degenerative joint disease. See December 2016 Medical Treatment Record Non-Government Facility. The Veteran underwent a VA examination on September 28, 2017. The examiner diagnosed the Veteran with lumbosacral strain, degenerative arthritis of the spine, and lumbar intravertebral disc syndrome involving the bilateral sciatic nerves. During the examination, the Veteran endorsed flare-ups, which occurred weekly due to duties required by his job, to include excessive walking, climbing stairs and ladders, and running to emergencies. He also endorsed functional loss or impairment, to include limited bending, stooping, twisting, turning, and lifting more than 25 pounds, as well as difficulty with excessive walking, standing, and climbing. However, the Veteran did not report any urinary or bowel impairment related to his diagnosed back disabilities. ROM testing revealed forward flexion to 35 degrees, extension to 10 degrees, right lateral flexion to 30 degrees, left lateral flexion to 25 degrees, and bilateral lateral rotation to 30 degrees. Abnormal ROM was found to contribute to functional loss by limiting the Veteran's ability to bend, stoop, twist, turn, lift more than 25 pounds, walk, stand, and climb. Pain was noted on forward flexion, extension, and bilateral lateral flexion, which caused functional loss, and with weight-bearing. Repetitive use testing did not result in further loss of ROM or function, but pain was noted to significantly limit the Veteran's functional ability with repeated use over a period of time. The examiner was unable to describe the additional loss in terms of ROM because it would vary depending on activities performed and pain experienced, but did state that the examination was being conducted during a flare-up. In this regard, the examiner noted that weakness and pain significantly limited the Veteran's functional ability during flare-ups. The examiner found no evidence of muscle spasm or localized tenderness, but guarding was found to result in abnormal gait or spinal contour. Additional factors contributing to disability included less movement than normal, disturbance of locomotion, interference with standing, and difficulty with bending, stooping, twisting, turning, lifting more than 25 pounds, walking, standing, and climbing. In addition, the Veteran's lumbar spine disability was not found to be manifested by ankylosis or muscle atrophy. An x-ray obtained in connection with the examination revealed early anterior degenerative osteophytes at L4 and L5 but was otherwise negative. In addition, although the examiner noted that the Veteran had been diagnosed with IVDS, it was not found to be manifested by any episodes or acute signs and symptoms that required bedrest prescribed by a physician or treatment by a physician in the preceding 12 months. See October 2017 C&P examination. The Veteran also underwent a VA examination in January 2021. The examiner noted that the Veteran had been diagnosed with IVDS and bilateral lower extremity radiculopathy. During the examination, the Veteran continued to report sharp pain, stiffness, and throbbing in his upper and lower back, which radiated down his bilateral lower extremities, with numbness and tingling. In addition, he stated that he had problems standing or walking for long periods of time and indicated that he was thinking about filing for early retirement. The Veteran also endorsed severe, monthly flare-ups, which lasted for a few days and were precipitated by bending and sitting. He also endorsed functional loss or impairment, to include inability to stand, sit, or walk for long periods of time. The veteran did not report any urinary or bowel impairment due to his diagnosed back disabilities. ROM testing revealed forward flexion to 45 degrees, extension to 20 degrees, and bilateral lateral flexion and rotation to 20 degrees. The Veteran exhibited pain on all active ROM measurements, which was noted to result in functional loss. The examiner also found evidence of pain with weight-bearing and of localized tenderness or pain on palpation of the joint or associated soft tissue of the lower back, which was related to his IVDS. However, the examiner found no evidence of pain on passive ROM and non-weightbearing testing. Repetitive use testing did not result in further loss of ROM or function, but pain and weakness were noted to significantly limit the Veteran's functional ability with repeated use over a period of time. In this regard, the examiner found that repetitive use would cause additional loss of ROM, resulting in forward flexion to 40 degrees, extension to 15 degrees, and bilateral lateral flexion and rotation to 15 degrees. The examiner reported that the examination was not being conducted during a flare-up but found that pain and weakness significantly limited the Veteran's functional ability with flare-ups, and would limit forward flexion to 35 degrees, extension to 10 degrees, and bilateral lateral flexion and rotation to 10 degrees. In addition, muscle spasms and guarding were found to result in abnormal gait or spinal contour, but the Veteran's lumbar spine disability was not found to be manifested by ankylosis or muscle atrophy. The examiner further noted that the Veteran had been diagnosed with IVDS but found that it was not manifested by any episodes or acute signs and symptoms that required bed rest prescribed by a physician or treatment by a physician in the preceding 12 months. Following the examination, the examiner reported that the Veteran's lumbar spine disability impacted his ability to work by preventing him from sitting or standing for more than 15 minutes at a time. See January 2021 C&P examination. After a review of the evidence of record, the Board finds that the Veteran is entitled to a rating of 20 percent, but no higher, for a lumbar spine disability under DC 5242-5243 for the period on appeal. With regard to the initial period on appeal, the Board acknowledges that the January 2009 and April 2016 VA examiners found that the Veteran's forward flexion was limited to 65 degrees. However, neither medical examiner indicated whether ROM testing was done on active or passive motion or with or without weightbearing, and the January 2009 VA examiner also failed to discuss the functional impact of the Veteran's flare-ups. However, the Veteran has continually reported flare-ups, which result in additional functional and ROM loss throughout the periods on appeal. In this regard, the Veteran stated that he experienced an additional 50 percent reduction in motion during flare-ups, which would result in forward flexion to 32.5 degrees, at his January 2009 VA examination, and he stated that he was essentially confined to his house and unable to work during such periods during his October 2016 Board hearing. See March 2016 CAPRI; October 2016 Hearing Transcript, pages 19-22. Importantly, while the Veteran's ROM was found to be limited multiple times, there are no other records documenting ROM in terms of degrees during the initial period on appeal. Thus, after resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's service-connected lumbar spine disability more nearly approximated the 20 percent rating criteria during the initial period on appeal. The Board further notes that the Veteran has not argued, and the evidence does not reflect, that the January 2021 VA examination was inadequate. In this regard, the January 2021 examination report shows that the examiner performed a physical examination, to include ROM and repetitive use testing, discussed the relevant evidence, considered the contentions of the Veteran, and provided an adequate supporting rationale for the conclusions reached. In this regard, the evidence of record shows that the Veteran's lumbar spine ROM was manifested by forward flexion to, at worst, 35 degrees, throughout the relevant period. See, e.g., January 2021 C&P examination. The Board acknowledges that the Veteran was diagnosed with IVDS during the September 2017 and January 2021 VA examinations. However, the Board notes that both examiners found that the Veteran's IVDS was not manifested by any episodes or acute signs and symptoms that required bed rest prescribed by a physician or treatment by a physician in the preceding 12 months. See March 2016 CAPRI; January 2021 C&P examination. To this end, the evidence of record does not show, and the Veteran has not reported, that his lumbar spine disability has been manifested by IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Thus, even if the Board were to consider rating the Veteran's lumbar spine disability under the Formula for Rating Intervertebral Disc Syndrome, the criteria for a 40 percent rating have not been met. The Board recognizes the Veteran's assertion that his urinary symptoms were caused by his service-connected lumbar spine disability. However, he has not been shown to be competent to relate his current urinary symptoms to his service-connected lumbar spine disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376, 1377 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the January 2009 VA examiner noted that the Veteran experienced nocturia two times per night, but found that the etiology of such symptoms was unrelated to his low back disability, and the April 2016 VA examiner opined that, although the Veteran reported urinary incontinency with back pain, urgency, and a sensation of incomplete emptying of bladder, it was more likely that the Veteran's urinary symptoms were related to his prostate and not attributable to his lumbar spine disability. See March 2016 CAPRI; April 2016 C&P examination. Moreover, a November 2010 VA treatment record found that the Veteran's urinary symptoms, to include increased frequency and urgency, were caused by a urinary tract infection/prostatitis. See August 2017 CAPRI. Thus, the Board concludes that the Veteran's lay assertions are outweighed by the medical evidence of record. In this regard, the examiners have the training, knowledge, and expertise on which they relied to form their opinions and provided a persuasive rationale to support the conclusions reached. Importantly, there is no competent medical evidence to the contrary. The Board has also considered assigning higher disability ratings pursuant to 38 C.F.R. §§ 4.40 and 4.45. In this regard, the Board acknowledges the Veteran's reported complaints of pain and painful motion. However, the Veteran's lumbar spine disability has been rated based on limitation of motion (i.e. functional loss) caused by pain. As such, the Board finds that the currently assigned disability rating takes into account functional limitations based on painful motion and there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination. As such, a higher rating based on pain and functional loss is not warranted in this case. See DeLuca v. Brown, 8 Vet. App. at 207; see also Mitchell v. Shinseki, 25 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158; Sharp v. Shulkin, 29 Vet. App. at 26. Accordingly, throughout the period on appeal, the highest rating available is 20 percent. A higher 40 percent evaluation is not warranted as the Veteran's spine disability has not been manifested by forward flexion limited to 30 degrees or less or by ankylosis. Moreover, IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months has not been shown. The Board finds that a 20 percent evaluation is warranted throughout the appeal. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.