Citation Nr: 21028948 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 10-15 293 DATE: May 12, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for service-connected status post closed fracture of the left ankle (left ankle disability) is denied. Entitlement to an initial rating of 20 percent but no higher, prior to August 23, 2017, for service-connected low back strain is granted. Entitlement to an initial rating in excess of 20 percent since August 23, 2017 for service-connected low back strain is denied. FINDINGS OF FACT 1. Throughout the entire appeal period, the Veteran's left ankle disability has manifested as moderate limitation of motion. 2. Resolving reasonable doubt in the Veteran's favor, for the period prior to August 23, 2017, his low back strain disability was manifested, at worst, by forward flexion to 60 degrees, with evidence of pain, but without ankylosis of the spine, intervertebral disc syndrome (IVDS), or incapacitating episodes. 3. Since August 23, 2017, the Veteran's low back strain disability is manifested, at worst, by forward flexion to 45 degrees, without ankylosis of the spine, or incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for the service-connected left ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.10-4.14, 4.71a, Diagnostic Code (DC) 5271. 2. Prior to August 23, 2017, the criteria for a rating of 20 percent, but no higher, for the service-connected low back strain are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.71a, DCs 5237, 5243. 3. Since August 23, 2017, the criteria for a rating in excess of 20 percent for the service-connected low back strain are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, DCs 5237, 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 2003 to June 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2007 Rating Decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2012, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ). A transcript of that hearing is of record. In correspondence dated in October 2020, the Veteran was notified that the VLJ who conducted his July 2012 hearing was no longer employed at the Board, and he was given the opportunity to testify before another VLJ. As the Veteran did not respond to this correspondence within 30 days, however, the Board presumes he does not wish to have another hearing. The record reflects that the Veteran erroneously received correspondence in September 2020, indicating that he could request a virtual tele-hearing instead of waiting for a Travel Board hearing. Upon further review, the Board notes that the Veteran did not have a pending hearing request. As the Veteran provided testimony at a hearing before a VLJ in July 2012, the Board will consider the transcript of that hearing as evidence. In a November 2017 rating decision, the RO increased the Veteran's rating for his low back strain from 10 percent to 20 percent disabling, effective August 23, 2017. As 20 percent is not the highest rating possible under the relevant DCs, this issue remains under appellate consideration at the Board. The Board remanded this case for additional development in December 2013, April 2016, April 2017, and January 2021. As that development has been completed, the Board will proceed with adjudication of these issues. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate ratings are assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence of record submitted by the Veteran or on his behalf. See Gonzales v. West,218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Left Ankle Disability The Veteran contends his left ankle disability warrants an initial rating greater than the current evaluation of 10 percent. During the pendency of the appeal, 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 DCs "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. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim 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. Prior to the regulatory change, under DC 5271 a 10 percent rating was warranted for moderate limitation of motion. 38 C.F.R. § 4.71a, DC 5271. A 20 percent rating was warranted for marked limitation of motion. Id. For VA purposes, a normal range of ankle motion is from 45 degrees of plantar flexion to 20 degrees of dorsiflexion. 38 C.F.R. § 4.71, Plate II. As of February 7, 2021, under the amended criteria, a 10 percent rating is warranted for moderate limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion). Id. A 20 percent rating is warranted for marked limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). Id. The amended criteria are more favorable to the Veteran and will be considered for determining if an increased disability rating is warranted for the Veteran's left ankle disability. There are additional DCs that apply to ankle disabilities. 38 C.F.R. § 4.71a, DC 5270 pertains to ankylosis of the ankle. 38 C.F.R. § 4.71a, DC 5272 pertains to ankylosis of the subastragalar or tarsal joint. 38 C.F.R. § 4.71a, DC 5273 pertains to malunion of the os calcis or astragalus. 38 C.F.R. § 4.71a, DC 5274 pertains to an astragalectomy. At a December 2012 VA examination, the Veteran complained of chronic left ankle pain on a daily basis. He described the pain as a throbbing sensation, with an intensity of 5/10. He denied experiencing flare-ups of the ankle. Range of motion measurements revealed plantar flexion to 40 degrees and dorsiflexion (extension) to 15 degrees, with no objective evidence of pain. The Veteran did not have additional limitation in range of motion of the ankle after repetitive-use testing. There was no localized tenderness or pain on palpation of the joints or soft tissue. Muscle strength testing results were normal. There was no joint instability. Ankylosis was not present. It was noted that the Veteran did not have "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The examiner indicated there was no functional loss or impairment of the left ankle. At a February 2015 VA examination, the Veteran reported flare-ups of the ankle, described as occasional pain. He did not report having any functional loss or functional impairment of the joint or extremity, regardless of repetitive use. Range of motion measurements revealed plantar flexion to 30 degrees and dorsiflexion to 10 degrees. Pain was noted on the examination, but it did not result in functional loss. There was no evidence of pain with weight bearing, localized tenderness, or pain on palpation of the joints or soft tissue. The examination was not conducted during a flare-up, and the examiner indicated that the examination neither supports nor contradicts the Veteran's statements describing functional loss during flare-ups. Muscle strength testing results were normal. There was no muscle atrophy or ankylosis. Left ankle instability or dislocation was suspected. It was noted that the Veteran did not have "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The examiner indicated there was no functional loss or impairment of the left ankle. The examiner also remarked that increased pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. At a June 2016 VA examination, the Veteran complained of left ankle pain that can sometimes last for a day or a day and a half. He denied experiencing flare-ups of the ankle. He did not report having any functional loss or functional impairment of the joint or extremity, regardless of repetitive use. Range of motion measurements revealed plantar flexion to 40 degrees and dorsiflexion to 20 degrees. Pain was not noted on the examination. There was no evidence of pain with weight bearing. There was no localized tenderness or pain on palpation of the joints or soft tissue. There was no objective evidence of crepitus. He did not have additional limitation in range of motion of the ankle after repetitive-use testing. Muscle strength testing results were normal. There was no muscle atrophy. Ankylosis was not present. Left ankle instability or dislocation was suspected. He did not have "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The examiner indicated there was no functional loss or impairment of the left ankle. At an August 2017 VA examination, the Veteran reported flare-ups of the ankle, described as pain with ambulation. He did not report having any functional loss or functional impairment of the joint or extremity, regardless of repetitive use. Range of motion measurements revealed plantar flexion to 30 degrees and dorsiflexion to 10 degrees. Pain was noted on the examination, but it did not result in functional loss. There was no evidence of pain with weight bearing. There was no localized tenderness or pain on palpation of the joints or soft tissue. There was no objective evidence of crepitus. The Veteran did not have additional limitation in range of motion of the ankle after repetitive-use testing. The examination was not conducted during a flare-up, and the examiner indicated that the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Muscle strength testing results were normal. Ankylosis was not present. Left ankle instability or dislocation was suspected. It was noted that the Veteran did not have "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The examiner indicated there was no functional loss or impairment of the left ankle. At the February 2021 VA examination, the Veteran reported that he has persistent pain in his left ankle. He reported flare-ups, described as moderate, dull pain on a daily basis, which lasts for a few hours and changes with the weather and overuse. He does not have a history of instability of the ankle. Range of motion testing revealed plantar flexion to 40 degrees and dorsiflexion to 15 degrees, with pain. There was evidence of pain with weight-bearing and active motion, including pain causing functional loss. There was objective evidence of localized tenderness or pain on palpation of the medial and lateral ankle, moderate in severity. There was also objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, and there was no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time. Pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. Plantar flexion was limited to 30 degrees, and dorsiflexion was limited to 10 degrees. The examination was not conducted during a flare up, but the VA examiner indicated that pain, fatigability, and weakness limit functional ability with flare-ups. Plantar flexion was limited to 30 degrees, and dorsiflexion was limited to 10 degrees. Muscle strength was normal. There was no ankylosis of the subastragalar or tarsal and no malunion of the os calcis or astragalus. The examiner described the functional impact of the Veteran's left ankle disability as limited ability to squat, climb, and walk on uneven surfaces due to pain and stiffness and concluded that the Veteran is capable of working full-time. VA treatment records dated during the period of appeal consistently note that the Veteran experiences ankle pain, but do not specify range of motion measurements or severity level. Based upon review of the record, the Board finds that the Veteran's left ankle disability is best contemplated by the 10 percent rating criteria under DC 5271. There is no evidence of ankylosis, malunion of the os calcis or astragalus, or an astragalectomy. The Veteran's plantar flexion and dorsiflexion are limited to, at worst, 30 degrees and 10 degrees, respectively. He has limited range of motion, but the evidence does not show that it was more accurately described as "marked." At no point during the appeal period was there less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion, even after repetitive-use testing. Moreover, muscle strength testing results were all normal, with no ankylosis present. These factors weigh more in favor of what is described as "moderate" limited motion of the Veteran's left ankle, and less in favor of "marked' limitation of motion. As such, the Board finds that a rating in excess of 10 percent is not warranted for the service-connected left ankle disability. The Board has considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. There is no probative evidence that these factors caused limitation of function equivalent to "marked" limitation of motion. The preponderance of the evidence is against this claim. 38 C.F.R. § 4.3. A disability rating in excess of 10 percent for the service-connected left ankle disability is denied. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Low Back Strain The Veteran is currently in receipt of a 10 percent rating prior to August 23, 2017, and a 20 percent rating since August 23, 2017, for his service-connected low back strain. He seeks higher ratings for each appeal period. The Board finds that a rating of 20 percent is warranted for the period prior to August 23, 2017, but that the next higher rating of 40 percent is not warranted for any portion of the appeal period. Disabilities of the spine, such as the Veteran's lumbar spine disability, can be rated according to the General Rating Formula for Diseases and Injuries of the Spine, which allows for separate ratings for neurologic disabilities, or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, depending on whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 3.25. Under the formula for rating spine disorders (Diagnostic Codes 5235-5242), a 20 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is 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 where forward thoracolumbar flexion is limited to 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, while a 100 percent evaluation contemplates unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula of Disease and Injuries of the Spine. Unfavorable ankylosis is a condition where the entire thoracolumbar spine is held in flexion or extension and the condition 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. 38 C.F.R. § 4.71a, General Rating Formula of Disease and Injuries of the Spine, Note (5). Under the formula for IVDS based on incapacitating episodes, 38 C.F.R. § 4.71a, Diagnostic Code 5243, a 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12-month period on appeal. A 40 percent disability rating contemplates incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. A 60 percent rating contemplates incapacitating episodes having a total duration of at least six weeks during the past twelve months. These criteria are an alternative to rating on the basis of orthopedic and neurologic manifestations under the General Formula for Diseases and Injuries of the Spine, and a rating is assigned on the basis of whichever method results in the higher rating. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, flare-ups, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Court has recently held that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, to support an increased rating, pain must result in functional loss in terms of limitations in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. A. Prior to August 23, 2017 Prior to August 23, 2017, the Veteran's medical records do show findings consistent with a 20 percent rating, but no higher. Specifically, at a December 2012 VA examination, the Veteran reported having chronic, intermittent low back pain which occurs on a daily basis. He described the pain as having a stinging or throbbing sensation, with an intensity of 10/10, which is worsened by prolonged sitting and is improved somewhat when he moves about. He denied having flare ups. On examination, the Veteran demonstrated forward flexion to 80 degrees, with objective evidence of painful motion beginning at 60 degrees; extension to 25 degrees, with pain; right and left lateral flexion to 30 degrees; and right and left lateral rotation to 25 degrees. Repetitive use testing resulted in no additional limitation of motion. The examiner indicated that repetitive use testing resulted in functional loss due to pain on movement and less movement than normal. There was no objective evidence of localized tenderness or pain to palpation of the joint or soft tissue of the thoracolumbar spine. The examiner indicated that there was guarding or muscle spasm of the thoracolumbar spine, but it did not result in abnormal gait or spinal contour. The Veteran retained normal 5/5 lower extremity strength with no muscle atrophy. The examiner indicated that the Veteran did not have ankylosis of the spine. IVDS was not present. At a February 2015 VA examination, the Veteran reported having flare-ups that result in occasional low back pain. He did not report any functional loss or functional impairment of the back, regardless of repetitive use. On examination, range of motion measurements showed forward flexion to 70 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 20 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. It was noted that range of motion itself did not contribute to functional loss. Pain was noted on examination, but it did not result in functional loss. There was no evidence of pain with weight bearing. There was also no objective evidence of localized tenderness or pain to palpation of the joint or soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing after three repetitions, with no additional limitation in range of motion measurements. He was not examined immediately after repetitive use over time or during a flare-up. The examiner indicated that the examination neither supports nor contradicts the Veteran's statements describing functional loss with repetitive use over time or during flare-ups. The examiner indicated that that Veteran did not have guarding or muscle spasms of the thoracolumbar spine. The Veteran retained normal 5/5 lower extremity strength with no muscle atrophy. The examiner indicated that the Veteran did not have ankylosis of the spine. IVDS was not present. The examiner noted that the Veteran's thoracolumbar spine condition did not impact his ability to work. He remarked that there was no additional increased pain, weakness, fatigability, or incoordination to significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. After a complete review of the medical records, with resolution of reasonable doubt in the Veteran's favor, the Board finds the evidence demonstrates that the Veteran's disability more nearly approximates a rating of 20 percent prior to August 23, 2017. While initial range of motion measurements from the December 2012 VA examination reveal forward flexion to 80 degrees, the Veteran demonstrated forward flexion to 60 degrees, with objective evidence of painful motion. The Board finds that this is consistent with a 20 percent rating, which is warranted for forward flexion greater than 30 degrees but not greater than 60 degrees. However, the next-higher 40 percent rating is not warranted. Even considering the effects of pain, none of the VA examinations revealed forward flexion of the thoracolumbar spine of 30 degrees or less. There was also no evidence of ankylosis or IVDS. The medical records do not demonstrate findings consistent with a higher 40 percent evaluation, and as such, a rating in excess of 20 percent is not warranted for the appeal period prior to August 23, 2017. B. Since August 23, 2017 As previously stated, to be awarded a disability rating in excess of 20 percent, the evidence must demonstrate forward flexion of the thoracolumbar spine limited to 30 degrees or less, ankylosis of some kind in the entire thoracolumbar spine, or IVDS with doctor prescribed bed rest for incapacitating episodes having a total duration of at least four weeks during the past twelve months. At an August 2017 VA examination, the Veteran reported having flare-ups that result in occasional low back pain. He did not report any functional loss or functional impairment of the back, regardless of repetitive use. On examination, range of motion measurements showed forward flexion to 60 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 20 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. It was noted that range of motion itself did not contribute to functional loss. Pain was noted on examination, but it did not result in functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain to palpation of the joint or soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing after three repetitions, with no additional limitation in range of motion measurements. The Veteran was not examined immediately after repetitive use over time or during a flare-up. The examiner indicated that the examination neither supports nor contradicts the Veteran's statements describing functional loss with repetitive use over time or during flare-ups. The examiner indicated that that Veteran had guarding or muscle spasm of the thoracolumbar spine, but it did not result in abnormal gait or abnormal spinal contour. The Veteran retained normal 5/5 lower extremity. The examiner indicated that the Veteran did not have ankylosis of the spine. IVDS was present, but the examiner noted that the Veteran did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The examiner noted that the Veteran's thoracolumbar spine condition did not impact the Veteran's ability to work. He remarked that there was no pain with passive range of motion and no pain with nonweight-bearing. At a February 2021 VA examination, the Veteran reported having significant low back pain, for which he was previously prescribed OxyContin and tramadol. He also reported that he has had physical therapy. He reported flare-ups, described as moderate, dull pain on a daily basis, which lasts for a few hours and changes with the weather and excessive activity. The Veteran reported functional loss or functional impairment of the lumbar spine as difficulty with squatting for more than a few seconds and difficulty climbing ladders and walking on uneven surfaces. On examination, range of motion measurements showed forward flexion to 90 degrees; and extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation, each limited to 30 degrees. The examiner noted that it was not possible to do passive range of motion of the spine. There was evidence of pain with weight-bearing and active motion. It was noted that pain did not result in functional loss. There was objective evidence of localized tenderness or pain to palpation of the midline lower back, described as mild in severity. The Veteran was able to perform repetitive-use testing after three repetitions, with no additional limitation in range of motion measurements. He was not examined immediately after repeated use over time or during a flare-up. The examiner noted that pain, weakness, and fatigability significantly limited functional ability with repeated use over a period of time and with flare-ups. Described in terms of range of motion, forward flexion was limited to 45 degrees; and extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation, each limited to 15 degrees. The examiner indicated that that Veteran had localized tenderness of the thoracolumbar spine, but it did not result in abnormal gait or abnormal spinal contour. There was no guarding or muscle spasm. Muscle strength testing results were all normal. There was no muscle atrophy. Sensation to light touch testing results were normal. Deep tendon reflexes results were normal. Straight leg raising test results were negative. There was no ankylosis of the spine. No other neurologic abnormalities were noted. IVDS was not present. The examiner described the functional impact of the Veteran's low back disability as limited ability to do heavy lifting, prolonged standing or sitting, and significant squatting. It was noted that the Veteran is capable of doing full-time work. Throughout numerous pages of medical records, including the VA examination reports, forward flexion has been limited, at most, to 45 degrees, including after repetitive use testing. Use after three repetitions and factors such as pain, flare-ups, fatigue, weakness, and incoordination have not been shown to result in additional limitation of motion or compensable loss of function beyond that which what was estimated by the VA examiners. As such, a higher disability rating based upon limitation of motion is not warranted. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Also, ankylosis has not been demonstrated. Medical and lay evidence show no indication that the spine has been fixed in extension or flexion at any time during the appeal period, thus demonstrating the absence of ankylosis. Therefore, a rating in excess of 20 percent is not warranted under Diagnostic Code 5237. Similarly, the evidence does not demonstrate that the Veteran has ever been prescribed bed rest by a physician. Although the August 2017 examiner indicated that IVDS was present, it was also noted that the Veteran did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Moreover, the February 2021 examiner specifically found that the Veteran did not have IVDS and that the Veteran has not described any period of such bed rest due to his low back disability. As such, a disability rating in excess of 20 percent is not warranted under the rating criteria for IVDS. The Board acknowledges that the August 2017 examiner noted evidence of left lower extremity radiculopathy associated with the Veteran's low back strain. As such, he was service connected for this disability, effective August 23, 2017, and assigned a separate 10 percent rating, pursuant to DC 8520. All diagnostic codes relevant to the thoracolumbar spine disability have been considered, but the Board finds that no other codes are applicable. All current neurologic findings are rated separately and considered herein. Accordingly, the Board finds that a disability rating in excess of 20 percent for the Veteran's low back disability is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Trowers, 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.