Citation Nr: 21030300 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 08-39 226 DATE: May 18, 2021 ORDER An effective date earlier than May 8, 2017 for the establishment of service connection for right lower extremity radiculopathy is denied. A rating of no more than 20 percent for service-connected right lower extremity radiculopathy is granted, subject to the law and regulations governing the award of monetary benefits. A rating in excess of 20 percent for service-connected kyphoscoliosis with lumbosacral strain and degenerative arthritis of the spine (hereinafter, "lumbar spine disability") is denied. A compensable rating of no more than 10 percent for service-connected valvular heart disease from July 19, 1995 to February 21, 2003 is granted, subject to the law and regulations governing the award of monetary benefits. REMANDED Entitlement to a rating in excess of 30 percent for service-connected valvular heart disease from January 23, 2015 is remanded. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disability is remanded. FINDINGS OF FACT 1. It is not factually ascertainable prior to May 8, 2017 that the Veteran had radiculopathy of the right lower extremity due to his service-connected lumbar spine disability. 2. The Veteran's service-connected right lower extremity radiculopathy more nearly approximates than not impairment consistent with moderate incomplete paralysis. 3. The Veteran's service-connected right lower extremity radiculopathy has not been manifested by impairment consistent with moderately severe incomplete paralysis. 4. The Veteran's service-connected lumbar spine disability has not been manifested by forward flexion limited to 30 degrees or less, even when taking into account his complaints of pain; incapacitating episodes as defined by VA regulations; or associated neurologic impairment other than the already separately evaluated right lower extremity radiculopathy. 5. From July 19, 1995 to February 21, 2003 the Veteran's service-connected valvular heart disease more nearly approximated than not the criteria of an identifiable valvular lesion; slight, if any, dyspnea; and the heart is not enlarged. 6. Prior to February 21, 2003 the Veteran's service-connected valvular heart disease was not within three years of the termination of an established service episode of rheumatic fever or a subsequent recurrence, with cardiac manifestations during the episode or recurrence; diastolic murmur with either characteristic EKG manifestations or a definitely enlarged heart; a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope; nor evidence of cardiac hypertrophy or dilatation on EKG, echocardiogram, or X-ray. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than May 8, 2017 for the establishment of service connection for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.400, 4.71a. 2. The criteria for a rating of no more than 20 percent for service-connected right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520. 3. The criteria for a rating in excess of 20 percent for service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a (General Rating Formula for Diseases and Injuries of the Spine). 4. The criteria for a compensable rating of no more than 10 percent for service-connected valvular heart disease for the period from July 19, 1995 to February 21, 2003 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10; 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997 and 2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from September 1978 to June 1992, and from March 1995 to July 1995. The present matter is before the Board of Veterans' Appeals (Board) from rating decisions by a Department of Veterans Affairs (VA) Regional Office in March 2007, March 2016, and July 2017. The Veteran's appeal has a complex procedural history, which includes multiple prior actions by the Board, as well as the United States Court of Appeals for Veterans Claims (Court). There were also other issues in addition to those listed above. However, these other issues have been addressed such that the issues listed above are the only ones that remain before the Board for appellate consideration. Regarding the issues on appeal, the Veteran, in pertinent part, appealed a March 2007 rating decision which assigned a 20 percent rating for the service-connected lumbar spine disability effective November 6, 2006, confirmed and continued a prior denial of service connection for heart disease, and denied TDIU. By an April 2010 decision, the Board denied a rating in excess of 20 percent for the lumbar spine disability, and remanded the other issues for further development. In November 2010, the Court, pursuant to a joint motion for partial remand (JMPR), vacated the Board's decision to the extent it denied a rating in excess of 20 percent for the service-connected lumbar spine disability. The Board subsequently remanded that claim for further development in April 2011, in accord with the terms of the JMPR. The Board again remanded that claim for further development in August 2013, as well as the claims of service connection for heart disease and entitlement to TDIU. By a March 2016 rating decision, service connection was established for valvular heart disease with an initial noncompensable (zero percent) rating assigned effective April 18, 2003; a 60 percent rating was assigned effective April 16, 2005; and a 30 percent rating from January 23, 2015. A subsequent October 2016 rating decision assigned an earlier effective date of July 19, 1995, for the establishment of service connection for valvular heart disease with a noncompensable rating being in effect. A March 2017 decision review officer (DRO) decision assigned a 30 percent rating effective April 18, 2003. A July 2017 rating decision, in pertinent part, granted a separate 10 percent rating for right lower extremity radiculopathy, associated with the service-connected lumbar spine disability, effective May 8, 2017. By a July 2018 decision, the Board found the Veteran was not entitled to a compensable rating for his service-connected heart disease prior to February 21, 2003; and that he was entitled to a rating of no more than 30 percent from February 21, 2003. In addition, the Board remanded for further development the issues of entitlement to a rating in excess of 30 percent for the heart disease from January 23, 2015 and entitlement to a TDIU. By an April 2019 Order, the Court, pursuant to a new JMPR, vacated the Board's July 2018 decision to the extent it denied a compensable rating for the service-connected heart disease prior to February 21, 2003; and remanded that issue for action consistent with the JMPR. In January 2020, the Board remanded for further development the issues of entitlement to a compensable rating for service-connected heart disease prior to February 21, 2003; a rating in excess of 20 percent for the service-connected lumbar spine disability; a rating in excess of 10 percent for the service-connected right lower extremity radiculopathy; and an effective date earlier than May 8, 2017 for the establishment of a separate compensable rating for the right lower extremity radiculopathy. In April 2020, the Board remanded for further development the issues of entitlement to a rating in excess of 30 percent for service-connected heart disease from January 23, 2015; and TDIU. There has been at least substantial compliance with the Board's remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Further, the Veteran has not identified any specific deficiency regarding the development conducted pursuant to the most recent Board remands in 2020. In pertinent part, the Board takes note that the earlier effective date for the right lower extremity radiculopathy was remanded for the promulgation of a Statement of the Case (SOC). Such an SOC was promulgated in June 2020, and the Veteran perfected that appeal by filing a timely Form 9 in July 2020. The Board also notes that additional VA medical treatment records dated through February 2021 have been added to the record available for review since the case was last adjudicated by the agency of original jurisdiction (AOJ) via a January 2021 Supplemental SOC (SSOC). In pertinent part, that SSOC noted treated records dated through December 2020. As explained in greater detail below, these records reflect that further development is still warranted for the claims of entitlement to a rating in excess of 30 percent for valvular heart disease from January 23, 2015 and TDIU. Although the Board regrets the additional delay, a remand is required for these claims. However, these records contain no entries which would affect the outcome of the other issues adjudicated by this decision. In addition, the earlier effective date claim for the right lower extremity radiculopathy was not addressed in the January 2021 SSOC, but the evidence added to the record since the pertinent June 2020 SOC would not affect the outcome of that issue. The Board notes that, as a general rule, the adjudication of a claim for an earlier effective date is based upon evidence already in the claims folder; the resolution of the claim depends upon when certain document(s) were either received by VA and/or promulgated to the Veteran in this case. The additional records are dated after the current effective date that is the focus of this appeal. The Board further notes that the Veteran has not identified any deficiency regarding the assistance he has received in the development of the claims adjudicated by this decision. For example, he has not identified any records that has not been obtained or requested regarding his claim for a compensable rating for his service-connected heart disease prior to February 21, 2003; and higher rating(s) for the service-connected lumbar spine disability and right lower extremity radiculopathy. Further, he has not identified any error regarding the findings on the most recent VA examination of his lumbar spine disability and right lower extremity radiculopathy in January 2021, nor reported that either disability has increased in severity since that examination. Absent specific assertions to the contrary, the Board finds that the duty to assist has been satisfied. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Similarly, he has not identified any deficiency regarding the notification he has received in this case. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Effective Dates 1. Entitlement to an effective date earlier than May 8, 2017 for the establishment of service connection for right lower extremity radiculopathy. The effective date for the award of service connection for a disease or injury is the day following separation from active duty, or the date entitlement arose, if a claim is received within one year after separation from service. Otherwise, the effective date is the date of receipt of the claim, or the date entitlement arose, whichever is later. The effective date of an award based on a claim reopened after final adjudication shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Similarly, the effective date for an increased rating will be the date of receipt of the claim, or the date entitlement arose, whichever is later. Id. For an increase in disability compensation, the effective date will be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if a claim is received within 1 year from such date; otherwise, it is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). Initially, the Board notes that separate compensable rating for radiculopathy of the right lower extremity was established effective May 8, 2017 pursuant to Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, which provides that that any associated objective neurologic impairments should be rated separately under the appropriate Diagnostic Code. The Board further notes that the Veteran did not explicitly file a claim of entitlement to separate rating(s) for radiculopathy of the right lower extremity prior to May 8, 2017. Nevertheless, as this separate rating arose from adjudication of the Veteran's claim for an increased rating for his service-connected lumbar spine disability, which is recognized as November 6, 2006, the Board finds that must be considered the date of claim in this case. The Board also finds, however, that it was not factually ascertainable prior to May 8, 2017 that the Veteran had radiculopathy of the right lower extremity due to his service-connected lumbar spine disability. For example, treatment records from July 2006 note complaints regarding the right lower extremity, but electrodiagnostic findings were not consistent with lumbar radiculopathy. The Board also notes that a March 2007 VA examination of the Veteran's spine noted that his neurologic was completely normal. Granted, the JMR which was the basis for the Court's November 2010 Order in this case contended that the examination was inadequate "because the examiner did not adequately address the functional effects caused by Appellant's service-connected, disability consistent with DeLuca and 38 C.F.R. sections 4.40, 4.45, and 459 - which require that the disabling effect of painful. motion must be considered when rating disabilities involving the musculoskeletal system." Here, the JMR did not contend there was any inaccuracy regarding the finding neurologic was normal. The Board finds this to be of particular significance as its April 2010 decision explicitly found that a separate rating was not warranted because "[t]he evidence of record does not show the existence of any associated objective neurologic abnormalities ..." The Court has stated that advancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court, and that such a practice hinders the decision-making process and raises the undesirable specter of piecemeal litigation. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) ["Court will [not] review BVA decisions in a piecemeal fashion"]; see also Fugere v. Derwinski, 1 Vet. App. 103, 105 (1990), aff'd, 972 F.2d 331 (Fed. Cir. 1992) ["[a]dvancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court"]. As the schedular criteria provide for the assignment of a separate rating for associated neurologic impairment, the Board is therefore confident that if the Veteran or the Court had any substantive comments concerning this aspect of the 2007 VA examination it would have surfaced in the JMPR or the Court Order so that any deficiencies could be corrected. In addition, the Board notes, for reference purposes, that prior examinations of the spine in April 2005 and April 2006 contain findings to the effect there was no associated neurologic impairment. The Board acknowledges treatment records from January 2009 indicate complaints were consistent with left and right radiculopathy associated with low back pain. The Veteran also reported overall weakness of the lower extremities at a December 2009 VA examination. However, no impairment of the lower extremities was found on physical examination, and neurologic findings were normal. Moreover, subsequent VA examinations of the back in September 2012 and January 2015 explicitly found there was no radiculopathy. A June 2017 VA examination did find radiculopathy, but this is subsequent to the current effective date of May 8, 2017. The medical treatment records do not otherwise reflect the Veteran was diagnosed with right lower extremity radiculopathy prior to May 8, 2017. The Board notes the Veteran has indicated, to include at a January 2021 VA examination for peripheral nerves, that his condition had its onset in the 2000s. As noted, his report of weakness of the lower extremities was noted on the December 2009 VA examination. Nevertheless, the Board finds that competent medical evidence is required to determine whether such symptoms were due to a chronic condition like radiculopathy, and no such competent medical evidence was of record prior to May 8, 2017. Rather, on specific evaluation for such, to include the 2012 and 2015 VA examinations, it was explicitly found he did not have radiculopathy. The Board further notes that the Veteran's contentions in this case, including the February 2018 Notice of Disagreement (NOD) and July 2020 Form 9, reflect a general disagreement with the effective date but do not identify any basis why an earlier effective date is warranted. The Board acknowledges that the attorney's statement which accompanied the NOD summarizes legal requirements pertinent to the duty to assist such as adequacy of examinations, but does not identify any explicit error regarding the assistance received with respect to the effective date of the right lower extremity radiculopathy. In light of the foregoing, the Board finds the preponderance of the evidence is against an earlier effective date in this case. Accordingly, the claim is denied. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Here, the Veteran is already in receipt of such "staged" ratings for his valvular heart disease. 2. Entitlement to a rating in excess of 10 percent for service-connected right lower extremity radiculopathy The Veteran's service-connected radiculopathy of the right lower extremity has been evaluated pursuant to the criteria found at 38 C.F.R. § 4.124a, Diagnostic Code 8520 as analogous to impairment of the sciatic nerve. Under this Code, complete paralysis, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Incomplete paralysis of the sciatic nerve warrants a 60 percent evaluation if it is severe with marked muscular dystrophy; a 40 percent evaluation if it is moderately severe; a 20 percent evaluation if it is moderate; or a 10 percent evaluation if it is mild. Neuritis and neuralgia of the nerve are evaluated on a similar scale under Diagnostic Codes 8620 and 8720. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board notes, for reference and illustrative purposes, that the definition for "mild" includes not very severe. WEBSTER'S II NEW COLLEGE DICTIONARY at 694 (1995). In addition, a synonym for "mild" is "slight" and definitions for "slight" include small in size, degree, or amount. Id. at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions of "severe" include extremely intense. Id. at 1012. It is noted that the term "moderately severe" indicates impairment greater than moderate but not to the extent as to be considered severe. The Board also acknowledges VA's Adjudication Manual, M21-1, III.iv.4.N.4.c (November 16, 2017) discusses the terminology in 38 C.F.R. § 4 .124a, DCs 8510-8730. The Manual indicates with regard to "mild": As this is the lowest level of evaluation for each nerve this is the default assigned based on the symptoms, however slight, as long as they were sufficient to support a diagnosis of the peripheral nerve impairment for service connection purposes. In general, look for a disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis. The Manual indicates with regard to "moderate": Symptoms will likely be described by the claimants and medically graded as significantly disabling. In such cases a larger area in the nerve distribution may be affected by sensory symptoms. Other sign/symptom combinations that may fall into the moderate category include combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. The Manual indicates with regard to "moderately severe": The moderately severe evaluation level is only applicable for involvement of the sciatic nerve. This is the maximum rating for sciatic nerve neuritis not characterized by the organic changes specified in 38 C.F.R. § 4.123. Motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability is expected. Atrophy may be present. However, for marked muscular atrophy see the criteria for a severe evaluation under 38 C.F.R. § 4.124a, DC 8520. The Manual indicates with regard to "severe": In general, expect motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. For the sciatic nerve (38 C.F.R. § 4.124a, DC 8520) marked muscular atrophy is expected. Even though severe incomplete paralysis cases should show findings substantially less than representative findings for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs/symptoms resembling some of those expected in cases of complete paralysis of the nerve. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve (38 C.F.R. § 4.123). Prior to November 2017 revisions, VA's Adjudication Procedures Manual M21-1, Part III, Subpart iv, Chapter 4, § G(4)) defined "mild" incomplete paralysis as demonstrating subjective symptoms or diminished sensation; "moderate" incomplete paralysis as featuring the absence of sensation confirmed by objective findings; and "severe" incomplete paralysis as featuring more than sensory findings (such as atrophy, weakness, and diminished reflexes). In June 2016, VA amended the M21-1 adjudication manual "to further clarify the intent of VA's policy," and the relevant portion of the M21-1 adjudication manual included the following: Important: This provision does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength. The Adjudication Manual is not binding on the Board. DAV v. Sec'y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) ("The M21-1 Manual is binding on neither the agency nor tribunals"). Nevertheless, it does provide useful guidance in defining these terms, particularly if the Veteran demonstrates impairment consistent with higher rating(s) than currently in effect. Stated another way, the Board will look to see if there are findings that would warrant a higher rating under the M2-1 provisions, but would not deny the benefit sought on appeal if those provisions are not satisfied. Here, the Veteran's service-connected right lower extremity radiculopathy more nearly approximates impairment consistent with moderate incomplete paralysis. In pertinent part, the June 2017 VA examination described the Veteran's impairment as moderate. Granted, the Board is not bound by this determination of the VA examiner. Further, subsequent examinations in March 2019 and January 2021 described the impairment as mild. Nevertheless, it is probative evidence for consideration. The Board also notes the Veteran has generally described mild to moderate symptomatology during the pendency of this case. For example, at the June 2017 VA examination he denied constant pain, but reported moderate intermittent pain, numbness, and paresthesias and/or dysesthesias. He again denied constant pain at the March 2019 VA examination, but reported mild intermittent pain, numbness, and paresthesias and/or dysesthesias. At VA examinations for peripheral nerves and the back in January 2021, he denied constant pain and paresthesias and/or dysesthesias, but reported moderate intermittent pain and numbness. The Board further notes that the record includes evidence of sensory changes and reflex or motor changes, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) that the M21-1 provisions indicate are reflective of moderate incomplete paralysis. For example, at the June 2017 VA examination his reflexes were 1+ (hypoactive) for the right ankle. In addition, sensory examination was decreased for the right upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. The March 2019 VA examination noted, in pertinent part, that strength testing showed right hip flexion was 4/5 (active movement against some resistance). Sensory examination was again decreased for the right lower leg/ankle and foot/toes. Both of the January 2021 VA examinations showed reflexes of the right knee to be 3+ (hyperactive without clonus). In light of the foregoing, and resolving all reasonable doubt in favor of the case, the Board finds the Veteran is entitled to a 20 percent rating for his service-connected right lower extremity radiculopathy throughout the pendency of this appeal, which is from May 8, 2017. See 38 C.F.R. §§ 4.3, 4.7. The Board also finds that a rating in excess of 20 percent is not warranted as the Veteran's service-connected right lower extremity radiculopathy has not been manifested by impairment consistent with moderately severe incomplete paralysis. In pertinent part, none of the aforementioned VA examinations have found the right lower extremity to be manifested by moderately severe incomplete paralysis, nor has the Veteran reported symptomatology that is more than moderate. Further, the functional impairment demonstrated by the record, including the VA examinations, does not reflect impairment that is more than moderate; i.e., that is more than average or medium quantity, quality, or extent. In pertinent part, the Board notes that while right ankle reflexes were 1+ at the June 2017 VA examination, they were 2+ (normal) for the right knee. Reflexes were also 2+ for both the right knee and ankle at the March 2019 VA examination, and 2+ for the right ankle at the January 2021 VA examinations. The Board also notes that while sensory was decreased throughout the right lower extremity at the June 2017 VA examination, and for the right lower leg/ankle and foot/toes in March 2019, it was not absent. Further, sensory evaluation of the right upper anterior thigh, and thigh/knee, was normal at the March 2019 VA examination. Sensation testing for light touch was normal throughout the right lower extremity at the January 2021 VA examinations. The Board further notes that with the exception of the 4/5 finding for right hip flexion in March 2019, motor strength testing was otherwise 5/5 (normal strength) throughout the right lower extremity on the June 2017, March 2019, and January 2021 VA examinations. Nothing in the medical treatment records reflects the Veteran otherwise has moderately severe incomplete paralysis of the right lower extremity, nor has he explicitly contended he has such impairment. In fact, while it was contended as part of the February 2018 NOD that the record supported assignment of the next higher evaluation (which would be 20 percent), it was not contended a rating in excess of 20 percent was warranted in this case; nor has such been contended in subsequent communications from the Veteran, including the pertinent August 2019 Form 9, nor the April 2021 attorney's statement. For these reasons, the Board finds the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for this service-connected disability, to include as a "staged" rating(s). The Board also concurs with the determination below that the service-connected left knee disability does not present such an exceptional or unusual disability picture so as to warrant consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). 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. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The evidence in this case does not establish the presence of such an exceptional or unusual disability picture that the available schedular standards are inadequate. A comparison between the level of severity and symptomatology of this disability with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In pertinent part, the rating criteria required the Board to take into account all evidence of record, including the Veteran's contentions, to determine the overall level of functional impairment in terms of actual incomplete paralysis or impairment analogous thereto. The Board also notes the Veteran has not contended he is entitled to an extraschedular rating for his right lower extremity radiculopathy, to include as part of his February 2018 NOD nor August 2019 Form 9. 3. Entitlement to a rating in excess of 20 percent for service-connected lumbar spine disability The Veteran's lumbar spine disability has been evaluated pursuant to the General Rating Formula for Diseases and Injuries of the Spine, which provides that 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, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, if the combined range of motion of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees; or if there is muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, if there has been a vertebral body fracture with loss of 50 percent or more of the height. An evaluation of 20 percent is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or if 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. An evaluation of 40 percent is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less; or for favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees, and the normal ranges of motion for each component of spinal motion 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, Note (2). 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. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Veteran's lumbar spine disability has been manifested by pain and resulting functional impairment to include limitation of motion. He has also reported limitation of walking, standing, and lifting. When evaluating joint disabilities rated on the basis of limitation of motion, 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 by 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 has 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. 589, 592 (1991). The Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The evaluation criteria are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine. Therefore, an evaluation based on pain alone would not be appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. Here, even when taking into account the Veteran's complaints of pain, his lumbar spine disability has not been manifested by forward flexion limited to 30 degrees or less to include during flare-ups. The March 2007 VA examination showed forward flexion to 65 degrees, with no change after three repetitions. As noted, the JMPR contended that this examination did not adequately address the effect of pain on range of motion. Nevertheless, no inaccuracy was noted regarding the initial range of motion finding. A December 2009 VA examination did note the Veteran reported stiffness, limited motion and back pain. He also reported severe spinal flare-ups that occurred every other day, and lasting 1 to 2 days. During flare-ups he had increased back pain with normal ambulation. However, no specific range of motion results were noted on this examination At a June 2012 VA examination, the Veteran reported his back was always stiff and sore, and it would take a couple hours to move properly. He reported constant pain about 4/10 on pain intensity. Further he reported flare-ups, stating that almost every morning he had severe low back pain about 6/10 on pain intensity; and it interfered with his sleep pattern. Range of motion testing showed forward flexion to 75 degrees, with pain at the end of motion. There was no additional limitation following repetitive-use testing. At a January 2015 VA examination, the Veteran reported chronic low back pain, which was sometimes troublesome when he first awakens. At times the back pain was severe, described as if the "bones are crushing together". The low back pain was exacerbated by standing, but no radiation into the lower extremities. In addition, he reported severe flare-ups approximately every 2 months, resulting in inability to lift. He reported the flares last approximately 1 week and were unpredictable. Range of motion testing showed forward flexion to 45 degrees, and it was noted he was limited in bending and picking up objects. There was evidence of pain with weight bearing. There was no change with repetitive testing. The examiner noted pain would significantly limit functional ability with repeated use over a period of time, but could not express in terms of range of motion. Moreover, the examiner stated the examination supports the Veteran's statements describing functional loss during flare-ups, but could not describe in terms of range of motion. At the June 2017 VA examination, the Veteran reported the back constantly aches and was worse with standing. He also reported limited movement and difficulty with prolonged standing and walking. It was noted the flare ups of the back could be described as intense soreness. Initial range of motion testing showed forward flexion to 65 degrees, which decreased to 60 degrees after repetitive motion testing. Further, the examiner stated the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. The examiner opined that the Veteran had additional functional loss during these periods due to pain and lack of endurance, as well as fatigue during flare-ups. Moreover, the examiner opined that with repeated use over time forward flexion would be limited to 50 degrees, and during flare-ups it would be limited to 45 degrees. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). It was noted that passive range of motion testing was not performed as it was not medically appropriate due to dizziness during exam. See Correia v. McDonald, 28 Vet. App. 158 (2016). There was pain with weight bearing, but not with non-weight bearing testing. Id. The Board notes that in a February 2018 NOD, the Veteran did not dispute the accuracy of the June 2017 VA examination findings. In fact, it was contended in an associated statement from his attorney that these findings warranted the next higher rating, to include increased involvement during flare-ups. During a March 2019 VA examination, the Veteran's current symptoms were noted as stiffness, loss of range of motion, lack of sleep, increased pain, stiffness in right arm, loss of range of motion to the back and neck, that the back had progress more than the neck, as well as popping sounds in the back and muscle spasm. He reported flare-ups, stating "there are times my back is worse than others, I can't tell exactly what makes it flare-up but the slightest activity to the back will cause my back to flare up." Range of motion showed forward flexion to 40 degrees; and it was noted he was limited in bending, stooping, pushing, pulling, carrying, and lifting moderate objects. There was no change with repetitive-use testing. The examiner stated the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups; and opined during both periods he would have forward flexion limited to 40 degrees. Passive motion was noted as being the same as active motion; and there was pain with weight bearing, but not with non-weight bearing. It was also noted that he had disturbance of locomotion, interference with sitting and standing due to limited range of motion and pain. The Board notes that the Veteran's attorney contended in an August 2019 statement that the March 2019 examination did not adequately address impairment during flare-ups. Further, in the January 2020 remand the Board stated that given that the examiner earlier indicated that the Veteran was not experiencing a flare-up at the time of the examination, but that he experienced significant limitations following repeated use and during flare ups due to pain, fatigue, weakness, and lack of endurance, the examiner's conclusion that his range of motion would essentially stay the same following repeated use or during flare-ups was contradictory with the other findings contained in the examination report. At the most recent VA examination of the back in January 2021, the Veteran described his current symptoms as when standing still even for a few minutes everything felt like it was crushing down; that he could not lift heavy things anymore; that he had difficulty sleeping because of pain; intermittent shooting pains into right leg; and constant numbness in right foot. He reported flare-ups which felt like a shooting pain across the lower back, occurred twice weekly, pain was a 7/10, and lasted 2 hours. In addition, it was noted he could not lift heavy objects anymore., could not lie flat on back or stomach, and had trouble getting up from floor if he lies down. Range of motion testing showed forward flexion to 70 degrees, and it was noted he had difficulty bending over and picking things up. There was no change with repetitive-use testing. The examiner stated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time, nor during flare-ups. Nevertheless, the examiner did opine that with repeated use over time and during flare-ups the Veteran would have forward flexion to 65 degrees. Passive range of motion testing was not performed as it was not feasible to do this in a safe and reasonable manner. There was no evidence of pain in weight bearing nor non-weight bearing. As noted, the Veteran has not reported his service-connected lumbar spine disability has increased in severity since the January 2021 VA examination. The Veteran's attorney did contend in an April 2021 statement that VA failed to account for flare-ups of the Veteran and that VA and the examiner(s) must consider flare-ups and determine the functional loss caused by these flare-ups. However, as detailed above, VA examinations explicitly noted the Veteran's account of his impairment during flare-ups. Moreover, the June 2017, March 2019, and January 2021 VA examiners all provided opinions to the extent forward flexion would be limited with repeated use over time and during flare-ups. Although the Board previously found the March 2019 VA examination to be inadequate in this regard, no such deficiency is demonstrated by the June 2017 and/or January 2021 VA examinations. Further, the Veteran has not identified any error with respect to the 2017 and 2021 examinations, to include the opinions regarding the extent forward flexion was limited during flare-ups. As noted, he referred to the 2017 examination findings in support of his claim. In summary, range of motion findings, as exemplified by the aforementioned VA examinations, all showed forward flexion to be in excess of 30 degrees. Although the 2007 and 2019 examinations did not adequately address the issue of additional limitation due to pain, to include during flare-ups, no error has been identified with respect to the initial range of motion findings. Moreover, no error has been identified regarding the opinions expressed by the June 2017 and January 2021 VA examiners regarding the extent of additional limitation during flare-ups or with repeated use over time. Both of these opinions reflect forward flexion would still be in excess of 30 degrees during such periods. Nothing in the other evidence of record, including the medical treatment records, documents limitation of forward flexion to the extent necessary for a rating in excess of 20 percent. Moreover, the Veteran has not demonstrated that he would have such limitation of motion, to include during flare-ups, and/or but for the use of medication. See Jones v. Shinseki, 26 Vet. App. 56 (2012). The record also does not reflect functional impairment that is the equivalent of favorable and/or unfavorable ankylosis under the General Rating Formula for Diseases and Injuries of the Spine, to include during flare-ups. See Chavis v. McDonough, No. 18-2928 (U.S. Vet. App. April 16, 2021). As a general matter, the Board notes that ankylosis is the immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The aforementioned range of motion findings do not reflect immobility of the joint, to include during flare-ups. Further, the Veteran's description of his flare-ups does not reflect such functional impairment, to include analogous to favorable and/or unfavorable ankylosis. The Board acknowledges that the Veteran has, at times during the pendency of this appeal, referred to his service-connected lumbar spine disability as ankylosing spondylitis. However, medical evaluations, including the VA examinations in this case, have consistently found he does not have ankylosis of the spine. The Board has also considered the applicability of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS). See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board notes, however, that for purposes of the Formula, 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). Here, a thorough review of the record, including the medical treatment records, does not reflect that the Veteran's lumbar spine has been manifested by incapacitating episodes as defined by VA regulation. In other words, the record does not reflect he has had bed rest prescribed by a physician and treatment by a physician. As an additional matter, the Board observes that Note (1) of the General Rating Formula for Diseases and Injuries of the Spine provides that any associated objective neurologic impairments should be rated separately under the appropriate Diagnostic Code. See 38 C.F.R. § 4.71a. Here, the record, including the VA examinations in this case, do not reflect he has associated neurologic impairment other than the already separately evaluated radiculopathy of the right lower extremity. Granted, as noted by the Veteran's attorney in statement associated with the February 2018 NOD, the June 2017 VA examination noted bilateral involvement of the L4/L5/S1/S2/S3 nerves. However, that examination only diagnosed radiculopathy of the right lower extremity. No radiculopathy of other neurologic impairment of the left lower extremity was diagnosed on subsequent VA examinations including in March 2019 and January 2021. A January 2021 VA examination for peripheral nerves also included findings of neurologic impairment of the right upper extremity. However, that examination did not explicitly find that impairment was associated with the service-connected lumbar spine disability. Further, the VA examination of the back was conducted that same date and found there was no associated neurologic impairment other than the already separately evaluated right lower extremity radiculopathy. In light of the foregoing, no additional, separate rating(s) are warranted based upon associated neurologic impairment. For all these reasons, the Board must find that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for the Veteran's service-connected lumbar spine disability, to include on the basis of additional "staged" rating(s). The appeal of this issue must be denied. The Board also concurs with the determination below that the service-connected lumbar spine disability does not warrant consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321. The Board finds that the rating criteria fully compensate the impairment associated with this disability. As discussed above, he has reported that this disability is primarily manifested by pain and resulting functional impairment to include limitation of motion. Such impairment is addressed by the schedular criteria, to include the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 regarding the effect of pain. Moreover, while multiple statements were advanced by and on behalf of the Veteran in support of a higher rating for his service-connected lumbar spine disability, it was not explicitly contended that consideration of an extraschedular rating was warranted. This is of particular significance as the issue was discussed below, as well as in the prior Board decision in April 2010. As such, the Veteran was aware of the fact such issue was being considered in this case. In making the above determination, the Board was cognizant that there were multiple revisions to the rating criteria for evaluating musculoskeletal system and muscle injuries, effective February 7, 2021. See 85 Fed. Reg. 76453 (November 30, 2020). VA thus must consider the claim 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). The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 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. In this case, the Board notes that these revisions include adding degenerative disc disease other than intervertebral disc syndrome to Diagnostic Code 5242. However, these revisions made no substantive changes to the rating criteria contained in General Rating Formula for Diseases and Injuries of the Spine, nor the Formula for Rating Intervertebral Disc Syndrome Based Upon Incapacitating Episodes. These revisions also added new criteria for evaluating paraplegia and quadriplegia under a new Diagnostic Code 5244, but these criteria are not applicable to the Veteran's service-connected lumbar spine disability. Consequently, the Board concludes there was no prejudice to the Veteran by proceeding with adjudication of this appeal. 4. Entitlement to a compensable rating for service-connected valvular heart disease prior to February 21, 2003. The Board notes that, effective January 12, 1998, during the pendency of this appeal, the VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4, was amended with regard to rating disabilities of the cardiovascular system. 62 Fed. Reg. 65,207 (1997) (codified at 38 C.F.R. § 4.104). Because the Veteran's claim was filed before the regulatory change occurred, he is entitled to application of the version most favorable to him. Under the pre-January 12, 1998 rating criteria, a 10 percent disability rating for rheumatic heart disease is warranted for the following: an identifiable valvular lesion; slight, if any, dyspnea; and the heart is not enlarged. 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). A 30 percent evaluation is warranted for three years following the termination of an established service episode of rheumatic fever or a subsequent recurrence, with cardiac manifestations during the episode or recurrence. A 30 percent disability rating is also warranted for a diastolic murmur with either characteristic EKG manifestations or a definitely enlarged heart. A 60 percent evaluation requires the following: the heart definitely enlarged; severe dyspnea on exertion, evaluation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; and more than light manual labor is precluded. A 100 percent evaluation requires the following: definite enlargement of the heart, confirmed by roentgenogram and clinically; dyspnea on slight exertion; rales, pretibial pitting at the end of the day or other definite signs of beginning congestive failure; and more than sedentary employment is precluded. A 100 percent disability rating is also warranted during a period of active rheumatic heart disease and for a period of six months following a period of active rheumatic heart disease where there are ascertainable cardiac manifestations. Under the revised version of Diagnostic Code 7000, effective January 12, 1998, a 10 percent disability rating is warranted for rheumatic heart disease when continuous medication is required or where a workload of greater than seven METs (metabolic equivalents) but not greater than ten METs results in dyspnea, fatigue, angina, dizziness, or syncope. 38 C.F.R. § 4.104, Diagnostic Code 7000 (2020). A 30 percent evaluation requires either (1) that a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope; or (2) that there is evidence of cardiac hypertrophy or dilatation on EKG, echocardiogram, or X-ray. A 60 percent evaluation is warranted when one of the following is present: (1) more than one episode of acute congestive heart failure in the past year; (2) a workload of greater than three METs but not greater than five METs results in dyspnea, fatigue, angina, dizziness, or syncope; or (3) there is evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent disability rating is warranted during an active infection with valvular heart damage and for three months following cessation of therapy for the active infection. A total disability rating is also warranted when one of the following is present: (1) chronic congestive heart failure; (2) a workload of three METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or (3) there is evidence of left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. The JMPR which was the basis for the Court's April 2019 Order noted that VA revised the criteria for evaluating disabilities of the heart during the period under review and that, while the new criteria specifically accounts for valvular heart disease, Diagnostic Code 7000 under the old criteria was specifically captioned rheumatic heart disease. Because the Veteran's service-connected valvular heart disease was not shown to be etiologically related to rheumatic fever, the parties noted that Diagnostic Code 7000 was applicable only by analogy, and it was not expected that the Veteran's non-rheumatic heart disease would perfectly mesh with the old criteria. The JMPR contended that the Board's analysis in the July 2018 decision was inadequate as it failed to consider whether the analogous criteria of the older version of Diagnostic Code reasonably approximated the Veteran's heart valve dysfunction so as to permit the award of a compensable rating. In pertinent part, both the JMPR and a July 2019 statement from the Veteran's attorney noted the Veteran had been diagnosed with heart valve dysfunction, namely mitral valve prolapse, as early as August 1984. It was contended that the Board failed to consider whether the analogous criteria of the old version of Diagnostic Code 7000 reasonably approximated his heart valve dysfunction as to warrant a compensable evaluation. The July 2019 attorney statement also noted the Veteran had a heart murmur in April 1994. In addition, the Veteran reported fatigue in October 1995, and had a systolic murmur at that time. Therefore, his attorney contended that his mitral valve prolaps was symptomatic, and deserving of a higher evaluation. As the Court's Order directed the Board to take action consistent with the terms of the JMPR, the Board is bound by its terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006) (holding that the duty to ensure compliance with the Court's order extends to the terms of the agreement struck by the parties that forms the basis of the joint motion to remand); cf. McBurney v. Shinseki, 23 Vet. App. 136, 140 (2009) (Board has a duty on remand to ensure compliance with the favorable terms stated in the [JMR] or explain why the terms will not be fulfilled.). The Board also notes that other medical evidence of record, including an April 1995 echocardiogram, confirms the mitral valve prolapse. Pursuant to the terms of the JMPR, and resolving all reasonable doubt in favor of the case, the Board finds the mitral valve prolapse to be the equivalent of an identifiable valvular lesion. He is also competent, as a lay person, to describe symptoms such as dyspnea. His actions in this appeal indicate he did have such symptoms during the pertinent period. Further, the record, including the April 1995 echocardiogram and October 1995 examination report from the John L. McClellan Memorial Veterans Hospital, reflects the heart was not enlarged. Resolving reasonable doubt in favor the case, the Board finds that the Veteran is entitled to a compensable rating of at least 10 percent under the "old" version of Diagnostic Code 7000 for the period from July 19, 1995 to February 21, 2003. The Board further finds the Veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent for his service-connected heart disease prior to February 21, 2003, under the "old" or revised version of Diagnostic Code 7000. The record does not reflect during this period he was within three years of the termination of an established service episode of rheumatic fever or a subsequent recurrence, with cardiac manifestations during the episode or recurrence; diastolic murmur with either characteristic EKG manifestations or a definitely enlarged heart; a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope; nor evidence of cardiac hypertrophy or dilatation on EKG, echocardiogram, or X-ray. The Board observes that the April 1995 echocardiogram report noted that the Veteran was brought in for an assessment of a history of mitral valve prolapse with mitral regurgitation. The report stated that the echocardiogram corroborated the presence of mitral valve prolapse with probable fibrocalcific changes of the anterior mitral leaflet and mild mitral regurgitation, without evidence of left atrial enlargement, or left and right ventricular enlargement or hypertrophy. The October 1995 examination report from the John L. McClellan Memorial Veterans Hospital noted that a heart murmur was observed in 1982 but has not been heard since. Further, it was noted the Veteran was not being treated for heart trouble. On physical examination, a grade III/VI systolic murmur was heard over the precordium, but no diastolic murmurs were heard. There was no evidence of congestive heart failure. Further, breath sounds were clear and there were no rales or rhonchi. An October 1995 radiographic report noted the Veteran's clinical history of chest pain. However, the report stated that the Veteran's lung fields, CP angles, diaphragm and cardiovascular structures were unremarkable. Axial osteoporosis was seen. Overall, the Veteran was noted to have a normal chest. The October 1996 Report of Medical Examination noted the Veteran had a heart murmur associated with mitral valve prolapse, and stated that the condition was asymptomatic. The examiner's notes in a concurrent Report of Medical History stated the Veteran had an asymptomatic heart murmur with no complications and no sequelae, and no treatment was needed. No other competent medical testing is of record for this period which demonstrates findings that would warrant a rating in excess of 10 percent under the "old" or revised versions of Diagnostic Code 7000. In pertinent part, there is no evidence of cardiac manifestations upon such testing, evidence of an enlarged heart, cardiac hypertrophy or dilatation. Moreover, no evidence is of record which demonstrates that a workload of greater than five METs but not greater than seven METs results in dyspnea, fatigue, angina, dizziness, or syncope. For these reasons, the Board finds the preponderance of the evidence is against a rating in excess of 10 percent for the service-connected valvular heart disease prior to February 21, 2003 to include as a "staged" rating(s). To this extent, the appeal is denied. REASONS FOR REMAND 1. Entitlement to a rating in excess of 30 percent for service-connected valvular heart disease from January 23, 2015 is remanded. In this case, the Board observes that VA treatment records note the Veteran was hospitalized at Baptist Health Little Rock in January 2021 for chest pain. Further, subsequent records from February 2021 reflect he underwent surgery for mitral valve repair. Simply stated, these notations indicate there are additional medical records regarding the service-connected valvular heart disease that are not of record. Moreover, these notations indicate a worsening of the service-connected disability since the most recent VA examination of the heart in December 2019. Therefore, a remand is required to obtain such records, and to accord the Veteran a new competent medical examination of this service-connected disability. 2. Entitlement to a TDIU due to service-connected disability is remanded. Resolution of the valvular heart disease claim herein remanded may impact the determination with respect to whether the Veteran is entitled to a TDIU and, if so, at what point in time he became so entitled. As such, the Board will remand the TDIU issue as well. See, e.g., Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on an appellant's claim for another issue). The matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issues remaining on appeal. He should be specifically asked about his hospitalization at Baptist Health Little Rock in January 2021, as well as his surgery for mitral valve repair in February 2021. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his attorney should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. (Continued on the next page) 3. After the foregoing has been completed to the extent possible, arrange to have the Veteran scheduled for examinations of his service-connected valvular heart disease. The examiner(s) should provide a full description of the Veteran's associated functional impairments as they relate to the relevant rating criteria. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his attorney should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Richard Kettler Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board John Kitlas, 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.