Citation Nr: 21031822 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 19-21 657 DATE: May 24, 2021 ORDERS Entitlement to service connection for a cervical spine disability is denied. Entitlement to an increased rating in excess of 30 percent for right shoulder tendinitis is denied. Entitlement to an increased rating in excess of 20 percent for left shoulder tendinitis is denied. Entitlement to an increased rating in excess of 20 percent for a lumbosacral strain is denied. REMAND Entitlement to special monthly compensation based on aid and attendance is remanded. FINDINGS OF FACT 1. The probative evidence of record does not show a medical nexus between the Veteran's military service and his cervical disability. 2. The probative evidence of record does not reflect limitation of motion of the major arm to midway between the side and shoulder level. 3. The probative evidence of record does not reflect limitation of motion of the minor arm to midway between the side and shoulder level. 4. The probative evidence of record does not reflect either (i) favorable ankylosis of the entire thoracolumbar spine or (ii) forward flexion of the thoracolumbar spine limited to 30 degrees or less. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical disability are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 2. The criteria for a rating in excess of 30 percent for service-connected right shoulder tendinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5201. 3. The criteria for a rating in excess of 20 percent for service-connected left shoulder tendinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5201. 4. The criteria for a rating in excess of 20 percent for service-connected lumbosacral spine strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from November 1984 to June 2009. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in October 2015 by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2020 the Board issued remand orders for further development. The Board finds that there has been substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). SERVICE CONNECTION Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303, 3.304. Service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Entitlement to service connection for a cervical spine disability. In October 2020 the Board issued a remand order. In doing so, the Board held that the Veteran had a current diagnosis for cervical spine stenosis, cervical degenerative disc disease and cervical radiculopathy. See October 2020 Remand BVA or CAVC, p. 7, see also June 2015, August 2015 and June 2016 CAPRI. As such, the first element of service connection, a current disability, is met. Furthermore, the Board has considered the Veteran's reports that his cervical spine disability was due to a documented in-service fall, in March 2007, and that he had experienced persistent symptoms since service. Id at 7. This is sufficient to meet the criteria of the second element of service connection, an in-service event or injury. However, the Board issued a remand order for a nexus opinion to be acquired, as the record did not contain a probative nexus opinion. As per Board remand directives, a VA examination was provided in January 2021. The examiner noted a thorough review of the Veteran's claims file including service treatment records and post-service records. The examiner noted degenerative arthritis of the spine and degenerative disc disease of the cervical spine. The Veteran reported that he developed neck pain while stationed in Germany around 2000 to 2001 without a history of an inciting traumatic neck. The Veteran reports that his neck pain worsened when he injured his neck in 2007 when he fell down a flight of aircraft stairs. The Veteran reports a gradual worsening of his neck condition over the years and had been treated with physical therapy in the past. The Veteran reported difficulty driving and sleeping due to his current neck pain. The examiner noted that he Veteran's neck condition impacts his ability to work in that he has difficulty looking down and turning his head to the left and right, impacting driving, pushing and pulling items. There, the VA examiner opined that the Veteran had a cervical spine disability that was less likely than not due to his military service. Specifically, he opined that the "C-file [is] silent for a cervical spine condition or a neck condition during active duty service. There is no evidence of chronicity of care. A nexus has not been established." See January 2021 C&P Exam. The Board finds the January 2021 VA examiner's nexus opinion to be of significant probative value, as the VA examiner conducted an in-person examination, reviewed the medical record, considered the Veteran's lay statements, and provided a rationale supported by the record. In reaching this conclusion, the Board has conducted a thorough review of the Veteran's medical record. The Veteran's service treatment records (STRs) shows that he injured his shoulders when falling downstairs in March 2007. At the time, the Veteran denied any neurologic issues. See August 2009 STR-Medical, p. 23. A month later the Veteran denied any numbness or tingling in the upper extremities and denied any cervical involvement, with concurrent x-rays being normal. Id at 17. The Board has not found any in-service complaint, treatment or diagnosis for a cervical disability, nor does the record show any complaint, treatment or diagnosis within one year of discharge. To the contrary, the first indication of a cervical issue in the record comes in the form of a January 2015 medical note, in which the Veteran stated that his neck pain began 4 to 5 months prior. The Veteran stated that he suffered no injury, and that the pain "just started." See July 2015 CAPRI, p. 18. Then, in June 2015 the Veteran stated that he "fell several weeks ago" which the treating physician found caused "moderate residual neck discomfort." Id at 8. The Board finds that this evidence supports the findings of the January 2021 VA examiner, and decreases the probative value of the Veteran's lay statements indicating that his cervical disability began in March 2007, or in 2000 or 2001 with chronicity of symptoms henceforth. A review of the record does not show any competing nexus opinions. And while the Board acknowledges the Veteran's lay statements, the Veteran is not shown to possess the requisite medical training or expertise to provide a competent opinion regarding the etiology of his disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Given that the January 2021 VA examiner's negative nexus opinion was of significant probative value, the Veteran's claim of service connection must be denied on the grounds that it does not meet the requirements of the third element of service connection. The Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's schedule for rating disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's right and left shoulder tendonitis are both rated under Diagnostic Code 5024-5201. Hyphenated Diagnostic Codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the first four digits, 5024, represent the diagnostic used to rate tenosynovitis. The second four digits after the hyphen, 5201, represent the Diagnostic Code for rating limitation of motion of the arm. Under Diagnostic Code 5201, a 20 percent rating is assigned for limitation of motion of the major arm or minor arm to the shoulder level, or for limitation of motion of the minor arm to midway between the side and shoulder level. A 30 percent rating is warranted for limitation of motion of the major arm to midway between the side and shoulder level, or for limitation of motion of the minor arm to 25 degrees from the side. A schedular maximum 40 percent rating is warranted for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The terms "major" and "minor" are used in the rating criteria to refer to the dominant or nondominant upper extremity. 38 C.F.R. § 4.69. Here, the Veteran's right shoulder is evaluated as major, and the left shoulder is minor. Standard range of motion of the shoulder is forward elevation (flexion) to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. Throughout the appellate period the Veteran's low back disability has been rated 20 percent under diagnostic code 5237. Disabilities rated under Diagnostic Code 5235 to 5242 are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). Under this formula, a 20 percent rating is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less; or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The current spine rating criteria instructs the Board to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Note (1). The current spine rating criteria provides specific values for range of motion of the thoracolumbar (thoracic and lumbar) spine. For the thoracolumbar spine, normal forward flexion is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. See 38 C.F.R. § 4.71a, Note (2) (see also Plate V). When rating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Moreover, joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). During the course of the appeal, effective February 7, 2021, 38 C.F.R. § 4.71a Schedule of Ratings-Musculoskeletal System including Diagnostic Code 5201 was amended. Effective February 7, 2021 forward, under the updated Diagnostic Code 5201, a 20 percent rating is warranted for the major and minor arm with limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees), A 30 percent rating is warranted for the major arm or minor arm with limitation of motion midway between side and shoulder level (flexion and/or abduction limited to 45 degrees). A 40 percent rating is warranted for the major arm and a 30 percent rating is warranted for the minor arm with flexion and/or abduction limited to 25 degrees from the side. Further, during the course of the appeal effective February 7, 2021, Diagnostic Code 5237 noted no change, that is relevant to the Veteran's current appeal. Entitlement to an increased rating in excess of 30 percent for right shoulder tendinitis Entitlement to an increased rating in excess of 20 percent for left shoulder tendinitis The Veteran submitted a claim for a rating in excess of 30 percent for right shoulder tendinitis and 20 percent for left shoulder tendinitis in May 2015. The Board has considered all evidence up to one year prior, to the date of the Veteran's increased rating claim. The maximum rating available to the Veteran is 40 percent for his dominant right shoulder and 30 percent for his left shoulder under Diagnostic Code 5201. For an increased rating to be warranted range motion must be limited to 25 degrees from the side, for both the major and minor arm. The Veteran is right arm dominant and such is his major arm, the Veteran's left arm is his minor arm. In August 2015, a VA examination was provided. The examiner noted bilateral degenerative shoulder arthritis. There the Veteran reported a progressive worsening for his bilateral shoulder since he last received treatment. He reported constant diffuse shoulder pain, aggravated by reaching, grabbing, puling and "just normal activities." He reported constant bilateral swelling and intermittent sharp pain occurring bilateral shoulder activity, improved by stretching and use of heat, ice and massage. The Veteran stated that the functional loss caused by his bilateral shoulder condition was that he couldn't drive far due to his shoulder aching and couldn't do dishes or housework due to pain. Upon examination of the right shoulder flexion was to 140 degrees, abduction to 90 degrees, external rotation to 60 degrees and internal rotation to 60 degrees, with pain. Upon examination of the left shoulder flexion was to 140 degrees, abduction was to 120 degrees, external rotation was to 90 degrees and internal rotation was to 90 degrees. Pain was noted which causes functional loss in both shoulders. There was no evidence of pain on weight bearing bilaterally. Tenderness was noted with subjective point tenderness on the left antero-lateral shoulder. Repetitive use testing did not result in any additional loss of range of motion of the right shoulder. Repetitive use testing of the left shoulder noted abduction to 100 degrees. Muscle strength testing was 5/5 bilaterally, with no muscle atrophy. Neither shoulder showed ankylosis, IVDS, instability, dislocation, labral pathology, AC joint or sternoclavicular joint conditions. Imaging noted bilateral degenerative or traumatic arthritis. The examiner found that the functional impact of the Veteran's disability was limitations for lifting, carrying, overhead work, throwing, pushing and pulling. See August 2015 C&P Exam. As the record did not show that the Veteran's range of motion was limited to 25 degrees, the RO denied the Veteran's claim in October 2015. In January 2016 the Veteran submitted a timely NOD, in which he argued that his pain was chronic and was causing an inability to work. See January 2016 NOD, p. 16. The Veteran perfected his appeal, and in September 2018 the Board issued a remand order, having found that a statement of the case (SOC) had to be provided before certification to the Board. The Veteran was provided an SOC, and then in October 2018 the Board issued a second remand order. In doing so, the Board found that the October 2015 VA examination was inadequate, as it did not contain a range of motion assessment during flareups, or an explanation as to why such an estimate could not be provided. As per Board remand directives, a VA examination was provided in January 2021. The Veteran reported that his bilateral shoulder conditions had worsened since his August 2015 VA examination, with current symptoms of bilateral shoulder clicking, pain and decreased range of motion. The Veteran did not report flareups for either shoulder. Regarding his right shoulder, the Veteran stated: "I have trouble lifting, pushing, pulling or carrying anything over 5 lbs. I have trouble sleeping due to the pain. I have trouble using my arms to do things over my head. It is hard for me to use my arms to dress myself, tie my shoes, type and write." Regarding his left shoulder "I have trouble lifting, pushing, pulling or carrying anything over 5 lbs. I have trouble sleeping due to the pain. I have trouble using my arms to do things over my head. It is hard for my to use my arms to dress myself, tie my shoes, type and write." Upon testing, the Veteran's right shoulder showed flexion to 80 degrees, abduction to 180 degrees, external rotation to 80 degrees and internal rotation to 90 degrees. The Veteran's left shoulder showed flexion to 80 degrees, abduction to 110 degrees, external rotation to 80 degrees and internal rotation to 90 degrees. Pain was noted what causes functional loss. Repetitive use testing was conducted on both shoulders without additional range of motion loss. Tenderness was noted with moderate diffuse tenderness to touch of the entire shoulder area on exam. No evidence of pain on weight bearing was noted. Muscle strength testing was normal. No ankylosis, shoulder instability, AC joint condition or sternoclavicular joint condition was found. The functional impact of the Veteran's bilateral shoulder condition was, as stated by the examiner: "Veteran reports that right shoulder chronic tendinitis, chronic musculoligamentous strains, glenohumeral arthritis condition impairs over-head activities, lifting/pushing/pulling/carrying anything over 5 lbs, typing and writing, and dressing. Veteran reports that left shoulder chronic tendinitis, chronic musculoligamentous strains, glenohumeral arthritis condition impairs over-head activities, lifting/pushing/pulling/carrying anything over 5 lbs, typing and writing, and dressing." See January 2021 VA examination. A review of the Veteran's medical records shows complaints and treatment for shoulder pain, however, there is no medical evidence of record that contradicts the findings of the October 2015 and January 2021 VA examinations. The Board thus finds, that based on the lay and medical evidence of record for the entirety of the appeal, the evidence of record does not show limitation of motion of the arm to 25 degrees from the side to warrant an increased rating for either shoulder under Diagnostic Code 5201. The Board notes the Veteran's contentions regarding his right and left shoulder pain and a worsening of his pain and symptomology. The Veteran is competent to testify to such lay observable symptomology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, such lay evidence in this case even when accepted as accurate does not establish a level of disability contemplated by a higher evaluation. As there is no lay or medical evidence indicating the Veteran's right or left shoulder has been manifested by limitation of motion to 25 degrees from the side. The Board has considered whether higher disability ratings are warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board notes, however, that the rating criteria are intended to take into account functional limitations, and therefore the provisions of 38 C.F.R. §§ 4.40 and 4.45 could not provide a basis for a higher evaluation. See 68 Fed. Reg. 51454 -5 (Aug. 27, 2003). In any event, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. Rather, the Board finds that the Veteran's current pain on motion is envisioned in his current ratings. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, the Board has considered whether an increased rating is warranted under the updated Diagnostic Code effective February 7, 2021. However, the Board finds that such is not for application, as there is no evidence of flexion/and or abduction limited to 25 degrees from the side. Finally, consideration has been given to other potentially applicable diagnostic codes. However, the Board finds no basis upon which to assign evaluations in excess of 30 or 20 percent for the right or left tendonitis at any point during the period of the appeal. The Veteran has not been found to have ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula to warrant consideration of Diagnostic Codes 5200 (scapulohumeral articulation, ankylosis of), 5202 (other impairment of humerus), or 5203 (impairment of clavicle or scapula). The aforementioned reasons, the Board must deny the Veteran's claims for increased ratings for his right and left shoulder. Entitlement to an increased rating in excess of 20 percent for a lumbosacral strain The Veteran submitted a claim for a rating in excess of 20 percent for lumbosacral strain in May 2015. The Board has considered all evidence up to one year prior. In August 2015, a VA examination was provided. The examiner noted a back strain with bilateral lower extremity radiculopathy. There, the Veteran reported decreased range of motion and near constant bilateral radicular pain. Flare ups were reported, with the Veteran rating the pain as 7 out of 10, though the examiner did not provide an estimate as to range of motion upon flareups. The Veteran reported functional loss in that he has increased pain with prolonged walking and standing. Range of motion testing showed forward flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees and left lateral rotation to 30 degrees. Repetitive use testing did not result in any additional loss of function. Neither range of motion or pain on motion was not found to cause functional loss. No ankylosis, IVDS, guarding or muscle spasms were found, muscle strength testing was normal and there was no evidence of muscle atrophy. Deep tendon reflexes testing and a sensory exam was normal. Mild intermittent pain was found, without constant pain or numbness. The examiner noted that the Veteran's back condition impacts his ability to work in that he has limitations for prolonged sitting, standing and walking. A second VA examination was provided in October 2015. The Veteran reported since his most recent examination he has been seen in the emergency room on two occasions for back pain. The Veteran reported flare ups with increased pain. Upon examination, forward flexion was to 80 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, right lateral flexion to 30 degrees and left lateral rotation to 30 degrees. Neither range of motion nor pain was found to cause functional loss. No pain on weight bearing was noted. Repetitive use testing did not result in any additional loss of motion. The examiner did not estimate range of motion loss during flare ups. Muscle strength testing was normal, no guarding or spasming was found, and the examiner did not find evidence of ankylosis of IVDS. See October 2015. The Veteran reported regular use of a cane and brace. The VA examiner summarized his findings as such: "The veteran performed heel to toe, and heel walk without difficulty but reported the presence of low back pain. Physical/neurological examination of the back revealed no spasm/swelling, no palpable tenderness and there were no noted radiculopathy/related neurological findings despite the reported intermittent radicular pain. The noted decreased ROM was due to reported pain and was inconsistent with findings of FROM shown during the last VA examination dated 08/25/15." Subsequently, in the same month, the Veteran's claim was denied by the RO. See October 2015 Rating Decision Narrative. The Veteran submitted a timely NOD, in which he argued that his back pain is chronic, with symptoms of swelling and inflammation. He further stated that his back pain had worsened in the few months after his last examination. See January 2016 NOD, pp. 16-17. He subsequently submitted a timely VA Form 9. In turn, the Board issued a remand order for a new examination to take place in September 2018, having found both previous examinations to be inadequate as they did not provide estimates for range of motion during flareups, nor did they provide rationales for the lack of said estimates. As per Board remand directives, a VA examination was provided in January 2021. At the examination, the Veteran reported that his back condition had worsened since his October 2015 examination, with symptoms of constant back pain, intermittent swelling, radicular symptoms and decreased range of motion due to pain. The Veteran reported functional loss in that he has difficulty with bending. Twisting, walking for a long time and trouble sleeping due to pain. Range of motion testing showed forward flexion to 50 degrees, extension to 10 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 15 degrees and left lateral rotation to 15 degrees, with pain. Tenderness was noted on palpation bilaterally. Repeated use testing did not result in any additional loss of function, and the Veteran did not report flare ups. Muscle spasms, guarding, ankylosis and constant pain were not found. A sensory exam was normal. Muscle strength testing was normal with no muscle atrophy. Intermittent pain, paresthias/dysesthesias and numbness were found to be moderate. Mild right and left lower extremity radiculopathy was noted. IVDS was found, but it did not cause physician prescribed bed rest. The Veteran reported regular use of brace and cane. The functional impact of the Veteran's disability was impairment of bending at the waist, lifting or pulling, running, prolonged walking and twisting. See January 2021 C&P Exam. The Veteran was then provided an SSOC in January 2021. The Board notes the Veteran's contentions of a worsening of his back pain during the appeal period. The Veteran is competent to testify to such lay observable symptomology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, such lay evidence in this case even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The Board has reviewed the Veteran's medical record and have not uncovered any medical or lay evidence that challenges the findings of the January 2021 VA examination. Likewise, neither the record, nor the Veteran, has indicated that there has been a subsequent worsening of symptomatology. In the present case, the evidence of record shows that the Veteran suffers from a worsening of symptomatology since his October 2015 VA examination. However, the probative evidence of record does not show forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees. Rather, the evidence of record shows that in October 2015 the Veteran's forward flexion was to 80 degrees, with normal flexion being to 90 degrees. As of January 2021, forward flexion was to 50 degrees. The next higher rating is warranted when forward flexion is 30 degrees or less. Likewise, the evidence of record does not show that the combined range of motion was not greater than 120 degrees at any time in the appellate period, nor does the record show muscle spasms or guarding, abnormal spinal contour, lordosis or kyphosis. Therefore, the criteria for the assignment of a rating in excess of 20 percent under DC 5237 have not been met or approximated at any time during the appeal period. Further, the Board has considered whether higher disability ratings are warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board notes, however, that the rating criteria are intended to take into account functional limitations, and therefore the provisions of 38 C.F.R. §§ 4.40 and 4.45 could not provide a basis for a higher evaluation. See 68 Fed. Reg. 51454 -5 (Aug. 27, 2003). In any event, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. Rather, the Board finds that the Veteran's current pain on motion is envisioned in his current rating. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Likewise, the Veteran is not entitled to a rating in excess of 20 percent under the Formula for Rating IVDS Based on Incapacitating Episodes as the evidence indicates that the Veteran does not suffer incapacitating episodes of IVDS requiring physician-prescribed bedrest as a result. See 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board has also considered whether the updated Diagnostic Code effective February 7, 2021 is for application as such has been considered but would not warrant an increased rating. In sum, the criteria for a rating in excess of 20 percent for the Veteran's service connected lumbosacral strain is not warranted at any point in the appellate period. REMAND Entitlement to Special Monthly Compensation for Aid and Attendance The Veteran contends that Special Monthly Compensation (SMC) for Aid and Attendance (A&A) is warranted. While the Board is aware that the Veteran has claimed SMC as part of his 10182, the Board finds that the Veteran's claim must be adjudicated under the legacy system as the RO considered this issue as part of the January 2021 Supplemental Statement of the Case (SSOC). As an initial matter, as of September 2015, the Veteran has been rated at 100 percent for posttraumatic stress disorder (PTSD). He has also been rated at 30 percent for right shoulder tendinitis, 20 percent for left shoulder tendinitis, 30 percent for headaches, 20 percent for chronic lumbosacral strain and bilateral sciatica, 10 percent for left elbow strain, 10 percent for left knee strain, 10 percent for right knee strain, 10 percent for right ankle tendinitis, 10 percent for tinnitus, 10 percent for allergic rhinitis, 10 percent for residuals of submental cyst with scar, 10 percent for restless leg syndrome, 10 percent for left wrist carpal tunnel syndrome, 10 percent for chronic sinusitis, 10 percent for gastroesophageal reflux disease, and noncompensable for right hamstring pull, eustachian tube dysfunction, recurrent bronchitis and external hemorrhoids. The Veteran's social security administration (SSA) records were made of file. SSA records show that the Veteran was found to be unable to continue working, as of 2012, due to his service-connected disabilities. See October 2018 Medical Treatment Records Furnished by SSA, p. 102. The Veteran was then found to be disabled as of March 2014 due to the same disabilities. Id at 294. As of March 2014, the Veteran wrote that he only left the house to go to church a couple of times a month and attended other events once every other couple months. He wrote that he could prepare simple meals in the microwave and could drive short distances. The Veteran further reported that he could shop for books, CDs and "small items such as milk, eggs and bread." He reported that he was able to pay bills, count change, handle his savings account and use a check book/money order. Id at 60. The Veteran submitted a claim for SMC in May 2015. In doing so, the Veteran described his daily routine as waking up at 4-6am due to service-connected pain, stretching, doing yoga, and then going for a 20-30 minute walk. The Veteran described how the rest of the day would be spent reading and watching television until going to sleep around 10pm. He stated that he could not do household chores, cook, clean, or do any other physical activity due to pain in the shoulders, neck, back and legs. The Veteran wrote that he only left the home for medical appointments or to visit family, with his wife driving. See May 2015 Correspondence. In conjunction with the Veteran's claim, letters were submitted in support of his claim. The Veteran's friend, M.L., wrote that the Veteran only left the house to go to medical appointments, and suffers from depression, anger and mood swings because he was unable to care for himself and could no longer work. The Veteran's daughter, R.C. wrote that that the Veteran only left home to attend medical appoints and did not want to leave house because he could not deal with others. The Veteran's wife, S.B., wrote that the Veteran needed regular care to protect him from the danger of his daily environment, and wrote about how the Veteran's mental health issues in conjunction with his physical disabilities caused him to be functionally helpless. Finally, the Veteran's son, J.R., wrote that the Veteran only left the home for medical appointments, could not drive himself, and had to be monitored to ensure that he did not hurt himself due to his mental and physical disabilities. See May 2015 Buddy / Lay Statements. The record further shows an A&A examination which appears to be completed by the Veteran. In it the Veteran wrote of how his physical and mental disabilities restricted his ability to care for himself, and of how he could not drive because of shoulder pain, panic attacks and the fear of passing out. See May 2015 VA 21-2680. In June 2015 an A&A examination was submitted by the Veteran's private physician. There, Dr. R.B. wrote that the Veteran was able to feed himself; but could not manage his own finances, prepare his own means or perform his own hygiene and bathing without assistance. The physician wrote that the Veteran did not require nursing home care. The physician wrote that the Veteran required a companion when out of the house to drive for emotional support due to anxiety and could leave the house by car with a companion. See June 2015 VA 21-2680. A review of the Veteran's medical record shows that in June 2015 a physician wrote that the Veteran required his wife's assistance to get a shirt on and off, was unable to shower his lower axillary area due to limited reach, was unable to drive, and could shop for food or stand to prepare meals, with his wife doing all of the cooking, cleaning, meal preparation and household work. See March 2020 CAPRI, p. 24. An October 2015 private examination for the Veteran's psychological condition was made of record. There, the private physician noted that the Veteran was limited in his functional ability to engage in household tasks, chores and physical activities due to chronic pain. The Veteran stated that he was able to independently groom himself, but that he had some difficulty dressing himself due to limited range of motion and chronic pain. See October 2015 Medical Treatment Record Non - Government Facility. A month later the Veteran a second examination was made of record. There, the examiner wrote that the Veteran could complete grooming activities independently but was unable to drive due to his psychological issues. See November 2015 VA Examination. In October 2015 the RO denied the Veteran's claim and the Veteran submitted a timely NOD in January 2016. In September 2018 the Board issued a remand order for the Veteran to be provided an SOC. In October 2018 the Veteran wrote to VA, stating that he was "not bedridden" but was "couch ridden [in my] house 24 hours 7 days a week unless I have a medical appointment which my spouse will bring me." The Veteran further stated that the private medical examination previously submitted contained errors due to confusion from his representatives. See October 2018 Correspondence. In the present case, the totality of the evidence shows that the Veteran, his spouse, children and friends have the good-faith belief that the Veteran is unable to care for himself and requires the aid and attendance of his wife for his daily living. However, the record does not show that the Veteran, nor his relatives or friends have the requisite medical knowledge, training and expertise to make such a determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999). Where, as in the present case, there is insufficient competent medical evidence in the record for the Board to adjudicate a claim, it must remand that claim for further development. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). This matter is therefore REMANDED for the following action: Schedule the Veteran for a VA examination for housebound status or permanent need for regular aid and attendance by an appropriate clinician to determine the current level of severity of all impairment resulting from his service-connected disabilities. The claims folder, including a copy of this remand, should be made available to the examiner for review prior to the examination. The examiner should acknowledge such review in the examination report. After examining the Veteran and reviewing the record, the examiner should address whether the Veteran is so helpless or so nearly helpless as to require the regular aid and attendance of another person due to his service-connected disabilities. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. K.R. Kardian Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Abels, 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.