Citation Nr: 22015773 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 14-11 010 DATE: March 18, 2022 ORDER Entitlement to an initial rating in excess of 10 percent for thoracolumbar strain prior to December 7, 2017, in excess of 20 percent prior to May 30, 2019, and in excess of 40 percent thereafter, is denied. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) prior to June 20, 2019 is granted. Entitlement to a TDIU from June 20, 2019 is dismissed as moot. FINDINGS OF FACT 1. Prior to December 7, 2017, the Veteran's thoracolumbar strain did not result in, or more closely approximate, forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, a combined range of motion of the thoracolumbar spine 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. 2. Prior to May 30, 2019, the Veteran's thoracolumbar strain did not result in, or more closely approximate, forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 3. From May 30, 2019, the Veteran's thoracolumbar strain has not resulted in, or more closely approximated, unfavorable ankylosis of the entire thoracolumbar spine. 4. Resolving reasonable doubt in his favor, the Veteran's service-connected disabilities precluded him from securing or following a substantially gainful occupation consistent with his education, training, and work history prior to June 20, 2019. 5. From June 20, 2019, the Veteran is in receipt of a 100 percent disability rating and Special Monthly Compensation (SMC), which renders the issue of entitlement to a TDIU moot for this period. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for thoracolumbar strain prior to December 7, 2017, in excess of 20 percent prior to May 30, 2019, and in excess of 40 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. The criteria for entitlement to a TDIU prior to June 20, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.1, 4.15, 4.16, 4.19. 3. From June 20, 2019, the appeal as to entitlement to a TDIU is moot. 38 U.S.C. §§ 1114, 7105; 38 C.F.R. § 20.202. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 2001 to August 2004. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board most recently remanded these matters in May 2021 for an addendum opinion to determine whether the Veteran should be afforded magnetic resonance imaging (MRI) on his lumbar spine. In a September 2021 opinion, a VA examiner indicated that there was no need for an MRI, and it would not change the rationale nor offer any clinical benefit to the Veteran. Thus, the Board's remand directives have been substantially completed and these matters have been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Duties to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. Neither the Veteran nor his representative have advanced any procedural arguments in relation to VA's duties to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 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 determinations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When the factual findings show distinct time periods during which the veteran exhibited symptoms of disability and such symptoms warrant different disability ratings, staged ratings may also be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 3 8 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021). 1. Entitlement to an initial increased rating for thoracolumbar strain The Veteran's service-connected thoracolumbar strain is currently rated 10 percent disabling prior to December 7, 2017; 20 percent disabling prior to May 30, 2019; and 40 percent disabling thereafter. The Veteran contends that the ratings assigned to his back disability do not accurately reflect the severity of his disability and its associated symptoms throughout the entire appeal period. He specifically argues that there is more limitation of function than the limitation of motion demonstrated, and that the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 must be applied in this case. The Board notes that the appeal period begins November 2, 2010, which is the effective date of the grant of service connection for thoracolumbar strain. Disabilities of the spine are rated under a General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) (encompassing Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). The General Rating Formula stipulates, 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, that the following ratings, in pertinent part, will apply: A 20 percent rating is assigned where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. For VA compensation purposes, unfavorable ankylosis is a condition in which 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. 38 C.F.R. § 4.71a, General Rating Formula, Note (5). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in February 2011, March 2014, February 2018, and March 2019, these examinations were not fully compliant with the requirements set forth by Correia and Sharp. However, the reports still contain relevant findings that are included herein. Turning to the relevant medical evidence, VA treatment notes reflect persistent low back complaints. In September 2010, the Veteran presented with complaints of low back pain. The Veteran reported that he had been seen twice in the emergency room for similar complaints. Physical examination revealed mild tenderness to palpation, intact sensation, and normal gait. In November 2010, the Veteran presented with back pain after he ran out of his medications. In December 2010, the Veteran presented to a physical therapy consult for low back pain. Physical examination revealed flexion to 80 degrees, extension to 25 degrees, right side bending to 30 degrees, left side bending to 20 degrees, and bilateral rotation to 40 degrees. Straight leg raises were negative. He was negative for an antalgic gait. ` The Veteran was afforded a VA examination in February 2011. He reported mild to moderate pain in his mid and left lower back with prolonged sitting or standing, with left radiculopathy, but stated that "it otherwise does not typically bother him." He denied incapacitating episodes or flare-ups. He treats the pain himself with over-the-counter pain medications, hot baths, and a heating pad. Physical examination revealed flexion to 90 degrees, extension to 30 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. The Veteran was able to perform three repetitions without experiencing changes in range of motion or level of pain. There was mild tenderness to palpation across the left lumbar spine with mild guarding. Straight leg raises were negative bilaterally, motor strength was 5/5, and deep tendon reflexes were 2+ bilaterally. His gait was normal. In April 2012, the Veteran presented for a routine visit with his VA primary care physician. He reported chronic low back pain, with pain radiating to the posterior thigh. Physical examination revealed positive straight leg raises, pain on palpation of the left flank, and 4/5 strength on left lower extremity flexion and extension. In June 2012, the Veteran presented to the emergency room with back pain. He reported that he had been doing some yard work, and later developed left low back and buttock pain radiating down the left leg. In September 2012, the Veteran presented again to the emergency room with back pain. He reported left-sided back pain that worsened with movement. Physical examination revealed left paraspinal tenderness to palpation. In April 2013, the Veteran presented with a three day history of back pain after lifting a heavy object at work. In May 2013, a follow up note indicated that the Veteran had presented to the emergency room after straining his back, and that the pain was different from his chronic back pain. The Veteran was afforded a VA examination in February 2014. The Veteran reported daily back pain and spasms, which he described as severe. He denied flare-ups. Range of motion testing revealed forward flexion to 70 degrees, extension to 10 degrees, bilateral lateral flexion to 20 degrees each way, and bilateral lateral rotation to 20 degrees each way. The Veteran did not have any additional limitation in range of motion following repetitive-use testing. The Veteran did not have localized tenderness or pain to palpation, muscle spasm, or guarding of the thoracolumbar spine. Testing of muscle strength, motor strength, reflexes, and sensation to light touch were all within normal limits. Straight leg testing was negative. There was no ankylosis of the spine. In April 2014, the Veteran was evaluated by an examiner for the Social Security Administration (SSA) for chronic back pain. The Veteran reported chronic back pain that radiated down his left leg. Range of motion of the lumbar spine revealed flexion to 90 degrees, extension to 25 degrees, bilateral lateral flexion to 25 degrees, and bilateral rotation to 30 degrees. Straight leg raising was positive on the left. Strength was 5/5, light touch and pinprick sensation were normal, and deep tendon reflexes were +1 throughout in all extremities. He was noted to walk with a stable and normal gait. The examiner diagnosed muscle spasms associated with back pain, but noted that they do not seem to prevent the Veteran from performing activities of daily living except if he has to lift heavy things. In July 2014, the Veteran reported for a routine visit with his VA primary care physician. He complained of back and neck pain, and requested physical therapy to help with the pain. In December 2017, the Veteran's representative requested remand for a new examination. The representative argued that the February 2014 VA examination was too old to be relied upon. The Veteran was afforded a VA examination in February 2018. The Veteran reported that he could not sit or stand for more than 10 minutes without pain, and needed to adjust and move for relief. He reported daily flare-ups with increased activity that last 30 minutes. He reported functional loss due to not being able to sit, stand, lift heavy objects, or pick up his daughter. Range of motion testing revealed forward flexion to 50 degrees, extension to 15 degrees, bilateral lateral flexion to 18 degrees, and bilateral lateral rotation to 20 degrees. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. The examiner did not offer an opinion regarding functional limitations or range of motion during flare-ups. The Veteran was noted to have muscle spasm of the thoracolumbar spine, which does not result in abnormal gait or abnormal spinal contour. Muscle strength, reflex, and sensory testing was normal. The Veteran did not have ankylosis of the spine. In a December 2018 VA physical therapy note, range of motion testing revealed flexion to 75 degrees and extension to 30 degrees. The Veteran's gait was normal. The Veteran was afforded another VA examination in March 2019. Upon examination, he reported that his back condition has gotten worse. He reported flare-ups, which he described as constant aching pain aggravated by prolonged sitting, standing up, and physical activity. The Veteran reported functional loss due to difficulty with sitting longer than 10 minutes, standing longer than five to 10 minutes, twisting, and physical activity such as heavy lifting or prolonged walking. Range of motion testing revealed flexion to 50 degrees, extension to 15 degrees, right lateral flexion to 25 degrees, left lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. On repetitive use testing, forward flexion was further limited to 45 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, and bilateral lateral rotation to 30 degrees. The examiner did not offer an opinion regarding functional limitations or range of motion during flare-ups. The Veteran did not have guarding or muscle spasm. No ankylosis of the spine was indicated. The Veteran was afforded another VA examination in May 2019. The Veteran reported constant low back pain which sometimes worsens. He related that he has flare-ups every two months, with severe pain for about a day. Functional loss is due to an inability to stand or walk for more than 10 minutes, sit for more than 20 minutes, or lift more than 30 pounds. Range of motion testing revealed forward flexion to 32 degrees, extension to 20 degrees, bilateral lateral flexion to 15 degrees, and bilateral lateral rotation to 30 degrees. Pain was noted with range of motion and with weight-bearing. The examiner estimated that during flare-ups, pan and lack of endurance would cause forward flexion to be limited to 10 degrees, extension to 0 degrees, bilateral lateral flexion to 5 degrees, and bilateral lateral rotation to 10 degrees. Muscle spasm was noted resulting in abnormal gait or abnormal spinal contour. The Veteran did not have ankylosis. In August 2019, the Board remanded the claim, finding the Veteran's March 2019 and May 2019 VA examinations were contradictory. Specifically, the examiners marked that the Veteran's back disability had "less movement than normal due to ankylosis, adhesions, etc.," but then stated that the Veteran did not have ankylosis. In August 2019, a VA examiner reviewed the May 2019 VA examination and offered an addendum opinion. The examiner indicated that the range of motion at the examination was the range of motion by the Veteran at that time. The examiner found the Veteran's limitation and report of symptoms was higher than one would anticipate given the lack of objective abnormalities on radiographic studies, but that it could be authentic. She concluded that the Veteran did not have symptomatology tantamount to ankylosis at rest, or with flare-ups. In May 2021, the Board remanded the claim finding that there was no explanation in the Veteran's file as to why such testing is not appropriate, and another remand was warranted to determine whether the Veteran should be afforded an MRI. In August 2021, a VA examiner reviewed the claims file. The examiner noted the range of motion findings at the February 2018, March 2019, and May 2019 VA examinations. Only on the May 2019 VA examination were estimates for repeated use and flare-ups recorded. After repeated use, the examiner opined that no additional loss of range of motion would occur. During flare-ups, the examiner estimated flexion limited to10 degrees, extension limited to 0 degrees, bilateral lateral flexion to 5 degrees, and bilateral lateral rotation to 10 degrees. There was no specific note as to why there is a discrepancy between the exam in March 2019 and May 2019, but this may be due to daily or periodic variation. The examiner opined that the estimates rendered for flare-ups on the May 2019 VA examination were somewhat excessive. After reviewing the three most recent exams, the Veteran's reported history, including during flare-ups, and the clinical findings for the respective exams, the examiner estimated that from February 2018 to May 2019, after repeated use over time the Veteran would experience an additional 0-to-5-degree loss from the initial ranges of motion across all planes. During flare-ups, the Veteran would be expected to experience an additional 5-to10-degree loss across all planes from the initial values obtained. In a September 2021 addendum, the VA examiner opined that there was no need for an MRI. The examiner explained that an MRI would not change the rationale, nor would it offer any clinical benefit to the Veteran. The findings would not alter the estimates, but only identify the exact pathology of his back disability. Finally, the Veteran was afforded a VA examination in October 2021. The Veteran reported current symptoms of back pain that is present nearly constantly and is currently worse in the superior back. He reported sharp, shooting pain and spasms approximately once a month. He uses a cane to help with mobility. The Veteran did not report flare-ups of the thoracolumbar spine, however, he described functional loss due to difficulty bending over which interferes with his ability to bath, put on shoes, or sit or stand for long periods of time. Range of motion testing revealed forward flexion to 40 degrees, extension to 25 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 30 degrees. The examiner indicated that passive range of motion testing of the back was not feasible. There was evidence of pain with active motion that causes functional loss due to difficulty bending over. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion after three repetitions. The examiner determined that there is no evidence to suggest pain, fatiguability, weakness, lack of endurance, or incoordination significantly limit functional ability with repeated use over time or during periods of flare-up. No ankylosis was indicated. The Veteran was noted to have IVDS of the thoracolumbar spine, but no episodes of acute signs and symptoms that required bed rest prescribed by a physician. Upon review of the medical evidence, the Board acknowledges that some of the VA examiners throughout the appeal period did not attempt to estimate additional loss of range of motion during flare-ups per Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). However, the Board finds that remanding once again for additional development to remedy this would only serve to further delay the Veteran's claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As outlined above, the Board finds that the respective examination reports contain sufficient evidence regarding the frequency, severity, and duration of the Veteran's increased level of pain during flare-ups per his own reports. The Board finds such information pertinent and useful when evaluating the overall disability picture concerning the Veteran's back disability. After careful review of the medical and lay evidence of record, the Board finds that the evidence persuasively weighs against the assignment of an initial rating in excess of 10 percent for thoracolumbar strain prior to December 7, 2017. Prior to December 7, 2017, the Veteran is in receipt of an initial 10 percent raring. To qualify for a higher rating of 20 percent, the Veteran must demonstrate forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine 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. However, the objective medical evidence shows that the Veteran's back disability manifested by, at most, flexion limited to 70 degrees and a combined range of motion of 160 degrees. See February 2014 VA examination report. Moreover, although the Veteran was determined to have muscle spasm in his thoracolumbar spine, at no time was he assessed to have muscle spasm severe enough to result in abnormal gait or spinal contour. The Board has further considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant a higher rating prior to December 7, 2017. See DeLuca, 8 Vet. App. at 202. In this regard, the Board has considered the Veteran's descriptions of the additional functional impairment he experienced during periods of flare-up. He has competently described throughout the appeal period experiencing episodes of increased pain, after periods of repetitive movement or after prolonged standing, sitting, lifting, or walking. However, there is nothing in the record, including the Veteran's own statements, to suggest these periods of increased symptomatology resulted in a disability picture that more nearly approximated the criteria for a 20 percent, or higher, rating. In this regard, functional loss is not shown beyond what is already contemplated by the currently-assigned 10 percent rating at any time. Notably, the Veteran was never found to experience additional loss in range of motion after repetitive use testing on examination, which is instructive for the purposes of determining whether the Veteran would experience additional loss in range of motion or other additional functional impairment following repeated use or during flare-ups. As such, the Board finds that the Veteran's thoracolumbar spine symptomatology during flare-ups and after repeated use over time is already fully contemplated by the currently-assigned 10 percent disability rating, and an increased rating cannot be assigned under this basis. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07. In light of the above, the Board finds that the evidence persuasively weighs against a finding that an initial increased rating in excess of 10 percent for thoracolumbar strain is warranted for the period prior to December 7, 2017. 38 C.F.R. § 4.71a, Diagnostic Code 5237. As such, the benefit-of-the-doubt doctrine is inapplicable, and the claim for a rating in excess of 10 percent is denied. 38 U.S.C. § 5107(b); Lynch, 999 F.3d at 1391. Next, the Board finds that the evidence persuasively weighs against the assignment of an initial rating in excess of 20 percent for thoracolumbar strain prior to May 30, 2019. From December 7, 2017 to May 30, 2019, the Veteran is in receipt of a 20 percent rating for thoracolumbar strain. As noted above, entitlement to a higher, 40 percent rating requires evidence of forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Here, there is no evidence that the Veteran's thoracolumbar strain manifested by flexion of 30 degrees or less or favorable ankylosis at any time prior to May 30, 2019. In this regard, range of motion testing during the relevant period revealed forward flexion limited to, at worst, 50 degrees. See February 2018 and March 2019 VA examination reports. Further, the Veteran was not found to have ankylosis of the spine at any time during the relevant period. In fact, he was always found to have some degree of motion in both forward flexion and extension upon testing. As such, there is no evidence that the Veteran's spine was fixed in a neutral position, even during periods of flare-up of disability. Further, the Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, pain during flare-ups, and pain during repetitive use over time prior to May 30, 2019. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that aching pain aggravated by prolonged sitting or standing, and by physical activity, would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Here, the Board gives great weight to the retrospective estimates offered by the August 2021 VA examiner regarding the Veteran's functional loss during flare-ups. The August 2021 VA examiner opined that the Veteran would experience an additional 5-to-10-degree loss during flare-ups across all planes from the initial values at February 2018, March 2019, and May 2019 VA examinations. Based upon the examiner's estimates, the Veteran would retain forward flexion to 40 degrees between the February 2018 and March 2019 VA examinations during flare-ups. As such, the Board finds that the Veteran's thoracolumbar spine symptomatology during flare-ups and after repeated use over time is already fully contemplated by the currently-assigned 20 percent disability rating, and an increased rating cannot be assigned under this basis. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07. In light of the above, the Board finds that the evidence persuasively weighs against a finding that an initial increased rating in excess of 20 percent for thoracolumbar strain is warranted for the period from December 7, 2017 to May 30, 2019. 38 C.F.R. § 4.71a, Diagnostic Code 5237. As such, the benefit-of-the-doubt doctrine is inapplicable, and the claim for a rating in excess of 20 percent is denied. 38 U.S.C. § 5107(b); Lynch, 999 F.3d at 1391. Finally, the Board finds that the evidence of record persuasively weighs against the assignment of an initial rating in excess of 40 percent for thoracolumbar strain since May 30, 2019. From May 30, 2019, the Veteran is in receipt of an initial 40 percent rating for thoracolumbar strain. As noted above, entitlement to a higher, 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. Here, there is no evidence to support a finding of ankylosis of the entire thoracolumbar spine. The May 2019 VA examination report estimated that even when the Veteran's disability is at its worst, during periods of flare-up, he would still be able to achieve forward flexion to 10 degrees. Upon examination in October 2021, the Veteran had forward flexion to 40 degrees. As such, there is no evidence or allegation that the Veteran's disability is manifested by ankylosis, and there is, therefore, no basis to further consider whether the Veteran's has unfavorable ankylosis. With respect to the possibility of assigning a higher rating under 38 C.F.R. § 4.40 and § 4.45, the Board notes that the criteria for a 50 percent rating under the General Rating Formula are not predicated on limitation of range of motion. Therefore, the Board need not consider whether the Veteran is entitled to a higher rating due to additional functional loss under §§ 4.40 and 4.45. See Spencer v. West, 13 Vet. App. 376, 382 (2000); Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. In light of the above, the Board finds that the evidence persuasively weighs against a finding that an initial increased rating in excess of 40 percent for thoracolumbar strain is warranted from May 30, 2019. 38 C.F.R. § 4.71a, Diagnostic Code 5237. As such, the benefit-of-the-doubt doctrine is inapplicable, and the claim for a rating in excess of 40 percent is denied. 38 U.S.C. § 5107(b); Lynch, 999 F.3d at 1391. In reaching the above conclusions, the Board sympathizes with the Veteran that his back disability causes significant pain and discomfort and impacts his quality of life. However, the symptomatology and functional impairment described by the Veteran throughout the period on appeal are fully contemplated by the General Rating Formula for Diseases and Injuries of the Spine, directly as limitation of motion or indirectly as orthopedic factors that limit motion and function, such as pain, fatigability, weakness, or incoordination. See 38 C.F.R. § 4.71a; see also 38 C.F.R. §§ 4.40, 4.45, 4.71a; DeLuca, 8 Vet. App. at 206-207. Specifically, with respect to functional limitation and impairment due to pain, limited motion with bending, and difficulty walking, carrying objects, prolonged standing or sitting, all such impairment is specifically contemplated in the schedular rating criteria. See id., see also 38 C.F.R. § 4.45 (the factors of disability of the joints reside in reductions of their normal excursion of movements in different planes). Finally, the Board notes that the Veteran is already compensated for his radicular symptoms as he is in receipt of a separate rating for radiculopathy of the left lower extremity. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Finally, the Board notes that the Veteran is competent to testify to the presence of observable symptoms, such as increased pain, or limited motion. See Layno v. Brown, 6 Vet. App. 465 (1994). However, he is not competent to report that his thoracolumbar strain is of sufficient severity to warrant a higher rating under the rating schedule, as such an opinion requires specialized medical expertise which falls outside the realm of the common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board must rely on the medical evidence of record to assign the appropriate disability rating, and therefore, accords the objective medical findings greater weight than subjective complaints of increased symptomatology. In summary, entitlement to an initial rating in excess of 10 percent for thoracolumbar strain prior to December 7, 2017, in excess of 20 percent prior to May 30, 2019, and in excess of 40 percent thereafter, is denied. As the evidence in this case persuasively weighs against the claim, the benefit-of-the-doubt doctrine is not for application, and the Veteran's claim is denied. 38 U.S.C. § 5107(b); Lynch, 999 F.3d at 1391. 2. Entitlement to a TDIU The Veteran contends that he is unable to obtain or maintain employment due to his service-connected posttraumatic stress disorder (PTSD) and back disability. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. If the total rating is based on a disability or combination of disabilities for which the Rating Schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability. 38 C.F.R. § 3.341(a). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the veteran's service-connected disabilities render him incapable of substantially gainful employment. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board notes that the ultimate question of whether a veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 773 F.3d 1350, 1354 (Fed. Cir. 2013). Thus, the conclusions of VA examiners are not dispositive. However, the observations of the examiners regarding functional impairment due to service-connected disability go to the question of physical or mental limitations that may impact the veteran's ability to obtain and maintain employment. The Veteran is currently service-connected for PTSD (100 percent); thoracolumbar strain (40 percent); left lower extremity radiculopathy (20 percent); pseudofolliculitis barbae (10 percent); and inguinal furuncle (noncompensable). From February 27, 2018, the Veteran has two or more service-connected disabilities, with one disability rated at 40 percent or higher, and a combined rating of at least 70 percent. As such, the Board finds that the Veteran met the percentage requirements under 38 C.F.R. § 4.16(a) for consideration of a schedular TDIU from February 27, 2018. The question remains, however, whether the Veteran has been precluded from obtaining or maintaining a substantially gainful occupation as a result of his service-connected disabilities. i. Prior to June 20, 2019 The Veteran was afforded a VA examination for his back in February 2011. The Veteran reported back pain associated with prolonged sitting or standing. He reported that he was employed as a driver, and that his back disability affected his work because he had to sit for long periods at a time. The Veteran was afforded a VA examination for his back in February 2014. The Veteran reported that he had worked as a warehouse worker until June 2013, when he was terminated, and had not been employed since that time. He reported daily back pain and spasms. The examiner opined that the Veteran's back disability did not impact his ability to work. The Veteran was afforded an SSA examination for his psychiatric disability in March 2014. The clinician determined that the Veteran would be able to remember simple work instructions. However, the examiner found that the Veteran would have difficulty responding appropriately to coworkers and supervisors, and would have problems coping under ordinary work pressures. An April 2014 evaluation indicated that the Veteran could carry out simple tasks and tolerate ordinary work pressure, but should avoid quick decision making, rapid workplace changes, and should limit contact with the general public and peers. The Veteran was afforded an SSA examination for his physical disabilities in April 2014. The Veteran reported chronic back pain and left extremity radiculopathy. The examiner assessed muscle spasms associated with back pain, which did not seem to affect his daily activities except when the Veteran lifted heavy objects. The Veteran was afforded a VA examination for his back in February 2018. The Veteran reported persistent back pain. The examiner opined that the Veteran's back pain did not impact his ability to work. A September 2018 VA psychiatric note indicated that the Veteran endorsed anxiety, ruminating thoughts, and irritability. He reported difficulty maintaining jobs, and related that he was unemployable. He indicated that he had had 2 jobs in the last year, but never longer than a year. In March 2019, the Veteran presented with a questionnaire for his SSA claim. The Veteran reported intrusive memories, irritability and anger, and difficulty getting along with others. The clinician opined that the Veteran's PTSD symptoms prevented him from being able to maintain employment. Specifically, the clinician noted that the Veteran had had 3 jobs in 2 months, and had been terminated for erratic behavior. The Veteran was afforded a VA examination for his back in March 2019. The Veteran reported difficulty with prolonged sitting, prolonged standing minutes, twisting, physical activity such as lifting 40 pounds or more, and walking long distances. The examiner opined that the Veteran would have difficulty with standing or sitting longer than 10 minutes, twisting, lifting 40 pounds or more walking 50 yards or more The Veteran was afforded a VA examination for his back in May 2019. The Veteran reported that he could not stand or walk long distances, sit for long periods, or lift more than 30 pounds. The examiner opined that the Veteran could not do work that required standing, walking, or lifting. The Veteran was afforded a VA examination for his PTSD in July 2019. The examiner noted that the Veteran had a history of difficulty maintaining employment. The examiner opined that the Veteran's high level of irritability, low tolerance level, and significant emotional dysregulation would likely impact his ability to work. Moreover, the Veteran did not appear capable of working for another individual or company without being reprimanded or having significant conflict. Regarding the Veteran's occupational history, the record reveals the Veteran has had a sporadic work history. The Veteran reported to the SSA that he worked as a saw man from November 2010 to November 2011, worked a day labor job from December 2012 to November 2014, and worked as a dump man from April 2016 to September 2017. In his June 2019 VA Form 21-8940, the Veteran reported that he had last worked in November 2017 for a highway construction company. VA treatment notes confirm a sporadic work history. In January 2014, he reported that he worked a warehouse job until he hurt his back and was let go. He entered the VA compensated work therapy (CWT) program and worked for AmeriCorps until he lost his job when he was incarcerated. A December 2015 note indicated that the Veteran had sporadic income from a job as a laborer. The Veteran, per the above SSA work history, found work at a highway construction company from April 2016 to September 2017. At an October 2017 telephone contact, the Veteran reported that he had lost his job doing highway construction after showing up for work late too many times. He reported that he was currently looking for employment. In November 2018, the Veteran attended a CWT orientation meeting. In March 2019 treatment notes showed the Veteran had had three jobs in two months, and had been terminated from each job for erratic behavior. In determining whether a TDIU is warranted, a central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Based on the above evidence, the Board concludes that a TDIU is warranted as the Veteran's service-connected disabilities, to include PTSD and thoracolumbar strain, are of sufficient severity to produce unemployability. The evidence is at least in relative equipoise in this regard. Thus, resolving all reasonable doubt in the Veteran's favor, entitlement to a TDIU prior to June 20, 2019 is warranted. See 38 U.S.C. §5107(b); Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). ii. From June 20, 2019 The Board notes that the Veteran has been in receipt of a 100 percent disability rating for PTSD and depression and Special Monthly Compensation (SMC) since June 20, 2019. The United States Court of Appeals for Veterans Claims has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate the Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for a TDIU moot where 100 percent schedular rating was awarded for the same period). However, a grant of a 100 percent disability does not always render the issue of a TDIU moot. VA's duty to maximize a claimant's benefits includes consideration of whether his disabilities establish entitlement to SMC under 38 U.S.C. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In this case, the Veteran is already in receipt of both a 100 percent disability rating and SMC since June 20, 2019. Therefore, the potential for SMC as discussed in Buie and Bradley is not applicable. As consideration of a TDIU for the period since June 20, 2019 would result in no additional discernable benefit to the Veteran, the issue is moot. Accordingly, there is no question or controversy for consideration by the Board with regard to entitlement to a TDIU from June 20, 2019. Because no allegation of error of fact or law remains for appellate consideration, the Board has no jurisdiction to review the appeal of the issue for entitlement to a TDIU from June 20, 2019, and it is dismissed as moot. See 38 U.S.C. § 7105(d)(5); Sabonis v. Brown, 6 Vet. App. 426 (1994). Melissa Barbee Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Lauritzen, 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.