Citation Nr: 22017103 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 18-06 063A DATE: March 24, 2022 ORDER A rating higher than 20 percent for lumbosacral strain with degenerative disc disease and arthritis is denied A rating higher than 10 percent for radiculopathy of the right lower extremity (sciatic nerve) prior to May 16, 2019, is denied. A 20 percent rating for radiculopathy of the right lower extremity (sciatic nerve) as from May 16, 2019, to October 8, 2021, is granted. A rating higher than 10 percent for radiculopathy of the right lower extremity (sciatic nerve) from October 8, 2021, is denied. A rating higher than 10 percent for radiculopathy of the left lower extremity (sciatic nerve) prior to May 16, 2019, is denied. A 20 percent rating for radiculopathy of the left lower extremity (sciatic nerve) as of May 16, 2019, to October 8, 2021, is granted. A rating higher than 20 percent for radiculopathy of the right lower extremity (sciatic nerve) from October 8, 2021, is denied. A compensable rating for bilateral lower extremity radiculopathy (femoral nerve) prior to October 8, 2021, and a rating higher than 20 percent for bilateral lower extremity radiculopathy (femoral nerve) from October 8, 2021 is denied. A rating higher than 20 percent for left eye atrophy with visual field loss prior to April 6, 2021, is denied. A rating higher than higher than a 30 percent evaluation for bilateral glaucoma with left eye atrophy from April 6, 2021, to October 11, 2021, is denied. A rating higher than 40 percent evaluation for bilateral glaucoma with left eye atrophy as of October 11, 2021, is denied. REMANDED Service connection for Rathke's cleft cyst, claimed as a brain tumor, is remanded. A total disability rating based on individual unemployability (TDIU) prior to August 8, 2014, is remanded. FINDINGS OF FACT 1. The Veteran's lumbosacral strain with degenerative disc disease and arthritis manifests as pain, limitation of forward flexion to no less than 50 degrees, and combined range of motion no less than 125 degrees; there is no finding of ankylosis or its equivalent during flare-ups. 2. The Veteran's associated radiculopathy of the bilateral lower extremities (sciatic nerves) was mild prior to May 16, 2019, and moderate thereafter. Radiculopathy of the right and left lower extremity (femoral nerves) was not present prior to October 8, 2021. 3. Prior to April 6, 2021, the Veteran's left eye atrophy with visual field loss manifested as concentric contraction of visual field in the left eye with remaining visual field of no less than 8 degrees, corrected visual acuity was consistently 20/40 or better, no impairment of muscle function, and no incapacitating episodes. 4. From April 6, 2021, to October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy manifested as concentric contraction of visual field in the left eye, corrected visual acuity was consistently 20/40 or better, no impairment of muscle function, and no incapacitating episodes. Her glaucoma required continuous medication for treatment. 5. As of October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy manifests as concentric contraction of visual field in the right eye with remaining visual field of no less than 56 degrees in the left eye with remaining visual field of no less than 9 degrees; the difference in corrected visual acuity for distance and near vision was equal to two or more lines on the Snellen test type chart, so her visual acuity was adjusted to 20/20 in the right eye and 20/50 in the left eye. The Veteran had no impairment of muscle function and no incapacitating episodes. Her glaucoma requires continuous medication for treatment. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for lumbosacral strain with degenerative disc disease and arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5242. 2. The criteria for a rating greater than 10 percent rating for radiculopathy of the right lower extremity (sciatic nerve) prior to May 16, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 3. The criteria for a 20 percent rating, but not more, for radiculopathy of the right lower extremity (sciatic nerve) as of May 16, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 4. The criteria for a rating greater than 10 percent rating for radiculopathy of the left lower extremity (sciatic nerve) prior to May 16, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 5. The criteria for a 20 percent rating, but not more, for radiculopathy of the left lower extremity (sciatic nerve) as of May 16, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 6. The criteria for a compensable rating for radiculopathy of the bilateral lower extremities (femoral nerve) and a rating greater than 20 percent beginning on October 8, 2021, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8526. 7. The criteria for a rating higher than 20 percent for left eye atrophy with visual field loss prior to April 6, 2021, were not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Codes 6026-6080. 8. The criteria for a rating higher than higher than a 30 percent evaluation for bilateral glaucoma with left eye atrophy from April 6, 2021, to October 11, 2021, were not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Codes 6026-6080. 9. The criteria for a rating higher than 40 percent evaluation for bilateral glaucoma with left eye atrophy as of October 11, 2021, are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Codes 6026-6080. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1994 to August 2001. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a February 2018 decision review officer (DRO) decision, the rating for left eye atrophy with vision field loss was increased to 20 percent effective February 1, 2018. In an August 2021 rating decision, a 20 percent rating for this disability was assigned effective April 16, 2013. In an October 2021 rating decision, the Veteran's low back strain was recharacterized as lumbosacral strain with degenerative disc disease. This disability was assigned a 20 percent rating effective April 16, 2013. Additionally, service connection was granted for associated radiculopathy of the bilateral lower extremities for both the femoral and sciatic nerves. TDIU and DEA were granted effective August 3, 2014. Finally, service connection for bilateral glaucoma was awarded effective April 6, 2021. The Veteran's left eye disability became a bilateral eye disability at that point and was recharacterized as bilateral glaucoma with left eye atrophy. This bilateral eye disability was assigned a 30 percent rating as of April 6, 2021, and a 40 percent rating as of October 11, 2021. As the increased rating for the back and the staged ratings assigned for the eyes are less than the maximum available ratings, these issues remained on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in February 2021. A transcript of the hearing is associated with the claims file. Increased Rating 1. A rating higher than 20 percent for lumbosacral strain with degenerative disc disease and arthritis 2. A rating higher than 10 percent for radiculopathy of the right lower extremity (sciatic nerves) prior to October 8, 2021, and 20 percent thereafter 3. A higher rating than 10 percent for radiculopathy of the left lower extremity (sciatic nerves) prior to October 8, 2021, and 20 percent thereafter 4. A higher rating for radiculopathy of the bilateral lower extremities (femoral nerve) rated as 20 percent from October 8, 2021 The Veteran was originally granted service connection for low back strain in a September 2001 rating decision. At that time, this disability was assigned a 10 percent rating effective August 9, 2001. The Veteran's current claim for an increased rating was received April 16, 2013. In an October 2021 rating decision, the Veteran's low back strain was recharacterized as lumbosacral strain with degenerative disc disease. This disability was assigned a 20 percent rating effective April 16, 2013. Additionally, service connection was granted for associated radiculopathy of the bilateral lower extremities for both the femoral and sciatic nerves. Ten (10) percent ratings were assigned for radiculopathy of the right and left lower extremity (sciatic nerves) effective March 8, 2013, and 20 percent ratings were assigned for radiculopathy of the right and left lower extremity (sciatic nerves) effective October 8, 2021. Separate 20 percent ratings were assigned for radiculopathy of the right and left lower extremity (femoral nerves) effective October 8, 2021. The Veteran's lumbosacral strain with degenerative disc disease and arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for 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; 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 warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at 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. The June 2014 back conditions disability benefits questionnaire (DBQ) notes the Veteran's complaints of low back pain. She used muscle relaxants and a TENS unit. She did not report flare-ups of back symptoms. Range of motion testing showed forward flexion to 85 degrees, extension to 25 degrees, bilateral lateral flexion to 30 degrees or more, and bilateral lateral rotation to 30 degrees or more. There was no objective evidence of painful motion in any plane. The examiner noted that the Veteran's decreased range of motion was secondary to her age and body habitus. The Veteran was able to perform repetitive-use testing with three repetitions. Post-test, her bilateral lateral flexion was limited to 25 degrees. Nevertheless, the examiner found no additional limitation of range of motion after repetitive-use testing. The Veteran did not have any functional loss and/or functional impairment of the thoracolumbar spine. Pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability during a flare-up or when the joint was used repeatedly over a period of time. The Veteran did not have localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine. She did not have guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing, reflexes, and sensory exam were normal throughout. The Veteran did not have muscle atrophy. Straight leg testing was negative bilaterally. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. She did not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition. She did not have intervertebral disc syndrome. She did not use an assistive device as a normal mode of locomotion. The Veteran's thoracolumbar spine condition did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies were not performed. This disability did not impact the Veteran's ability to work. The April 2015 back conditions DBQ notes the Veteran's complaints of activity-dependent low back pain that was intermittent and present three or four times per week. She treated this with medication, physical therapy, and a TENS machine. Range of motion testing showed forward flexion to 90 degrees or greater, with objective evidence of painful motion beginning at 70 degrees, extension to 20 degrees with objective evidence of painful motion beginning at 20 degrees, bilateral lateral flexion to 30 degrees or greater with objective evidence of painful motion beginning at 30 degrees or greater, and bilateral lateral rotation to 30 degrees or greater without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions without additional limitation of range of motion after repetitive-use testing. Functionally, the Veteran had less movement than normal and pain on movement. Her lumbar paraspinous area was tender bilaterally. She did not have muscle spasm or guarding. Muscle strength testing, reflexes, and sensory exam were normal throughout. The Veteran did not have muscle atrophy. Straight leg testing was positive bilaterally. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. She did not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition. She did not have intervertebral disc syndrome. She did not use an assistive device as a normal mode of locomotion. The Veteran's thoracolumbar spine condition did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies documented arthritis and showed a retained metallic foreign body near the spine that did not involve the bone of the spine. With regard to flare -ups, the Veteran reported 190 episodes of moderate to severe pain per year lasting from half a day to three days. Pain significantly limited functional ability during flareups or when joint was used repeatedly over a period of time. This was not expressed in terms of additional limitation of range of motion as the Veteran was unable to replicate the estimated limitation at the time of the examination. This disability impacted the Veteran's ability to work in that she was limited to lifting no more than 30 pounds, walking no more than one mile at a time, sitting thirty minutes at one time, and standing 20 minutes at a time. Over the course of an eight-hour workday, the Veteran's walking would be limited by a need to take a rest break every twenty minutes. Likewise, her ability to sit or stand over the course of an eight-hour workday would be limited by a need to reposition every fifteen minutes. She also had to avoid repetitive lifting and stooping. The January 2018 back conditions DBQ notes the Veteran's report of constant back symptoms. She had some relief from injections, but reported that physical therapy made her worse. She had not undergone surgery or chiropractic treatment. She did not report flare-ups of her thoracolumbar disability. Functionally, she reported difficulty dressing, bathing, and performing household chores. Range of motion testing showed forward flexion to 85 degrees, extension to 5 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 25 degrees. Pain was noted in extension on examination but did not result in or cause functional loss. There was no evidence of pain with weight-bearing, but there was evidence of pain when joint was used in non-weight-bearing. Passive range of motion testing was not performed or was not medically appropriate. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. She was not examined immediately after repetitive use over time and this examiner found the examination neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and/or incoordination did not significantly limit functional ability with repeated use over time. The Veteran did not have guarding or muscle spasms of the thoracolumbar spine. She had less movement than normal. Muscle strength testing, reflexes, and sensory exam were normal throughout. The Veteran did not have muscle atrophy. Straight leg testing was negative bilaterally. She did not have ankylosis of the spine. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. She did not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition. She did not have intervertebral disc syndrome. She did not use an assistive device as a normal mode of locomotion. The Veteran's thoracolumbar spine condition did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran did not have any associated scars. She had a 0/5 Waddell sign score. Imaging studies were performed but did not document arthritis or thoracic vertebral fracture with loss of 50 percent or more of height. This disability impacted the Veteran's ability to work in that she may be limited in any vocation that involves repetitive heavy lifting and carrying. She may benefit by an ergonomic workstation. The May 2019 back conditions DBQ notes the Veteran's complaints of constant aching back pain that she treated with multiple medications. She reported flare-ups of pain every one or two months where nothing can relieve the pain and she has to lie still until the pain subsides. She used lidocaine patches and a heating pad. Functionally, she reported difficulty performing day to day activities. She had limitations of bending, standing, and putting on clothes below the waist. Range of motion testing showed forward flexion to 80 degrees, extension to 25 degrees, bilateral lateral flexion to 25 degrees, and bilateral lateral rotation to 25 degrees. This range of motion itself did not contribute to a functional loss. Pain was noted in all planes on examination but did not result in or cause functional loss. There was evidence of pain with weight-bearing and when joint was used in non-weight-bearing. Passive range of motion testing was not performed or was not medically appropriate. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. She was not examined immediately after repetitive use over time and this examiner found the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over time. The examiner was unable to express this in terms of range of motion because the limitation of motion after repetitive use over time varied depending on how much the joint was utilized and overused. At times, range of motion was minimal and limited due to pain. There was no further range of motion loss anticipated after repetitive use over time, only increased symptoms of moderately severe pain and fatigability. This could be noted if overexertion occurred with various activities. Similarly, the Veteran was not examined during a flare-up and this examiner found the examination was medically consistent with the Veteran's statements describing functional loss during a flare-up. Pain significantly limited functional ability during a flare-up. The examiner was unable to express this in terms of range of motion because the limitation of motion after repetitive use over time varied depending on how much the joint was utilized and overused. At times, range of motion was minimal and limited due to pain. There was no further range of motion loss anticipated during a potential flare-up, only increased symptoms of moderately severe pain and fatigability. This could be noted if overexertion occurred with various activities. The Veteran did not have guarding or muscle spasms of the thoracolumbar spine. The Veteran's additional factors contributing to disability were interference with standing, reduced capacity to perform bending, lifting, twisting, stooping, and turning. She was unable to stand and walk for prolonged periods without frequent breaks. She had limited ability to run, kneel, stair climb, and climb ladders. She had decreased (4/5: active movement against some resistance) muscle strength throughout the bilateral lower extremities. She did not have muscle atrophy. Reflex and sensory exam results were normal. Straight leg testing was negative bilaterally. She did not have ankylosis of the spine. The Veteran had moderate intermittent pain and mild constant pain, paresthesias/dysesthesias, and numbness in the bilateral lower extremities, but no other signs of radiculopathy. Thus, this examiner found mild radiculopathy of the bilateral sciatic nerves. The Veteran did not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition. She did not have intervertebral disc syndrome. She constantly used a cane and occasionally used a wheelchair due to her back disability. The Veteran's thoracolumbar spine condition did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs, symptoms, or scars. Imaging studies were performed and documented arthritis, but not a thoracic vertebral fracture with loss of 50 percent or more of height. This disability impacted the Veteran's ability to work in that she had reduced capacity to perform bending, lifting, twisting, stooping, turning. She was unable to stand and walk for prolonged periods of time without frequent breaks. She had limited ability to run, kneel, stair climb, and climb ladders. The July 2019 addendum noted that diagnoses of radiculopathy had been based on the Veteran's subjective symptoms, which is usually sufficient. These diagnoses could be remover if it was not sufficient. In the current case, the Veteran has an existing diagnosis of anti-synthetase syndrome with overlapping symptoms. The October 2021 back conditions DBQ notes the Veteran's complaints of back pain and radiating pain, numbness, and tingling sensation to the bilateral lower extremities. She treated her symptoms with medication, patches, and creams. She did not report flare-ups of this disability. Functionally, she reported that bending over hurt and she was unable to stand or sit for long periods of time. Range of motion testing showed forward flexion to 50 degrees, extension to 15 degrees, bilateral lateral flexion to 15 degrees, and bilateral lateral rotation to 15 degrees. Pain was noted in all planes on examination but did not result in or cause functional loss. Passive range of motion testing was not performed as it may cause severe pain or risk further injury. There was evidence of pain with active motion that caused functional loss (difficulties bending and twisting at the waist), but no evidence of pain at rest, in weight-bearing, or in non-weight-bearing. There was no objective evidence of crepitus. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. She was not examined immediately after repetitive use over time. The procured evidence did not suggest pain, fatigability, weakness, lac of endurance, or incoordination significantly limited functional ability with repeated use over time. Similarly, the Veteran was not examined during a flare-up and the procured evidence did not suggest pain, fatigability, weakness, lac of endurance, or incoordination significantly limited functional ability during a flare-up. The Veteran did not have localized tenderness, guarding, or muscle spasms of the thoracolumbar spine. The Veteran did not have additional factors contributing to disability. She had decreased (4/5: active movement against some resistance) muscle strength throughout the bilateral lower extremities. She did not have muscle atrophy. Reflex and sensory exam results were normal. Straight leg testing was positive bilaterally. The Veteran had mild intermittent pain, paresthesias/dysesthesias, and numbness in the bilateral lower extremities, but no other signs of radiculopathy. Thus, this examiner found radiculopathy of the bilateral sciatic and femoral nerves. She did not have ankylosis of the spine. The Veteran did not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition. She did not have intervertebral disc syndrome. She constantly used a cane and regularly used a strolling walker due to her radiculopathy. The Veteran's thoracolumbar spine condition did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs, symptoms, or scars. Imaging studies were not performed. This disability impacted the Veteran's ability to work in that she would have difficulty with prolonged sitting, standing, walking, pushing, pulling, lifting, driving, and climbing ladders. The October 2021 opinion found that the Veteran had radiculopathy, noting a diagnosis of radiculopathy in March 2013 and earlier complaints of radiating pain. VA treatment records from this period show ongoing complaints of low back pain with radiating pain down her legs. There is also evidence of paraspinal tenderness, muscle spasm, and radiculopathy of the bilateral lower extremities. The Board finds that the evidence of record persuasively weighs against a rating in excess of 20 percent for lumbosacral strain with degenerative disc disease and arthritis. Throughout the appeals period, the Veteran's lumbosacral strain with degenerative disc disease and arthritis has manifested as pain, limitation of forward flexion to no less than 50 degrees, and combined range of motion no less than 125 degrees. There are conflicting reports as to the presence of muscle spasm, but no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. There is no finding of ankylosis. 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. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or equate to favorable ankylosis of the entire thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and 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. The Veteran has provided lay evidence of flare-ups of severe pain that caused her to lie down until the pain subsided, but there is no evidence suggesting that a physician prescribed bedrest at any time for this disability. Moreover, effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." In this case, there is no evidence of disc herniation with compression or irritation of the adjacent nerve root. Regarding neurological impairment, the Veteran has already been granted service connection for bilateral radiculopathy of the sciatic and femoral nerves and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. As noted above, the Veteran has been awarded 10 percent ratings for radiculopathy both right and left lower extremity sciatic nerves prior to October 8, 2021, and 20 percent each thereafter. This reflects mild incomplete paralysis of the sciatic nerves prior to October 8, 2021, and moderate incomplete paralysis of the sciatic nerves thereafter. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board has considered whether higher ratings are warranted for these disabilities. At no point did the Veteran exhibit trophic changes, loss of reflexes, loss of sensation, muscle atrophy, or complete paralysis of either sciatic nerve. The first record to note decreased (4/5: active movement against some resistance) muscle strength throughout the bilateral lower extremities was the May 16, 2019, back conditions DBQ. This record also noted moderate intermittent pain and mild constant pain, paresthesias/dysesthesias, and numbness in the bilateral lower extremities. This is substantially similar to the findings of the October 2021 back conditions DBQ upon which the current increased rating is based. Therefore, the Board finds that 20 percent ratings for radiculopathy of the right and left lower extremities (sciatic nerves) are warranted as of May 16, 2019. Additionally, the Veteran has been awarded 20 percent ratings for radiculopathy both right and left lower extremity femoral nerves as of October 8, 2021, which is the date of the first evidence of femoral nerve involvement in her radiculopathy of the bilateral lower extremities. See the October 2021 back conditions DBQ. This reflects moderate incomplete paralysis of the femoral nerves. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. Again, the record does not show symptoms of severe incomplete paralysis of either lower extremity during this period. Thus, a higher rating is not warranted for radiculopathy of the right and/or left lower extremity (femoral nerve) and these ratings remain unchanged. Based on the foregoing, the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 20 percent for lumbosacral strain with degenerative disc disease and arthritis. As the evidence of record persuasively weighs against a rating in excess of 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). To the extent that 20 percent ratings for the associated neurological abnormalities of radiculopathy of the right and left lower extremities (sciatic nerves) are warranted as of May 16, 2019, however, the appeal is granted. 5. Increased ratings for eye disability The Veteran was originally granted service connection for left eye atrophy with vision field loss in the August 2015 rating decision currently on appeal. At that time, this disability was assigned a 10 percent rating effective April 16, 2013. This disability rating has undergone several partial increases during the pendency of this appeal, resulting in the current staged rating reflected on the title page and described in the introduction. Below, the Board will address whether this or any other staged rating is more appropriate. The Veteran's eye disability is rated under hyphenated diagnostic code (DC) 6026-6080 prior to April 6, 2021, and 6013-6066 thereafter. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15,316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, DC 6026 instructed to evaluate optic neuropathy based on visual impairment. Under the revised criteria, DC 6026 instructs to evaluate optic under the General Rating Formula for Diseases of the Eye. Under the former criteria, DC 6013 instructed to evaluate pursuant to visual impairment due to open-angle glaucoma. Under the revised criteria, DC 6013 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye with a 10 percent minimum rating if continuous medication is required. Under the revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. With regard to visual impairment, the amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Impaired visual acuity is rated under diagnostic codes 6061-6066 based on the best corrected distance vision. 38 C.F.R. §§ 4.76, 4.79. Impairment of visual fields are rated under DC 6080-6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Impaired muscle function is rated under DC 6090-6091 with an evaluation for diplopia being assigned to only one eye. 38 C.F.R. §§ 4.78, 4.79. When only one eye is service connected, the other eye considered 20/40 for rating purposes regardless of the actual level of impairment. 38 C.F.R. § 4.75 (c). When both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the evaluation is determined by separately evaluating the visual acuity and visual field defect (expressed as a level of visual acuity) and combined under the provisions of 38 C.F.R. § 4.25. See 38 C.F.R. § 4.77 (c). 1. A rating higher than 20 percent for left eye atrophy with visual field loss prior to April 6, 2021 Private and VA treatment records from this period show limited visual field in the left eye. Her corrected vision was consistently 20/40 or better bilaterally. She did not have diplopia. The May 2015 eye conditions DBQ shows diagnoses of left optic atrophy and left eye visual field defect. She reported constant headaches and loss of peripheral vision in the left eye. She intermittently used prescription eye drops for this disability. The Veteran's uncorrected distance visual acuity was 20/40 or better in the right eye and 20/100 in the left eye, corrected to 20/40 or better bilaterally. Her uncorrected near visual acuity was 20/40 or better in the right eye and 20/50 in the left eye, corrected to 20/40 or better bilaterally. Her pupils were equal, round, and reactive to light. An afferent pupillary defect was present in the left eye. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. She did not have a corneal irregularity that resulted in severe irregular astigmatism. She did not have diplopia. Slit lamp and external eye exam found vacuole in the right lens and cortical opacities in the left lens. An internal eye exam found advanced cupping and pallor in the left optic disc. The Veteran had a documented visual field defect with contraction of a visual field and loss of nasal half and inferior half of visual field. She did not have a scotoma. The accompanying visual field perimeter chart showed loss of visual field as described below: Meridian Normal Right Eye Left Eye Up 45 45 5 Up temporally 55 55 45 Temporally 85 75 55 Down temporally 85 70 15 Down 65 60 15 Down nasally 50 50 15 Nasally 60 60 5 Up nasally 55 55 15 Total: 500 470 170 Average Concentric Contraction 62.5 58.75 21.25 The Veteran was not legally blind based on visual field loss. The Veteran's visual impairment was attributed to her left eye optic atrophy. She did not have any associated scarring or disfigurement. In the prior twelve months she did not have any incapacitating episodes attributable to any eye condition. This disability impacted the Veteran's ability to work in that the loss of peripheral vision posed a safety issue when driving. Specifically, inferior temporal portion of visual field loss coincides with the left side mirror function. The January 2018 eye conditions DBQ shows a diagnosis of left optic atrophy with decreased visual field. The Veteran's uncorrected distance visual acuity was 20/40 or better in the right eye and 20/70 in the left eye, corrected to 20/40 or better bilaterally. Her uncorrected near visual acuity was 20/40 or better in the right eye and 20/50 in the left eye, corrected to 20/40 or better bilaterally. Her pupils were equal, round, and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. She did not have a corneal irregularity that resulted in severe irregular astigmatism. She did not have diplopia. Slit lamp and external eye exam were normal bilaterally. An internal eye exam found left optic disc atrophy and a cup-to-disc ration of 0.6. The Veteran had a documented visual field defect with marked contraction of a visual field in the left eye only, but not loss of a visual field or a scotoma. She was not legally blind based on visual field loss. The Veteran's visual impairment was attributed to her left eye optic atrophy. She did not have any associated scarring or disfigurement. She did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to an eye condition. In the prior twelve months she did not have any incapacitating episodes attributable to any eye condition. This disability did not impact her ability to work. The February 2018 visual field perimeter chart showed loss of visual field as described below: Meridian Normal Right Eye Left Eye Up 45 42 5 Up temporally 55 55 10 Temporally 85 85 10 Down temporally 85 85 15 Down 65 65 10 Down nasally 50 50 5 Nasally 60 60 5 Up nasally 55 45 5 Total: 500 487 65 Average Concentric Contraction 62.5 60.875 8.125 The May 2019 eye conditions DBQ shows a diagnosis of left optic atrophy with visual field loss. The Veteran's uncorrected distance visual acuity was 20/40 bilaterally, both corrected to 20/20 or better. Her uncorrected near visual acuity was 20/100 bilaterally, corrected to 20/20 or better. Her pupils were equal, round, and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. She did not have a corneal irregularity that resulted in severe irregular astigmatism. She did not have diplopia. Slit lamp and external eye exam were normal bilaterally. An internal eye exam found severe left optic atrophy. The Veteran had a documented visual field defect. Visual field testing was performed using Humphrey Matrix 24-2. This examiner found no contraction of a visual field, but found loss of the left superior half of visual field and the inferior/nasal quadrant of left visual field. The Veteran did not have a scotoma. She was not legally blind based on visual field loss. The Veteran had optic neuropathy, but not nystagmus. Her visual impairment was attributed to her severe optic atrophy in the left eye. She did not have any scarring or disfigurement attributable to any eye condition. In the prior twelve months she did not have any incapacitating episodes attributable to any eye condition. This disability impacted her ability to work in that it made it difficult for her to navigate her environment and it was challenging for her to spot things on the left side of her visual field. The May 2019 visual field perimeter chart showed loss of visual field as described below: Meridian Normal Right Eye Left Eye Up 45 45 0 Up temporally 55 55 0 Temporally 85 85 70 Down temporally 85 85 70 Down 65 65 55 Down nasally 50 50 0 Nasally 60 60 0 Up nasally 55 55 0 Total: 500 500 195 Average Concentric Contraction 62.5 62.5 24.375 Based on the above, prior to April 6, 2021, the Veteran's left eye atrophy manifested as concentric contraction of visual field in the left eye with remaining visual field of no less than 8 degrees. As the Veteran was not service connected for a right eye disability, this is rated as a unilateral impairment of visual field and warrants the current 20 percent rating. See 38 C.F.R. § 4.79, DC 6080. The Board has considered whether a higher rating is available based on the loss of nasal and inferior halves of her left eye visual field noted in the March 2015 DBQ. Unilateral loss of nasal and inferior halves of visual field each warrant a 10 percent rating under DC 6080. See 38 C.F.R. § 4.79. Therefore, these findings do not provide a basis for a higher rating. The Veteran had no other visual impairment during this period as her corrected visual acuity was consistently 20/40 or better, and she had no impairment of muscle function. Similarly, she had no incapacitating episodes due to her eye disability. Thus, prior to April 6, 2021, the Veteran's left eye atrophy did not warrant a disability rating higher than the current 20 percent, and, therefore, her appeal is denied. 2. A rating higher than higher than a 30 percent evaluation for bilateral glaucoma with left eye atrophy from April 6, 2021, to October 11, 2021 As noted in the introduction, the Veteran was granted service connection for bilateral glaucoma effective April 6, 2021. The April 6, 2021, eye conditions DBQ shows a diagnosis of bilateral primary open angle glaucoma. The Veteran's eye symptoms included poor peripheral vision and pallor in the left eye. Her uncorrected distance visual acuity was 20/100 bilaterally, both corrected to 20/40. Her uncorrected near visual acuity was 20/40 bilaterally, corrected to 20/20 or better. Her pupils were equal, round, and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss or light perception only of either eye. She was able to recognize test letters at one foot or closer and to perceive objects, hand movements, or count fingers at three feet. She did not have legal blindness based on corrected visual acuity of 20/200 or less in the better eye. She did not have a corneal irregularity that resulted in severe irregular astigmatism. She did not have diplopia. Slit lamp and external eye exam were normal bilaterally. An internal eye exam found left optic atrophy. An internal eye exam found pallor in the left optic disc. She had a documented visual field defect, but visual field testing was not performed. This examiner noted possible generalized constriction of left eye visual field, but visual field testing was needed to perform a full assessment. The Veteran did not have a scotoma. She was not legally blind based on visual field loss. She had bilateral open angle glaucoma that required continuous medication for treatment. Her visual impairment was attributed to her glaucoma. She did not have any scarring or disfigurement attributable to any eye condition. In the prior twelve months she did not have any incapacitating episodes attributable to any eye condition. This disability did not impact her ability to work. During this period, from April 6, 2021, to October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy manifested as an unspecified concentric contraction of visual field in the left eye. The current 30 percent rating reflects unilateral concentric contraction of visual field to no more than 5 degrees. See 38 C.F.R. § 4.79, DC 6080. This exceeds the required minimum rating for glaucoma that requires continuous medication for control. See 38 C.F.R. § 4.79, DC 6013. The Veteran had no other visual impairment during this period as her corrected visual acuity was consistently 20/40 or better, and she had no impairment of muscle function. Similarly, she had no incapacitating episodes due to her eye disability. Thus, from April 6, 2021, to October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy did not warrant a disability rating higher than the current 30 percent, and, therefore, her appeal is denied. 3. A rating higher than 40 percent evaluation for bilateral glaucoma with left eye atrophy as of October 11, 2021 The October 11, 2021, eye conditions DBQ notes diagnose of open angle glaucoma and left eye optic atrophy. She treated her eye disability with eye drops. Her uncorrected distance visual acuity was 20/100 in the right eye and 20/200 in the left eye, both corrected to 20/20 or better. Her uncorrected near visual acuity was 20/70 in the right eye and 20/100 in the left eye, corrected to 20/20 or better in the right eye and 20/200 in the left eye. Her pupils were equal, round, and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. She did not have a corneal irregularity that resulted in severe irregular astigmatism. She did not have diplopia. Slit lamp and external eye exam were normal bilaterally. An internal eye exam found left optic atrophy. The Veteran had a documented visual field defect with loss of visual field as described below: Meridian Normal Right Eye Left Eye Up 45 40 5 Up temporally 55 50 20 Temporally 85 70 10 Down temporally 85 60 10 Down 65 55 10 Down nasally 50 50 10 Nasally 60 60 0 Up nasally 55 60 5 Total: 500 445 70 Average Concentric Contraction 62.5 55.625 8.75 The Veteran did not have loss of a visual field or a scotoma. She was not legally blind based on visual field loss. She had bilateral open angle glaucoma that required continuous medication for treatment, but was not responsible for visual impairment. Her visual impairment was attributed to her optic atrophy of the left eye. She did not have any scarring or disfigurement attributable to any eye condition. In the prior twelve months she did not have any incapacitating episodes attributable to any eye condition. This impacted her ability to work in that she was limited to driving no more than ten or fifteen minutes. She had headaches and eye strain due to decreased peripheral vision and overall quality. Her almost complete loss of peripheral vision in the left eye significantly limited the Veteran in many circumstances, as well as, decreasing depth perception. As of October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy manifested as concentric contraction of visual field to no less than 56 degrees in the right eye and no less than 9 degrees in the left eye. When the average concentric contraction of eyes in asymmetric, visual acuity equivalents are assigned. Here, the 56 degrees of concentric contraction in the right eye is equal to 20/50 and the 9 degrees of concentric contraction in the left eye is equal to 20/200. 38 C.F.R. § 4.79, DC 6080. When the worse eye is 20/200 and the better eye is 20/50, a 30 percent rating is warranted. 38 C.F.R. § 4.79, DC 6066. Again, this exceeds the required minimum rating for glaucoma that requires continuous medication for control. See 38 C.F.R. § 4.79, DC 6013. The Veteran's best corrected distance vision is 20/20 or better bilaterally. Confusingly, her corrected left eye near vision is recorded as worse than her uncorrected left eye near vision. The examiner did not indicate that the difference in corrected visual acuity for distance and near vision was equal to two or more lines on the Snellen test type chart, which further suggests that the 20/200 noted for corrected left eye near vision is incorrect. Nevertheless, the Board will accept the record as written and will evaluate based on corrected distance vision adjusted to one step poorer than measured. 38 C.F.R. § 4.76(b)(3). Thus, the Veteran's left eye visual acuity is treated as 20/50. When the worse eye is 20/50 and the better eye is 20/20, a 10 percent rating is warranted. 38 C.F.R. § 4.79, DC 6066. The 30 percent for impairment of visual field is then combined with the 10 percent for visual impairment under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.77 (c). This results in a 37 percent rating, which is rounded up to 40 percent. The Veteran has no impairment of muscle function and no incapacitating episodes due to her eye disability. Thus, from October 11, 2021, the Veteran's bilateral glaucoma with left eye atrophy did not warrant a disability rating higher than the current 40 percent, and, therefore, her appeal is denied. REASONS FOR REMAND 1. Service connection for Rathke's cleft cyst, claimed as a brain tumor, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for Rathke's cleft cyst because, while the October 2021 VA examiner found that this was a congenital deformity/defect, the record does not include an opinion as to whether this was aggravated by her active duty military service, to include the May 1997 incident when she struck her head on a forklift. Generally, service connection is not available for congenital defects unless there is a uperimposed disease or injury that occurred during service and resulted in additional disability. In this case, an opinion is needed to determine if the May 1997 injury is such a superimposed injury resulting in additional disability. Alternately, if this condition is determined to be a congenital disease instead, the examiner must determine whether there is clear and unmistakable evidence that this condition preexisted service and was not aggravated by service. 2. A total disability rating based on individual unemployability (TDIU) prior to August 8, 2014, is remanded. Finally, because a decision on the remanded issue of service connection for Rathke's cleft cyst could significantly impact a decision on the issue of TDIU prior to August 8, 2014, the issues are inextricably intertwined. A remand of the claim for TDIU prior to August 8, 2014, is required. The matters are REMANDED for the following action: 4. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's Rathke's cleft cyst. Specifically, this examiner should address the following: (a.) Rathke's cleft cyst is described as a congenital deformity. Please clarify whether it is a congenital defect, a congenital disease, or a disorder not of congenital/developmental origin. The examiner should note that a disease generally refers to condition that is considered capable of improving or deteriorating while a defect is generally not considered capable of improving or deteriorating (b.) If Rathke's cleft cyst that is determined to be a congenital defect, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that there was a superimposed disease or injury that occurred during service, to include the May 1997 head injury, and resulted in additional disability and explain the basis for the opinion. (c.) If Rathke's cleft cyst is determined to be a congenital or developmental disease, opine as to whether there is clear and unmistakable (undebatable) evidence that the disorder both (i) preexisted the Veteran's entry into active service, and (ii) did NOT undergo an increase in severity beyond the natural scope of the disability during the Veteran's active service and explain the basis for the opinion. (d.) If Rathke's cleft cyst is not congenital and/or did not preexist service, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder had its onset during active service or is otherwise related to active service and explain the basis for the opinion. 5. Finally, readjudicate the claim on appeal. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.