SPINAL STENOSIS

JONATHAN B. KRAMER · 2026 · Case ID: A26015438

GRANTED

Summary

The veteran, who served from April 1996 to September 1998, appeals the denial of an increased rating for his service-connected spinal stenosis. The Board reviewed the evidence of record, including VA treatment records, VA examination reports from June 2014 and March 2020, and private physical therapy records. The June 2014 VA exam noted pain on motion and mild left lower extremity sciatic radiculopathy, with functional impact described for strenuous activities. The March 2020 VA exam noted pain significantly limited functional ability with repetitive use, but the examiner's explanation for not performing passive range of motion testing was unclear, rendering the examination partially inadequate. However, the objective measurements and reports of symptoms were considered probative. The Board found that the June 2014 exam's objective evidence of pain at 60 degrees of flexion met the criteria for a 20 percent rating. Although subsequent evidence did not show this level of flexion limitation, the Board considered the ongoing complaints of pain, functional loss, and the examiner's finding of significant functional limitation due to pain. Resolving all reasonable doubt in the veteran's favor, the Board granted a 20 percent rating for spinal stenosis throughout the appeal period. A higher rating was not warranted as the record did not show ankylosis or IVDS, nor did it approximate the functional equivalent of ankylosis.

Rationale

June 2014 VA exam noted pain on motion at 60 degrees flexion and mild left sciatic radiculopathy.; March 2020 VA exam noted pain significantly limited functional ability, though passive range of motion testing was not fully completed.; Board resolved reasonable doubt in veteran's favor, granting 20% rating based on pain and functional loss.

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5238

Docket No.

200923-114094

Full Decision Text

Citation Nr: A26015438
Decision Date: 02/19/26 Archive Date: 02/19/26

DOCKET NO. 200923-114094
DATE: February 19, 2026

ORDER

A 20 percent rating, but no higher, for spinal stenosis is granted.

FINDINGS OF FACT

1. The Veteran served on active duty from April 1996 to September 1998.

2. The lumbar spine disability is manifested by complaints of chronic pain and difficulty with sitting, standing, walking and lifting; objective findings include forward flexion, at worst, to 60 degrees, with combined range of motion greater than 120 degrees and no evidence of ankylosis or intervertebral disc syndrome (IVDS).

CONCLUSION OF LAW

The criteria for a 20 percent rating, but no higher, for spinal stenosis have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code (DC) 5237 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

This decision has been written under the guidelines of the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). In July 2020, the agency of original jurisdiction (AOJ) issued a June 2020 decision which granted service connection and assigned a 10 percent rating for spinal stenosis, effective from October 23, 2013.

In September 2020, the Veteran appealed to the Board via a Form 10182 and elected the Hearing docket. In May 2024, the Veteran withdrew the hearing request.

Therefore, the Board may only consider the evidence of record at the time of the decision on appeal, as well as any evidence submitted by the Veteran within 90 days following receipt of the withdrawal of the hearing request. 38 C.F.R. § 20.302(b).

Notably, although the appeal did not specify whether the disagreement was with the effective date, the rating, or both; in August 2024 correspondence the Veteran's attorney clarified that the Veteran was seeking an increased evaluation.

Turning to the relevant laws and regulations, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4.

Lumbosacral spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, DCs 5237-5243. IVDS (DC 5243) is rated under the General Rating Formula or the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25.

When evaluating joint disabilities rated on the basis of limitation of motion, VA must also consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995).

The Veteran's low back disability has been rated at 10 percent under DC 5238 for spinal stenosis. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. The Board will consider all relevant diagnostic codes. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following:

· forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent);

· combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent);

· muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent);

· incapacitating episodes of IVDS
were revised effective February 7, 2021, this diagnostic code was not changed. The Board will consider all relevant diagnostic codes. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following:

· forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent);

· combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent);

· muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent);

· incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent);

· or, in the absence of limitation of motion, degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent).

For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See 38 C.F.R. § 4.71a, Plate V.

The amended regulations clarify that DC 5243 is to be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. No other changes were made to the rating criteria for the spine.

Turning to the evidence, VA treatment records show the Veteran has been prescribed medications, including hydrocodone, gabapentin, methocarbamol, naproxen and diclofenac for treatment of his back pain. These records do not indicate the level of pain relief experienced by the Veteran due to such medications.

A June 2014 VA examination report shows the Veteran reported having constant back pain with intermittent pain that radiates down the left leg. He also reported flare-ups when he is limited with all activity.

Initial range of motion testing was flexion to 80 degrees with evidence of painful motion at 60 degrees. Extension and bilateral lateral flexion and rotation were each to 30 degrees or greater with evidence of painful motion at 20 degrees. The Veteran was able to perform repetitive use testing with forward flexion to 80 degrees and extension and bilateral lateral flexion and rotation to 30 degrees or greater. Contributory factors to functional loss and/or impairment were less movement than normal and pain on movement.

The Veteran complained of tenderness with palpation of the lower spine with no muscle spasm or guarding of the thoracolumbar spine. Muscle strength was 5/5 (normal), there was no muscle atrophy, reflexes were normal (2+) and sensory examination was normal. The examiner noted positive left straight leg testing and mild left lower extremity sciatic radiculopathy. There was no ankylosis or other neurologic abnormalities, including IVDS.

The functional impact was described as activities such as lifting heavy loads, digging ditches, and working in the mines would be impacted by the low back disability.

During a July 2015 hearing before a Decision Review Officer (DRO) in connection with the claim for service connection, the Veteran described his current back disability as back pain which always radiates down the left leg and sometimes down the right (usually just the left).

A June 2017 VA examination report for housebound status or permanent need for aid and assistance shows, with respect to the spine and trunk, the Veteran reported difficulty lifting more than 35-40 pounds, being unable to lift and twist, and having difficulty sitting, standing and walking for long periods.

Private treatment records include a November 2017 report of evaluation for physical therapy. On examination, lower extremity strength was normal on the right and 4/5 on the left. Lumbar flexion and extension was WNL (within normal limits). It was noted that the Veteran ambulated with a cane if he knows he would walk long periods, just to have extra balance if symptoms flare up.

A March 2020 VA examination report shows the Veteran reported back pain had gotten worse and his current symptoms were constant aching pain that is aggravated by prolonged standing/sitting and lifting. He also reported severe flare-ups lasting 3-4 days which are precipitated by prolonged standing/sitting and lifting and alleviated with heat, ice and rest. The Veteran described his functional loss as being unable to do the job as a construction worker because of strenuous activity. Initial range of motion testing was flexion to 70 degrees and 30 degrees of extension and bilateral lateral flexion and rotation. Pain was noted on examination (moderate thoracic and severe lumbar) but did not result in functional loss. There was no additional functional loss after three repetitions. Although the examiner noted pain significantly limited functional ability with repetitive use over time, the described range of motion findings were the same as those reported on initial range of motion testing. The examiner also noted the examination was being conducted during a flare-up, with no change in range of motion findings. There was no guarding or muscle spasm of the thoracolumbar spine, muscle strength was normal, and there was no muscle atrophy. Reflex and sensory examinations were normal and bilateral straight leg raising test was negative. There was no ankylosis or IVDS. The Veteran made constant use of brace and occasionally used a cane, when his sciatica flares up. The functional impact of the Veteran's low back disability was no sitting or standing for mor than 30 minutes and no lifting over 30 pounds. The examiner explained that passive range of motion testing was not performed because "it was not medically appropriate because mechanical limitations of examiner." It was also noted that there was objective evidence of pain on non-weight bearing testing of the back.

In August 2024 correspondence, it is noted by the Veteran's attorney that the March 2020 examiner "failed and neglected to conduct any passive range of motion testing on the basis that the examiner deemed it was not appropriate, without providing an explanation as to why, and further stated that testing could not be performed on account of the 'mechanical limitations of [the] examiner'." It is argued the inability of the examiner to provide a comprehensive examination renders the examination inadequate.

The Board has considered the deficiencies in the March 2020 examination report. The unclear explanation as to why passive range of motion testing was not medically appropriate for the Veteran to perform as well as the finding that pain significantly limited functional ability, but no finding or description as to when objective evidence of painful motion began.

However, although these deficiencies in providing a complete examination render the examination partially inadequate, the objective measurements and documentation of the Veteran's reports of his symptoms are entitled to some probative value. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (noting that medical reports "must be read as a whole" in determinations of adequacy).

Based on the above, the Board finds that a 20 percent rating for spinal stenosis is warranted. The June 2014 VA examination report notes objective evidence of pain at 60 degrees of flexion, which falls within the criteria for a 20 percent rating. Although subsequent clinical evidence does not show limitation of lumbar flexion to 60 degrees or less, the evidence continues to show findings of limitation of motion, the Veteran's complaints of pain and functional loss, and VA examination findings that pain significantly limited functional ability.

In this regard, VA is required "to discount beneficial medication effects when relevant rating criteria do not specifically contemplate medication use." See Ingram v. Collins, 38 Vet. App. 130 (2025). Here, the beneficial effects of medication are not known and thus the Board has considered it in the adjudication of this matter, resolving all reasonable in the Veteran's favor. Thus, a 20 percent rating for spinal stenosis throughout the appeal period is warranted.

A rating in excess of 20 percent is not warranted at any time during the appeal. While treatment records document ongoing back pain, the record does not otherwise show forward flexion of the thoracolumbar spine to 30 degrees or less, ankylosis, or IVDS.

Moreover, the record does not otherwise reflect that the Veteran's lumbar spine is fixed, even when flare-ups and repeated use are considered. Therefore, ankylosis or its functional equivalent has not been
medication are not known and thus the Board has considered it in the adjudication of this matter, resolving all reasonable in the Veteran's favor. Thus, a 20 percent rating for spinal stenosis throughout the appeal period is warranted.

Moreover, the record does not otherwise reflect that the Veteran's lumbar spine is fixed, even when flare-ups and repeated use are considered. Therefore, ankylosis or its functional equivalent has not been more nearly approximated. See Chavis v. McDonough, 34 Vet. App. 1 (2021). Accordingly, a rating in excess of 20 percent is not warranted.

The Board recognizes the Veteran is competent to provide opinions on certain subjective medical issues and of observable symptomatology (and these competent assertions have been considered in awarding the increased 20 percent rating). However, any opinion regarding whether the Veteran's low back symptoms have worsened to a certain severity requires medical expertise that the Veteran has not demonstrated (or claimed to have).

The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

[SIGNATURE ON NEXT PAGE]

JONATHAN B. KRAMER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K Hughes, 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.

Analyze in VA Law Explorer