Citation Nr: 0003523 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 97-17 456A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a disability rating higher than 10 percent for post-operative left inguinal hernia repair times three with nerve entrapment, on appeal from the initial grant of service connection. 2. Entitlement to a disability rating higher than 10 percent prior to March 17, 1999, for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, on appeal from the initial grant of service connection. 3. Entitlement to a disability rating higher than 20 percent from March 17, 1999, for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, on appeal from the initial grant of service connection. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD M. L. Kane, Associate Counsel INTRODUCTION The veteran had more than 25 years of active military service, and his last period of service was from September 1985 to March 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which, in pertinent part, granted service connection for post-operative left inguinal hernia, with assignment of a 10 percent disability rating, and granted service connection for residuals of neck injury, with assignment of a zero percent disability rating. After the veteran perfected his appeal, a May 1998 rating decision assigned a 10 percent disability rating for the veteran's cervical spine disorder effective the day following his separation from service (April 1, 1996). An April 1999 decision by the local Hearing Officer then assigned a 20 percent disability rating for the veteran's cervical spine disorder effective March 17, 1999. This was not a full grant of the benefit sought on appeal because a higher disability rating is available under Diagnostic Code 5293. On a claim for an original or an increased rating, the claimant is generally presumed to be seeking the maximum benefit allowed by law and regulation, and such a claim remains in appellate status where a subsequent rating decision awarded a higher rating, but less than the maximum available benefit. AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, this issue remains before the Board. Since the 20 percent rating was effective from March 17, 1999, the issues on appeal have been rephrased as shown above. In October 1999, a videoconference hearing was held before the undersigned, who is the Board member making this decision and who was designated by the Chairman to conduct that hearing pursuant to 38 U.S.C.A. § 7107(c) (West Supp. 1999). FINDINGS OF FACT 1. The veteran's claims are plausible, and the RO has obtained sufficient evidence for correct disposition of these claims. 2. Since the left inguinal hernia repair performed in March 1993, the veteran has had no recurrences of a left hernia. 3. The veteran's post-operative left inguinal hernia requires the internal support of a mesh and use of a belt when engaging in physical activity and adversely affects the veteran's physical abilities. 4. The veteran is currently receiving the maximum schedular disability rating for impairment of the ilioinguinal nerve. 5. Prior to March 17, 1999, the veteran's cervical spine condition resulted in no objective evidence of disability or functional limitations. 6. Since March 17, 1999, the veteran's cervical spine condition has been manifested by evidence of pain with range of motion, resulting in no more than a moderate level of functional loss. CONCLUSIONS OF LAW 1. The veteran's claims for higher disability ratings for his post-operative left inguinal hernia and residuals of neck injury are well grounded, and VA has satisfied its duty to assist him in developing facts pertinent to these claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). 2. The criteria for assignment of a separate disability rating of 10 percent, and no higher, for post-operative left inguinal hernia repair times three were met as of the grant of service connection. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.25, 4.27, and 4.114, Diagnostic Code 7338 (1999). 3. The criteria for an evaluation higher than 10 percent for left ilioinguinal nerve impairment have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.27, 4.123, 4.124, and 4.124a, Diagnostic Codes 8530, 8630, and 8730 (1999). 4. The criteria for a disability rating higher than 10 percent for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, were not met prior to March 17, 1999. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, and 4.71a, Diagnostic Code 5293 (1999). 5. The criteria for a disability rating higher than 20 percent for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, have not been met since March 17, 1999. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.40, 4.45, and 4.71a, Diagnostic Code 5293 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). The veteran perfected his appeal as to the initial grants of service connection and original assignment of disability ratings for his left hernia and cervical spine disorders. Therefore, his claims continue to be well grounded as long as the rating schedule provides a higher rating for the service- connected conditions. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). VA has a duty to assist the veteran in the development of facts pertinent to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999). The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a well-grounded claim for an increase, but the medical evidence is not adequate for rating purposes, an examination will be authorized. 38 C.F.R. § 3.326(a) (1999). Reexamination will be requested whenever VA determines that there is a need to verify either the continued existence or the current severity of a disability. 38 C.F.R. § 3.327(a) (1999). Generally, reexaminations are required if it is likely that a disability has improved, if the evidence indicates that there has been a material change in a disability, or if the current rating may be incorrect. Id. In this case, the RO provided the veteran appropriate VA examinations. There is no evidence indicating that there has been a material change in the severity of either of his service-connected conditions since he was examined in 1999, and sufficient evidence is of record to rate the service- connected disabilities properly. The veteran has stated that he receives private treatment at Morganton Family Practice. The RO requested these records in August 1998, but no response was received. In October 1998, the RO informed the veteran of the failure to obtain these records, and he was given an opportunity to obtain the records himself and submit them to the RO. He did not do so. Accordingly, in the circumstances of this case, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78 (1990); Littke v. Derwinski, 1 Vet. App. 90 (1990). The veteran has disagreed with the original disability ratings assigned for his left hernia and cervical spine disorders. There is a distinction between a claim based on disagreement with the original rating awarded and a claim for an increased rating. Fenderson v. West, 12 Vet. App. 119 (1999). The distinction may be important in determining the evidence that can be used to decide whether the original rating on appeal was erroneous and in determining whether the veteran has been provided an appropriate Statement of the Case (SOC). Id. at 126 and 132. With an initial rating, the RO can assign separate disability ratings for separate periods of time based on the facts found. Id. at 126. With an increased rating claim, "the present level of disability is of primary importance." Francisco v. Brown, 7 Vet. App. 55, 58 (1994). This distinction between disagreement with the original rating awarded and a claim for an increased rating is important in terms of VA adjudicative actions. Fenderson, 12 Vet. App. at 132. The Supplemental Statements of the Case (SSOCs) provided to the veteran identified the issues on appeal as evaluation of the service-connected left hernia and cervical spine disorders. Throughout the course of this appeal, the RO has evaluated all the evidence of record in determining the proper evaluation for the veteran's service-connected disabilities. The August 1996 rating decision that granted service connection for these conditions considered all the evidence of record in assigning the original disability ratings. The RO did not limit its consideration to only the recent medical evidence of record, and did not therefore violate the principle of Fenderson. The veteran has been provided appropriate notice of the pertinent laws and regulations and has had his claims of disagreement with the original ratings properly considered based on all the evidence of record. The RO complied with the substantive tenets of Fenderson in its adjudication of the veteran's claims. Disability ratings are intended to compensate reductions in earning capacity as a result of the specific disorder. The ratings are intended, as far as practicably can be determined, to compensate the average impairment of earning capacity resulting from such disorder in civilian occupations. 38 U.S.C.A. § 1155 (West 1991). Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2 (1999). Because this appeal is from the initial rating assigned to a disability upon awarding service connection, the entire body of evidence is for equal consideration. Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (where an increased rating is at issue, the present level of the disability is the primary concern). Such staged ratings are not subject to the provisions of 38 C.F.R. § 3.105(e), which generally requires notice and a delay in implementation when there is proposed a reduction in evaluation that would result in reduction of compensation benefits being paid. Fenderson, 12 Vet. App. at 126. The Board will consider all evidence in determining the appropriate evaluation for the veteran's service-connected disabilities. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2 (1999), and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3 (1999). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. 38 C.F.R. § 4.14 (1999). The United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (Court) has held that a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that a veteran may have separate and distinct manifestations attributable to the same injury and should be compensated under different diagnostic codes. Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The Board has reviewed all the evidence of record, which consists of the veteran's service medical records, reports of VA examinations conducted in 1997 and 1999, and the veteran's testimony presented in 1998 and 1999. The pertinent evidence is discussed below. A. Left inguinal hernia During service, the veteran underwent three surgeries for a recurrent left inguinal hernia. The last surgery was performed in March 1993 and involved placement of Marlex mesh. After that surgery, the veteran's complaints included recurrent pain in the left inguinal area with mild exertion, including sexual activity and urination. Physical examinations showed no palpable hernia, but there was evidence of nerve entrapment along the left inner thigh and incision line. The veteran is evaluated under Diagnostic Code 7338-8630 at 10 percent. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (1999). The hyphenated diagnostic code in this case indicates that inguinal hernia under Diagnostic Code 7338 is the service- connected disorder, and impairment of the ilioinguinal nerve under Diagnostic Code 8630 is a residual condition. The RO assigned a 10 percent disability rating for this condition due solely to impairment of the ilioinguinal nerve. The veteran has not been assigned an evaluation for the hernia itself, although the RO has considered such a rating. If the veteran has separate and distinct manifestations attributable to the hernia under Diagnostic Code 7338, as opposed to symptomatology from the ilioinguinal nerve impairment for which he is being compensated under Diagnostic Code 8630, then he could possibly receive separate disability ratings. Disability ratings under Diagnostic Code 7338 are based on the presence and size of an inguinal hernia, as well as whether it necessitates any form of support. Disability ratings under Diagnostic Code 8630 are based on the sensory manifestations resulting from impairment of the ilioinguinal nerve. The symptomatology for an inguinal hernia appropriately rated under Diagnostic Code 7338 is not duplicative of or overlapping with the symptomatology of ilioinguinal nerve impairment appropriately rated under Diagnostic Code 8630. If there were additional disability attributable to the hernia itself, as opposed to the nerve entrapment, the veteran would be entitled to a separate disability rating. The veteran is seeking a higher rating for his service- connected left inguinal hernia disorder, and the issue of the evaluation to be assigned all manifestations of the service- connected disability is reasonably raised in the record and is inextricably intertwined with the claim for a higher rating before the Board. Accordingly, consideration will be given to whether any separate evaluations should be assigned under applicable diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994); 38 C.F.R. § 4.14 (1999). The veteran has been given notice of the laws and regulations regarding disability ratings for both an inguinal hernia and ilioinguinal nerve impairment and has had an opportunity to submit evidence and argument related to this issue. Therefore, the Board's action is not prejudicial to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Also, the following decision does not prejudice the veteran because, for the reasons and bases indicated below, the decision is favorable to him. The veteran is already receiving the maximum evaluation under the applicable diagnostic criteria for impairment of the ilioinguinal nerve. Diagnostic Code 8530 provides a zero percent disability rating for mild or moderate paralysis of the ilioinguinal nerve and a 10 percent disability rating for severe to complete paralysis of the ilioinguinal nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8530 (1999). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves (1999). Diagnostic Code 8630 refers to neuritis involving the ilioinguinal nerve. Neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, and is rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (1999). Diagnostic Code 8730 refers to neuralgia involving the ilioinguinal nerve. Neuralgia is characterized by dull and intermittent pain, of typical distribution so as to identify the nerve, and is also rated on the same scale provided for injury of the nerve involved, with a maximum equal to moderate, incomplete, paralysis. 38 C.F.R. § 4.124 (1999). The Secretary establishes disability ratings that are intended to compensate a veteran for average impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155 (West 1991). In this case, the veteran's entrapment of the left ilioinguinal nerve from the various hernia surgeries has resulted in decreased sensation in the left inguinal area, the medial aspect of the thigh, the lateral aspect of the scrotal area, and the area supplied by the ilioinguinal nerve; subjective complaints of tingling, numbness, and tenderness; and pain that is, at times, severe. This symptomatology has been assigned the maximum schedular rating of 10 percent. Regardless of whether the veteran's symptoms are classified as paralysis of the ilioinguinal nerve, or neuritis or neuralgia of the ilioinguinal nerve, the maximum available schedular rating is 10 percent. The 10 percent disability rating encompasses a level of compensation for persistent symptoms due to disorders of the ilioinguinal nerve and for any impairment in earning capacity due to the residual symptoms. There is a lack of entitlement to a higher schedular evaluation. Under Diagnostic Code 7338, a noncompensable (zero percent) disability rating requires either: (1) a small, reducible inguinal hernia, or an inguinal hernia without true hernia protrusion; or (2) an inguinal hernia that has not been operated on, but is remediable. A 10 percent disability rating is warranted where the evidence shows a post-operative recurrent inguinal hernia that is readily reducible and well supported by truss or belt. A 30 percent disability rating requires either: (1) a small, post-operative recurrent inguinal hernia that is not well supported by truss or not readily reducible; or (2) an unoperated, irremediable inguinal hernia that is not well supported by truss or not readily reducible. A 60 percent disability rating requires a large post-operative hernia that is recurrent, not well supported under ordinary conditions, and not readily reducible, when it is considered inoperable. 38 C.F.R. § 4.114, Diagnostic Code 7338 (1999). The service medical records from 1993 to 1996 and the post- service medical evidence do not show that the veteran's left inguinal hernia has recurred since the last surgery in 1993. Every physical examination since 1993 has shown no palpable bulging. Therefore, the veteran's left inguinal hernia, although certainly "recurrent" during service, has not been "recurrent" at any time since service. The veteran does not use a truss or belt to support his hernia because he does not have a hernia at this time. However, the Board concludes that the evidence shows disability that more nearly approximates that which warrants the assignment of a 10 percent disability rating. See 38 C.F.R. § 4.7 (1999). Although the veteran does not wear a truss or belt for support of an identifiable hernia, he does have a mesh device for internal support. Also, he testified that he has to wear a belt for support when lifting at work and often has to have assistance in lifting objects. In addition to the nerve-related pain, he has also consistently complained of pressure and pain with activities such as urination, bowel movements, and sexual activity. Although such complaints are not indicative of impairment of earning capacity as required by the rating schedule, the veteran has also testified that he has to monitor his physical activity and movements, particularly in his job as a clerk at a grocery store. He referred to his daily activities as "guarded." Although not precisely consistent with the diagnostic criteria, the residuals of the veteran's left inguinal hernia are clearly disabling to him to some degree, and a 10 percent disability rating is warranted. The impairment resulting from the veteran's service-connected post-operative left inguinal hernia more nearly approximates the impairment that would result if he currently had a post-operative hernia that was readily reducible and well supported by a truss or belt. In assigning this rating, the Board has resolved all reasonable doubt regarding the level of the veteran's disability in his favor. Accordingly, a separate 10 percent rating is granted, to be combined with the rating for ilioinguinal nerve impairment under 38 C.F.R. § 4.25. B. Cervical spine disorder The RO received the veteran's claim for service connection within the year following his separation from service, and service connection for this condition was awarded as of April 1, 1996, the day following his separation from service. See 38 C.F.R. § 3.400(b)(2)(i) (1999) (effective date of an award of disability benefits will be the day following separation from active service if claim is received within one year after separation from service). The veteran was initially assigned a zero percent disability rating for this condition, but it was increased to 10 percent in 1998 with an effective date of April 1, 1996. In 1999, he was awarded a 20 percent disability rating for this condition, with an effective date of March 17, 1999, which was the date of VA physical examination. As the veteran has perfected his appeal from the initial assignment of a disability rating for his cervical spine disorder, the Board will address whether he was entitled to a disability rating higher than 10 percent prior to March 17, 1999, as well as whether he is entitled to a disability rating higher than 20 percent from March 17, 1999. During service, the veteran incurred a neck injury while playing sports. His symptoms of pain and weakness in the left arm were consistent with a herniated disc at C6-7. In July 1986, he underwent anterior cervical diskectomy and fusion of the cervical spine. The service medical records showed an excellent post-operative recovery. The veteran is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5293. His service-connected disorder is residuals of a neck injury, including post-operative cervical diskectomy and fusion, which does not have a specific diagnostic code. When a veteran is diagnosed with an unlisted disease, it must be rated under an analogous diagnostic code. 38 C.F.R. §§ 4.20 and 4.27 (1999). Therefore, his cervical spine condition is rated as analogous to intervertebral disc syndrome under Diagnostic Code 5293. In evaluating this claim, the Board must consider whether a higher disability evaluation is warranted on the basis of functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40 (1999). A part that becomes painful on use must be regarded as seriously disabled. Id.; see also DeLuca. As regards the joints, factors to be evaluated include more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45(f) (1999). Diagnostic Code 5293 for intervertebral disc syndrome involves loss of range of motion because the nerve defects and resulting pain associated with injury to the affected nerve may cause limitation of motion of the cervical, thoracic, or lumbar vertebrae. VAOPGCPREC 36-97. Therefore, 38 C.F.R. §§ 4.40 and 4.45 must be considered. Under Diagnostic Code 5293, a 10 percent disability rating is provided for mild intervertebral disc syndrome, a 20 percent disability rating is provided for moderate intervertebral disc syndrome with recurring attacks, and a 40 percent disability rating is provided for severe intervertebral disc syndrome with recurring attacks and intermittent relief. A 60 percent disability rating is warranted for symptoms analogous to pronounced intervertebral disc syndrome with little intermittent relief and persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (1999). 1. Rating prior to March 17, 1999 The RO granted a 10 percent disability rating for the veteran's neck condition from April 1996 to March 1999. The only objective evidence regarding the severity of the veteran's neck disorder between his separation from service in 1996 and the assignment of a 20 percent disability rating as of March 17, 1999, is the report of the VA examination conducted in December 1997. Upon examination in December 1997, the veteran complained of pain radiating from the neck into the left upper extremity, which occurred, at most, once a month. He had not sought any treatment for his neck disorder since service. Examination of the cervical spine showed no deformity. Flexion of the cervical spine was normal, with the ability to touch the chin to the chest. Extension of the cervical spine was to 10 degrees; lateral rotation was to 40 degrees bilaterally; and lateral tilt was to 15 degrees bilaterally. The examiner concluded that the veteran was objectively and functionally normal. The 10 percent disability rating assigned prior to March 1999 contemplated a mild level of symptoms. The findings in December 1997 did not show that the veteran's neck condition was any more than mildly disabling to him, and the lack of objective findings preponderates against such a conclusion. The December 1997 VA examination showed that, despite his complaints, the veteran was functionally normal. There is no objective evidence regarding the severity of the veteran's neck disorder between December 1997 and March 1999. The veteran testified in July 1998 that he performed "self- treatment" for his neck which involved placing his neck in a certain position when he had pain. He argued that he experienced pain a minimum of three times per month, which he treated with heat and ice. He indicated that he had to be careful with bodily movements. The level of disability from the service-connected neck condition was not so disabling to the veteran that he complained of it or sought treatment for it. There is no evidence from which the Board could conclude that his neck disorder was more than mild prior to March 1999, and his 1998 testimony as to his symptomatology would not support such a conclusion. There is no evidence indicating that the veteran experienced any functional loss. Prior to March 1999, he did not report inability to perform any physical activities or any increased difficulties when doing so. In fact, he testified in 1998 that he felt the symptoms of his cervical spine disorder would be present regardless of his employment in a physically demanding position. He only reported "problems" if lifting something like a case of soda out of the car. The evidence, therefore, does not show any increased functional loss or pain with use of the cervical spine. Accordingly, the 10 percent disability rating assigned during this time period for a mild level of disability was appropriate, and the preponderance of the evidence is against assignment of a disability rating higher than 10 percent for the veteran's cervical spine disorder prior to March 17, 1999. The assigned 10 percent disability rating for, at most, slight impairment of the cervical spine adequately compensated the veteran for his pain and for any increased level of functional loss and pain that he may have experienced during flare-ups. The objective medical evidence did not create a reasonable doubt regarding the level of his neck disability. Although the Board is required to consider the effect of the veteran's pain when making a rating determination, and has done so in this case, the rating schedule does not require a separate rating for pain. Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Board has considered all other potentially applicable diagnostic codes. Under Diagnostic Code 5290, for limitation of cervical spine motion, a 10 percent disability rating is warranted for slight limitation of motion, a 20 percent disability rating for moderate limitation of motion, and a 30 percent disability rating for severe limitation of motion. Limitation of motion is contemplated within Diagnostic Code 5293, and it would not be appropriate to assign separate evaluations for limitation of motion and intervertebral disc disease, because to do so would constitute evaluation of the same disability twice. 38 C.F.R. § 4.14 (1999); see VAOPGCPREC 36-97. Regardless, there is no medical evidence indicating that the veteran has any more than slight limitation of motion of the cervical spine. Diagnostic Codes 5288, 5289, 5291, 5292, 5294, and 5295 are not pertinent since they apply to dorsal or lumbar spine disabilities, and the veteran's service-connected disorder is a cervical spine disability. Therefore, these diagnostic codes do not provide the basis for assignment of a higher rating. Diagnostic Code 5285 pertains to residuals of fractured vertebrae. However, consideration of the veteran's service- connected disability under Diagnostic Code 5285 is not warranted because the medical evidence does not show that the veteran fractured any cervical vertebrae during service. Under Diagnostic Code 5287 for ankylosis of the cervical spine, a 30 percent disability rating is warranted for favorable ankylosis, and a 40 percent disability rating is warranted for unfavorable ankylosis. There is no medical evidence showing that the veteran has ankylosis of the cervical spine, as opposed to limitation of motion. He is able to move the cervical spine, so it is clearly not immobile. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (defining ankylosis as "immobility and consolidation of a joint due to disease, injury, surgical procedure") (citation omitted). Therefore, consideration of the veteran's service- connected disability under Diagnostic Code 5286 for complete ankylosis of the spine is also not warranted. Accordingly, the preponderance of the evidence is against assignment of a disability rating higher than 10 percent prior to March 17, 1999, under all potentially applicable diagnostic codes. There is no reasonable doubt on this matter that could be resolved in the veteran's favor. 2. Rating from March 17, 1999 On March 17, 1999, the veteran underwent another VA physical examination. It is clear that, as of that date, the veteran had experienced an increase in disability. During this examination, he complained of pain, weakness, and stiffness of the neck on at least a weekly basis. He indicated that his symptoms were aggravated by movement of the neck and alleviated by rest. He reported limitation of function when experiencing symptoms. The VA examination in March 1999 showed pain with motion of the cervical spine and muscle spasms. Range of cervical spine motion was flexion to 60 degrees, extension to 50 degrees, lateral flexion to 40 degrees bilaterally, and rotation to 80 degrees bilaterally. There was tenderness at C5-6. The evidence from March 1999 clearly showed that the veteran's neck condition had become more symptomatic. The examiner in 1999 noted that the veteran had pain with range of motion of the cervical spine. Based on considerations of functional loss and pain on motion, the veteran's cervical spine disability is productive of disability warranting the assigned 20 percent evaluation, but no higher. Examining the medical history of his cervical spine condition, there has clearly been worsening of his disability in terms of the severity of his complaints since he was examined in 1997. However, he has no more than a moderate level of disability. The medical evidence does not show that the veteran has any abnormal neurological findings. Despite his complaints of radiating pain, the neurological examination of the upper extremities was normal in 1999. He has full motor function and sensation in the upper extremities. He does not have any muscle atrophy, indicating that full or nearly full function remains. There are no findings indicative of a severe or pronounced cervical spine disorder, such as impairment of motor strength or neurological deficits. Therefore, a disability rating higher than 20 percent is not warranted under Diagnostic Code 5293. The Board has considered all other potentially applicable diagnostic codes, as discussed above. However, the veteran is not service-connected for residuals of a fractured cervical vertebra, and he does not have ankylosis of the cervical spine. Any limitation of motion of the cervical spine that he does have is no more than slight. Accordingly, the preponderance of the evidence is against assignment of a disability rating higher than 20 percent from March 17, 1999, under all potentially applicable diagnostic codes. There is no reasonable doubt on this matter that could be resolved in the veteran's favor. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a separate 10 percent disability rating, and no more, for the post-operative residuals of left inguinal hernia repair times three is granted, subject to the governing regulations pertaining to the payment of monetary benefits. Entitlement to a disability rating higher than 10 percent for left ilioinguinal nerve impairment is denied. Entitlement to a disability rating higher than 10 percent prior to March 17, 1999, for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, is denied. Entitlement to a disability rating higher than 20 percent from March 17, 1999, for residuals of neck injury, C6-7 herniated disc, post-operative anterior cervical diskectomy and fusion, is denied. BETTINA S. CALLAWAY Member, Board of Veterans' Appeals