Citation Nr: 1237403 Decision Date: 11/01/12 Archive Date: 11/09/12 DOCKET NO. 06-10 109 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a right leg neurological disability, to include as secondary to a spinal disability. 2. Entitlement to service connection for a bilateral arm neurological disability, to include as secondary to a spinal disability. 3. Entitlement to service connection for a bilateral elbow disability, to include as secondary to a spinal disability. 4. Entitlement to service connection for a bilateral knee disability, to include as secondary to a spinal disability. 5. Entitlement to service connection for a right foot disability, to include as secondary to a spinal disability. 6. Entitlement to service connection for a left shoulder disability, to include as secondary to a spinal disability. 7. Entitlement to service connection for a headache disability, to include as secondary to a spinal disability. 8. Entitlement to service connection for a urinary disability, to include as secondary to a spinal disability. 9. Entitlement to service connection for sexual dysfunction, to include as secondary to a spinal disability. 10. Entitlement to service connection for hemorrhoids. 11. Entitlement to service connection for memory loss. 12. Entitlement to service connection for a bilateral hand disability. 13. Entitlement to service connection for a left ankle disability. 14. Entitlement to service connection for urolithiasis. 15. Entitlement to service connection for a skin disability, claimed as chronic urticaria. 16. Entitlement to a rating in excess of 20 percent for chronic cervical spine strain with degenerative disc disease. 17. Entitlement to a rating in excess of 10 percent for chronic lumbar spine strain with degenerative disc disease, prior to April 16, 2009, and in excess of 20 percent as of April 16, 2009. 18. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from February 1992 to July 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office in Seattle, Washington (RO). The issues of entitlement to service connection for (1) an allergy disability, to include as secondary to a spinal disability; (2) hypertension, to include as secondary to a spinal disability; (3) anal dysfunction, to include as secondary to a spinal disability; (4) throat spasms; and (5) a stomach disability, claimed as H. pylori, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over those issues, and they are referred to the AOJ for appropriate action. The issues of (1) entitlement to service connection for a bilateral hand disability; (2) entitlement to service connection for a left ankle disability; (3) entitlement to service connection for urolithiasis; (4) entitlement to service connection for a skin disability, claimed as chronic urticaria; and (5) entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability are REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The medical evidence of record shows that, throughout the entire period on appeal, the Veteran's lumbosacral spine disability was manifested by pain, bilateral radiculopathy, and limitation of motion that was analogous to flexion greater than 30 degrees but not greater than 60 degrees. 2. The medical evidence of record shows that the Veteran's cervical spine disability is manifested by pain and limitation of motion that was analogous to, at worst, forward flexion greater than greater than 15 degrees but not greater than 30 degrees. 3. The preponderance of the evidence is against a finding that a diagnosis of any bilateral arm neurological disability is warranted. 4. The preponderance of the evidence is against a finding that a diagnosis of a bilateral elbow disability is warranted. 5. The preponderance of the evidence is against a finding that a diagnosis of a bilateral knee disability is warranted. 6. The preponderance of the evidence is against a finding that a diagnosis of a right foot disability is warranted. 7. The preponderance of the evidence is against a finding that a diagnosis of a urinary disability is warranted. 8. The preponderance of the evidence is against a finding that a diagnosis of sexual dysfunction is warranted. 9. The preponderance of the evidence is against a finding that a diagnosis of hemorrhoids is warranted. 10. The preponderance of the evidence is against a finding that a diagnosis of memory loss is warranted. 11. The preponderance of the evidence is against a finding that any diagnosed left shoulder disability is related to service. 12. The preponderance of the evidence is against a finding that any diagnosed headache disability is related to service. CONCLUSIONS OF LAW 1. The criteria for a rating of 20 percent, but not higher, for a lumbosacral spine disability have been met throughout the entire period on appeal. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 2. The criteria for a separate rating for right leg neurologic manifestations of the Veteran's service-connected lumbosacral spine disability have been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5243 (2012). 3. The criteria for a rating in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 4. A bilateral arm neurological disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 5. A bilateral elbow disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 6. A bilateral knee disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 7. A right foot disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 8. A urinary disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 9. Sexual dysfunction was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 10. Hemorrhoids were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 11. Memory loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 12. A left shoulder disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 13. A headache disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in January 2005, June 2005, September 2005, January 2006, March 2006, July 2006, August 2006, and January 2009. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statements of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the back and neck increased rating claims, to include neurological testing of all related disabilities, and to evaluate the Veteran's employability. The evidence of record shows that the Veteran last received a neurological examination in January 2009 and a spinal examination in March 2006. There is evidence of record that suggests that the Veteran's low back and neck disabilities may have increased in severity since that time. However, the Veteran was scheduled for a new VA spine examination in April 2011, but refused the examination. The Veteran has not demonstrated good cause for his refusal to attend the examination. Accordingly, the Veteran's claims will be adjudicated based on the evidence of record. 38 C.F.R. § 3.655 (2012). The Board emphasizes that the duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). In a June 2012 hearing before the Board, the Veteran stated that that he wanted a non-VA medical examination because he did not trust VA. The Board notes that independent medical opinions are warranted in claims that involve medical complexity or controversy. 38 C.F.R. § 3.328 (2012). In this case, there is no such medical complexity or controversy. The Veteran seeks a private medical examination because he disagrees with multiple VA findings that there are no objective manifestations, or diagnoses, for some of his complaints. Such personal disagreement with otherwise undisputed medical opinions is not sufficient to result in a finding of medical complexity or controversy in this case. Therefore, the Board finds that a remand to provide the Veteran with an independent medical opinion is not warranted. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). In resolving the factual issue, the Board may only consider the specific factors enumerated in the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by a service connected disability or (b) aggravated by a service connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether the requirements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999). Initially, the Board notes that the Veteran is a pharmacist and, therefore, has more medical knowledge than the average lay person. As with any lay person, the Board finds the Veteran's statements to be competent to report observable symptomatology, and provide etiological evidence that relies on such observable symptomatology. Davidson v. Shinseki, 581 F.3d 1313 (2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). In addition, due to the Veteran's professional background, the Board finds that the Veteran is also competent to provide medical evidence regarding the use and side-effects of medication. However, the Board finds that the Veteran is not competent to provide diagnoses and etiological opinions that require any information other than observable symptomatology. While the Veteran is a pharmacist, that profession has a limited medical focus which does not include diagnosis or treatment. Accordingly, his medical background does give his statements any greater weight than other lay persons in those areas. Or, at the very least, his medical opinion would be accorded less weight than those of a trained medical professional such as a medical doctor. The Board finds that the Veteran's lay statements regarding diagnosis and etiology of any disability are not competent in the absence of corroborating medical evidence, and that his statements are not credible, even to whatever extent they are competent. The Veteran's statements regarding his symptoms have become increasingly vague, conflicting, and confusing over time. The Veteran currently claims that VA is actively discriminating against him and that there is some scheme in place to prevent VA physicians from giving diagnoses to his various reported symptoms. The Board finds those claims inherently incredible. Therefore, the Board finds that the Veteran's diagnostic and etiological statements for all disabilities on appeal are incredible except where they are corroborated or otherwise substantiated by the medical evidence of record. General Fact Pattern In an October 2003 private medical report, the Veteran complained of bilateral low back pain, greater on the left than the right, and ranging from mild to marked in intensity. On examination, the Veteran stood without difficulty and did not have any guarding. There was moderate hypertonicity, bilaterally, with mild to moderate tenderness of the lumbar paraspinal area. Straight leg raise testing was negative for radicular pain. The examiner stated that the normal range of motion of the lumbar spine was to 60 degrees of flexion, 25 degrees of extension, 25 degrees of right lateral flexion, and 25 degrees of left lateral flexion. Using that base measurement, the Veteran had lumbar spine range of motion to 52 degrees of flexion, 4 degrees of extension, 14 degrees of right lateral flexion, and 12 degrees of left lateral flexion. On radiographic examination, the Veteran had a reduced spinal angle, there were degenerative changes seen from L1 to L3, and there was a 6 millimeter right leg deficiency. The impression was chronic lumbar strain/sprain and lumbar segmental dysfunction. Multiple subsequent private medical reports dated in October 2003 and November 2003 noted pain and similar symptoms, but without measurement of the Veteran's spinal range of motion. An October 2003 private medical report dated 11 days after the first report included a range of motion examination, using the same normal range of motion standards as listed previously. On that examination, the Veteran had lumbar spine range of motion to 56 degrees of flexion, 26 degrees of extension, 22 degrees of right lateral flexion, and 20 degrees of left lateral flexion. On the final November 2003 private medical report, the Veteran's lumbar spine range of motion was described as mildly limited. In a March 2004 VA spine examination report, the Veteran complained of back and neck pain, ranging from two to eight on a scale from one to ten. He reported that sitting and standing for long periods aggravated his back pain. The Veteran reported experiencing additional loss of range of motion during flare-ups, but denied associated symptoms including weight loss, fever, malaise, dizziness, visual disturbances, numbness, weakness, bladder complaints, bowel complaints, and erectile dysfunction. The Veteran also denied unsteadiness, falls, incoordination, radicular symptoms in the upper or lower extremities, and incapacitating episodes in the previous 12 months. On physical examination, the Veteran's back had normal architecture without evidence of increased kyphosis or scoliosis, though there was loss of normal lordosis. The range of motion of the lumbar spine was to 70 degrees of flexion, with pain; 40 degrees of extension, without pain; 30 degrees of rotation, bilaterally, with pain; and 30 degrees of lateral flexion, bilaterally, without pain. The range of motion of the Veteran's cervical spine was to 20 degrees of extension, with pain; 50 degrees of flexion, with pain; 55 degrees of right rotation, without pain; 50 degrees of left rotation, without pain; and 35 degrees of lateral flexion, bilaterally, without pain. The pain on range of motion testing was at a level of three on a scale from one to ten. There was no pain on repetitive motion, as well as no spasms, weakness, tenderness, or objective evidence of painful motion. No neurological, muscular, or reflex abnormalities were noted. X-ray examination found degenerative changes at C5-6, L3-4, L2-3, and L1-2, and minimal facet degeneration in the lower lumbar spine. The assessment was chronic cervical and lumbar strains imposed upon degenerative disc disease. The examiner stated that the Veteran had a fairly small degree of loss of motion on examination of the cervical spine, with no objective signs of tenderness or pain. The examiner characterized the Veteran's cervical and lumbar degenerative disc disease as mild in severity, and estimated that flare-ups and repetitive use would result in an additional loss of 10 to 15 percent of the range of motion in the cervical and lumbar spines, but with no neurological deficits or gait disturbance. In a November 2004 private medical report, the Veteran complained of back pain for years which had increased over the previous few weeks. The Veteran denied any bowel or bladder symptoms. He reported that he worked 12 hour shifts as a pharmacist and that his back began to bother him after 8 hours. On examination, the Veteran had 90 percent of a normal back range of motion, with tenderness noted at L4-5 and the bilateral sacroiliac joints. The Veteran was advised to limit his work to 8 hour shifts. In a January 2005 VA spine examination report, the Veteran reported an increase in symptomatology, with neck and back problems from prolonged sitting or standing. He also reported flare-ups with repetitive lifting and carrying or with neck rotation, resulting in increased pain which he treated with medication. The Veteran denied using assistive devices, or experiencing numbness, tingling, tremors, or weakness in the upper extremities. He reported experiencing right leg pain, but no numbness, tingling, or loss of sensation. The Veteran reported that he had no limitations in walking or standing, though he experienced stiffness. He reported having a very limited range of motion, which increased in severity with daily flare-ups. The Veteran denied experiencing incapacitating episodes, swelling, deformity, discoloration, bowel dysfunction, and bladder dysfunction. On objective examination, the Veteran had a normal gait. Straight leg raise testing was positive on the right, and all movement of the right leg against resistance caused pain in the outside of the right quadriceps. No strength or reflex abnormalities were noted. The range of motion of the lumbar spine was to 80 degrees of flexion, with mild pain on return; 60 degrees of left rotation; 40 degrees of right rotation, with pain; and 20 degrees of lateral flexion, bilaterally. There was tenderness of the lumbar spine in the L1 to L4 region, but no swelling, deformity, or discoloration. Sensation was intact from hip to toe. No upper extremity abnormalities were noted. The range of motion of the Veteran's cervical spine was to 25 degrees of extension; 30 degrees of flexion; 30 degrees of rotation, bilaterally; and 20 degrees of lateral flexion, bilaterally. There was pain on all motions of the cervical spine. Hyperextension of the lumbar spine caused pain down the right leg. The assessment was cervical and lumbosacral strain both superimposed on degenerative disc disease confirmed by x-rays. The examiner stated that the Veteran had right leg radiculopathy which had been confirmed with positive straight leg tests. However the Veteran was sent for an electromyograph (EMG) examination to confirm the diagnosis, due to the absence of sensation and strength abnormalities. The examiner opined that the Veteran had lost between 20 and 40 percent of his range of motion, strength, coordination, and fatigability in his right leg and lumbar spine. The examiner further stated that during a flare-up the Veteran would be expected to lose an additional five percent of motion in both his cervical and lumbar spine. It was reported that the disabilities had resulted in the loss of four days of work in November, but without incapacitating episodes. In a February 2005 VA outpatient medical report, the Veteran complained of chronic right front thigh numbness and radiating pain from his right hip and lower back. On physical examination, straight leg raise testing was positive on the right for anterior thigh, hip, and lower back pain. The assessment was chronic lower back pain with chronic and persistent right lower extremity radiculopathy. In an April 2006 VA spine examination report, the Veteran complained of sciatica in both legs secondary to his back disability. He reported daily pain and stiffness, with a reduced range of motion and intermittent right leg muscle twitching. He stated that repetitive motion increased his back pain, with pain radiating into both legs to the knees. He denied experiencing numbness and had not been prescribed bed rest for any incapacitating episodes in the previous year. The Veteran reported that he was not working due to his chronic back pain. On physical examination, the Veteran had normal thoracolumbar spine architecture without muscle spasm. There was mild pain on movement which increased with repetitive movement, but did not cause additional loss of range of motion. The Veteran had a lumbar spine range of motion to 40 degrees of flexion; 5 degrees of hyperextension; 20 degrees of lateral flexion, bilaterally; and 20 degrees of rotation, bilaterally. There was pain at all of the end points of motion. No reflex, motor, or sensory abnormalities were noted. The examiner opined that flare-ups would not be expected to result in additional motion loss, fatigue, or incoordination. The examiner stated that the Veteran's radicular symptoms were consistent with magnetic resonance imaging (MRI) findings of his disease and, therefore, that his lower extremity radiculopathy was at least as likely as not related to his service-connected lumbar spine disability. The examiner stated that the Veteran could work as a pharmacist as long as he avoided heavy lifting and was able to move about at will and not be stationary for long periods of time. In an October 2006 VA outpatient medical report, the Veteran complained of chronic left shoulder and low back pain. He reported experiencing pain radiating from his neck to his shoulder and down his arm over the previous six months. The Veteran reported that he had stopped working in March 2005 due to the severity of the symptoms. After physical examination, the assessment was chronic shoulder pain with severe limitation of range of motion. The Veteran's cervical range of motion was fairly good and essentially pain free. The report stated that the Veteran had difficulty understanding that he had a problem in his shoulder joint, and that his symptoms were primarily related to his shoulder problem. In a March 2007 VA outpatient medical report, the Veteran complained of chronic neck pain which radiated down the left arm, and low back pain which radiated around the front of the thighs. After physical examination, the assessments were neck pain, low back pain, and right shoulder rotator cuff tendonitis. In an April 2007 VA outpatient medical report, the Veteran complained of chronic neck and back pain. On examination, the Veteran's lumbar range of motion was within normal limits, with no symptom reproduction with movement. The assessment was a chronic history of neck and back pain. In an April 2009 VA neurological examination report, the Veteran complained of leg cramping, with pain and tingling radiating into both legs. He reported difficulty with balance and stated that he used a cane for assistance with standing. The Veteran also reported difficulty with prolonged standing or sitting for greater than five to ten minutes. He also reported that ten minutes of yard work required hours of rest, and being able to lift approximately five to ten pounds without back symptoms. The Veteran reported that repetitive bending and twisting caused flare-ups in pain, which he stated resulted in lower extremity weakness. He reported that he treated the symptoms with rest, lying down, and using a back brace and a cane. On examination, the Veteran had a mild kyphotic posture. There was tenderness to palpation at the L3-S1 area and the paraspinal muscles, erector spine, and quadrates lumborum muscles, bilaterally. There was also tenderness of the bilateral sacroiliac joints, bilateral gluteus maximus, and sciatic notch. The Veteran had lumbar spine range of motion to 0 degrees of extension; 40 degrees of flexion; 15 degrees of lateral flexion, bilaterally; and 25 degrees of rotation, bilaterally. On repetitive motion, there was increased pain but no change in the Veteran's range of motion. On neurologic examination, there was weakness with function, particularly with heel and toe walking and squatting. The Veteran lost his balance when squatting. Sensation was intact throughout T12-S2, but the Veteran reported a duller sensation at the bottom of his feet, without a specific dermatome distribution noted. The diagnosis was lower extremity radiculopathy associated with chronic lumbar strain with degenerative disc disease. The examiner opined that the Veteran would not experience additional loss of range of motion, but he would continue to have moderate weakness, fatigability, and loss of coordination with repetitive activities and flare-ups. The examiner was uncertain as to whether the Veteran would be able to perform the duties of a pharmacist, as it demanded prolonged standing. The examiner opined that the Veteran may have been able to do part time sedentary work that allowed a frequent change of position. On EMG testing, there was no evidence of lumbosacral radiculopathy on either side. In a December 2009 private emergency record, the Veteran reported that he had experienced a sudden jolt of back pain which had caused him to fall. On neurological examination, no abnormalities of the extremities were noted. In a January 2010 VA outpatient medical report, the Veteran complained of left arm numbness that he believed was related to cervical spine disease. He also reported difficulty with urinary and fecal incontinence. The Veteran declined therapeutic injections and laboratory testing because he hated needles. The assessment was chronic cervical and lumbar spine pain. The Veteran was referred for neurosurgery consultation. In a February 2010 VA neurosurgery consultation report, the Veteran complained of chronic neck pain and headaches for many years. He reported that in approximately 2006 he experienced a sharp burning pain in his left arm, and was then unable to move the left arm at the shoulder for approximately one year, though it got better with some physical therapy. He reported the same thing happened to his right side in 2007 and also took a long time to go away. The Veteran also reported constant spasm-type pain in his neck that radiated into the shoulders and down the arms, with associated swelling of the sweat glands under his arms. He also reported constant numbness and tingling in his arms, with occasional weakness resulting in falling. On examination, the Veteran's neck range of motion was "not bad when he looks around the clinic" but it was limited when he was asked to do motions. There was tenderness throughout the upper extremities. Motor strength was reduced in the arms, and there was tenderness of the wrist bones. The impression was chronic pain in unusual distributions in the upper extremities and anterior chest wall. The examiner recommend that the Veteran be seen by a neurologist, as his falling episodes and other pain complaints did not fit the normal spinal distribution. In a March 2010 VA neurology consultation report, the Veteran had numerous complaints and it was difficult for the examiner to know what was bothering him the most. The examiner noted that the Veteran was a very tangential historian. The Veteran complained of pain all over his arms and legs for the previous five years, and from the top of his head to his toes on both sides, with pain mostly in the joints. He also reported a history of pain in the lumbar region that radiated into the right thigh and left leg, though he stated that those pains had not recurred for at least the previous year. The Veteran also reported bladder problems, including hesitancy, intermittency, and stream stops and starts, but denied urinary incontinence. He reported experiencing fecal urgency but no fecal incontinence. On examination, the Veteran moved "excessively slowly to command" but more easily when moving spontaneously. No neurological, motor, coordination, sensory, or reflex abnormalities were noted. After a review of diagnostic testing, the diagnosis was chronic pain syndrome, without evidence of a primarily neurologic disability, either central or peripheral, such as polyneuropathy. The examiner stated that the Veteran may have had a somatoform disorder and that a mental health consultation might assist, though the Veteran was convinced he had organic physical problems and might resist help for his anxiety. The report also gave a diagnosis of history of remote lumbar radicular symptoms without findings of active neurologic compromise on examination. A March 2010 VA outpatient medical report noted that the Veteran had been told that his symptoms were not related to autonomic problems and that he had no neurological deficits. However, the Veteran persisted in talking about his perceived bladder and gland problems and believed that his urinary and erectile issues were both related to his back disability. The examiner stated that there was no evidence of such a relationship. The examiner stated that the Veteran had odd health beliefs, got his medical information from the internet, and it was difficult to interpret what he was requesting or what his symptoms were. The assessment was vague symptoms, no treatment. In an April 2010 VA neurology note, the Veteran complained of back pain with radiation into his lower extremities. He reported that in 2006 he began experiencing erectile dysfunction, urinary abnormalities, difficulty controlling bowel movements, headaches, and sweating. The Veteran also reported having throat spasms which were brought on by leaning forward, chest pain, regurgitation, and decreased perspiration in his axillae. He reported that his headaches were in his temples, but also radiated from his neck. The Veteran reported experiencing intermittent paresthesias and pain in his arms, legs, and feet, with swelling and pain in his ankles. On examination, no neurological, motor, reflex, or sensory abnormalities were noted. After a review of diagnostic testing, the diagnosis was tension headaches. The examiner stated that no other neurological diagnosis was found, despite the Veteran's multifocal pain complaints and other symptoms. It was suspected that the Veteran had a chronic pain syndrome, similar to fibromyalgia, and depression. The examiner stated that there was no evidence of spinal cord or nerve root impingement on MRI or EMG examination. As is apparent from the above fact pattern, the Veteran's health complaints began as relatively common complaints which were specifically related to his service-connected neck and back disabilities, but over time grew to encompass a myriad of symptoms. As documented in both the medical evidence and the June 2012 hearing before the Board, the Veteran's statements regarding his symptoms have become increasingly vague, conflicting, and confusing over time. It is extremely difficult for the Board to determine on what basis the Veteran claims his various symptoms are related to service. It appears that he claims that all physical abnormalities he experiences are related to service, though without any specific etiological claim being made for many of them. Accordingly, the Board shall address the clearest issues on appeal first, namely the increased rating claims, including related disabilities which are specifically claimed as being separate manifestations of those service-connected disabilities. The Board shall then move on to those disabilities for which the Veteran has not clearly stated his beliefs as to any claimed relationship to service. Lumbar Spine Service connection for chronic lumbar spine strain with degenerative disc disease was granted by an April 2004 rating decision and a 10 percent rating was assigned, effective September 3, 2003, under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Subsequently, an April 2011 rating decision assigned a 20 percent rating, effective April 16, 2009, under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases or Injuries of the Spine (General Rating Formula), effective September 26, 2003, 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, the combined range of motion of the cervical spine not greater than 170 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 with favorable ankylosis of the thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula (2012). The medical evidence of record shows that, throughout the entire period on appeal, the Veteran's lumbosacral spine disability was manifested by pain, bilateral radiculopathy, and limitation of motion that was analogous to flexion greater than 30 degrees but not greater than 60 degrees. Initially, the Board notes that the range of motion measurements listed in the October 2003 and November 2003 private medical reports are of very low probative value. The reports specifically stated that the examiner considered the normal range of motion of the lumbar spine was to 60 degrees of flexion, 25 degrees of extension, 25 degrees of right lateral flexion, and 25 degrees of left lateral flexion. However, for VA purposes, the normal range of motion of the thoracolumbar spine is to 90 degrees of flexion, 30 degrees of extension, 30 degrees of right lateral flexion, and 30 degrees of left lateral flexion. 38 C.F.R. § 4.71a, Plate V (2012). Accordingly, the October 2003 and November 2003 private medical reports provide measurements based on an entirely different form of range of motion evaluation than that used by VA to determine ratings for spine disabilities. The "normal" range of motion listed in the October 2003 and November 2003 private medical reports would warrant a 20 percent disability rating under VA criteria. 38 C.F.R. § 4.71a, General Rating Formula (2012). Therefore, the Board shall disregard the range of motion measurements listed in the October 2003 and November 2003 private medical reports, as they cannot be translated into VA rating criteria with any form of reliability. The first probative range of motion examination of record is that found in the March 2004 VA spine examination report. That report found that the Veteran had 70 degrees of flexion, with pain. However, the examiner also specifically stated that that flare-ups and repetitive use would result in an additional loss of 10 to 15 percent of the range of motion in the lumbar spine. An additional loss of 10 to 15 percent of lumbar flexion equates to an additional loss of 9 to 13.5 degrees of flexion. 38 C.F.R. § 4.71a, Plate V (2012). Subtracting those numbers from the 70 degrees of flexion measured results in a range of motion of approximately 56.5 to 61 degrees. Accordingly, the Board finds that the March 2004 VA spine examination report demonstrated that the Veteran met the criteria for a 20 percent rating at that time. 38 C.F.R. § 4.7 (2012). In addition, while the Veteran's range of motion was reported to be well in excess of 60 degrees in January 2005, even including additional loss of motion during flare-ups, the Veteran was reported to be restricted to 40 degrees of flexion in both April 2006 and April 2009. Accordingly, the Board finds that the preponderance of the evidence of record shows that the Veteran's lumbar spine disability warrants a 20 percent rating throughout the entire period on appeal. As the Veteran's disability involves restricted articulation of a joint, the Board must also address the provisions regarding limitation of function due to pain, weakness, incoordination, excess motion, and fatigability. 38 C.F.R. §§ 4.40, 4.45 (2012). DeLuca v. Brown, 8 Vet. App. 202 (1995). However, as there is no indication in the record that the Veteran experienced any limitation of motion of the lumbar spine due to pain, weakness, or incoordination, that has resulted in disability that is analogous to limitation of forward flexion of the thoracolumbar spine to 30 degrees or less. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted at any point during the period on appeal. The Board has also considered the Veteran's lumbar spine disability under the criteria for intervertebral disc syndrome. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). The Board finds that the preponderance of the evidence of record does not show that the Veteran required bed rest prescribed by a physician at any point during the period on appeal, and during no 12 month period is he shown to have required bed rest prescribed by a physician for four weeks or more. The Board notes that the Veteran has reported that he treated his back symptoms with rest. However, there is no evidence that this treatment was prescribed by a physician. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted at any point during the period on appeal due to incapacitating episodes. The evidence also shows ranges of motion and no ankylosis of any part of the spine. The Board must also determine whether an increased rating can be assigned for the Veteran's lumbosacral spine disability by providing separate ratings for the chronic orthopedic and neurologic manifestations of the disability. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1) (2012). The medical evidence of record includes diagnoses of left and right leg radiculopathy which are related to his service-connected lumbosacral spine disability. However, service connection is already in effect for left leg radiculopathy and the Veteran did not perfect an appeal as to the rating assigned for that disability. Accordingly, the Board does not have jurisdiction to review the rating assigned for the Veteran's left leg radiculopathy. 38 C.F.R. § 20.200 (2012). However, the medical evidence of record is also replete with complaints and diagnoses of right leg radiculopathy. The January 2005 VA spine examination report stated that the Veteran had right leg radiculopathy which had been confirmed with positive straight leg tests. The February 2005 VA outpatient medical report gave an assessment of chronic lower back pain with chronic and persistent right lower extremity radiculopathy. The April 2006 VA spine examination report stated that the Veteran's radicular symptoms were consistent with MRI findings of his disease and, therefore, that his lower extremity radiculopathy was at least as likely as not related to his service-connected lumbar spine disability. The April 2009 VA neurological examination report gave a diagnosis of lower extremity radiculopathy associated with chronic lumbar strain with degenerative disc disease. Following the April 2009 report, EMG testing showed no evidence of lumbosacral radiculopathy on either side, and the medical evidence dated after this time repeatedly stated that the Veteran did not have lower extremity radiculopathy. However, the Board emphasizes that right leg radiculopathy was specifically diagnosed on multiple occasions, including diagnoses which were based on positive straight leg raise testing and MRI examination. Accordingly, resolving reasonable doubt in favor of the claimant, the Board finds that a separate rating is warranted for the Veteran's right leg radiculopathy symptoms. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that the Veteran has also reported experiencing urinary and bowel abnormalities on various occasions. However, there is no medical evidence of record that any urinary or bowel disability that the Veteran experiences is a neurological manifestation of his service-connected lumbar spine disability. Accordingly, a separate rating for those symptoms is not warranted. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's lumbosacral spine symptoms, the evidence shows distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 20 percent is needed to adequately compensate the disability. 38 U.S.C.A. § 5110 (West 2002); Hart v. Mansfield, 21 Vet. App. 505 (2007). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for a lumbosacral spine disability inadequate. The Veteran's lumbosacral spine disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. Throughout the entire period on appeal, the Veteran's lumbosacral spine disability was manifested by pain, bilateral radiculopathy, and limitation of motion that was analogous to flexion greater than 30 degrees but not greater than 60 degrees. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disabilities rating assigned for his lumbosacral spine disability. Ratings in excess of the rating assigned herein are provided for certain manifestations of spine disabilities, but the medical evidence shows that those manifestations are not present. The criteria for the rating assigned herein for the Veteran's lumbosacral spine disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012) In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's lumbosacral spine disability does not meet the criteria for ratings in excess of those assigned herein. Therefore, the claim for increased ratings beyond those assigned herein is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Cervical Spine Service connection for chronic cervical spine strain with degenerative disc disease was granted by an April 2004 rating decision and a 10 percent rating was assigned, effective September 3, 2003, under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Subsequently, an August 2005 rating decision amended the effective date for the 10 percent rating to August 1, 2002, and assigned a 20 percent rating, effective December 21, 2004, under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases or Injuries of the Spine (General Rating Formula), a 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, General Rating Formula (2012). The medical evidence of record shows that the Veteran's cervical spine disability is manifested by pain and limitation of motion that was analogous to, at worst, forward flexion greater than 15 degrees but not greater than 30 degrees. The March 2004 VA spine examination report found that the Veteran had 50 degrees of flexion, with pain. As with the Veteran's lumbar spine disability, the examiner also specifically stated that that flare-ups and repetitive use would result in an additional loss of 10 to 15 percent of the range of motion in the cervical spine. An additional loss of 10 to 15 percent of cervical forward flexion equates to an additional loss of 4.5 to 6.75 degrees of forward flexion. 38 C.F.R. § 4.71a, Plate V (2012). Subtracting these numbers from the 50 degrees of forward flexion measured results in a range of motion of approximately 43 to 45.5 degrees. Those findings do not meet the criteria for a 20 percent rating, let alone a 30 percent rating. Similarly, the January 2005 VA spine examination report found that the Veteran had 30 degrees of flexion, with pain, and an additional loss of 5 percent of the range of motion on flare-ups. Those findings equate to a total limitation of motion of approximately 27 degrees. The only other relevant medical evidence of record which comments on the Veteran's cervical spine range of motion are an October 2006 report, which found that the cervical range of motion was fairly good and essentially pain free, and a February 2010 report which found that the Veteran's neck range of motion was "not bad when he looks around the clinic" but it was limited when he was asked to do motions. Accordingly, the Board finds that the Veteran's cervical spine disability has never been manifested by symptoms which are analogous to a 30 percent rating. As the Veteran's disability involves restricted articulation of a joint, the Board must also address the provisions regarding limitation of function due to pain, weakness, incoordination, excess motion, and fatigability. 38 C.F.R. §§ 4.40, 4.45 (2012). DeLuca v. Brown, 8 Vet. App. 202 (1995). However, as there is no indication in the record that the Veteran experienced any limitation of motion of the cervical spine due to pain, weakness, or incoordination, that has resulted in disability that is analogous to limitation of forward flexion of the cervical spine to 15 degrees or less. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted at any point during the period on appeal. The evidence also shows ranges of motion and no ankylosis of any part of the spine. The preponderance of the evidence of record also does not show that the Veteran required bed rest prescribed by a physician for his cervical spine disability at any point, let alone for at least four weeks during any 12 month period. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted at any point due to incapacitating episodes. The Board must also determine whether an increased rating can be assigned for the Veteran's cervical spine disability by providing separate ratings for the chronic orthopedic and neurologic manifestations of the disability. 38 C.F.R. § 4.71a, Diagnostic Code 5242, Note (1) (2012). The medical evidence of record shows that the Veteran has repeatedly complained of upper extremity radiculopathy related to his cervical spine disability. However, there is no medical evidence of record that any neurological manifestations of the Veteran's cervical spine disability have ever been diagnosed. VA outpatient medical reports dated in October 2006 and March 2007 both stated that the Veteran's reported arm pain were related to shoulder disabilities, not his cervical spine disability. In addition, the February 2010 VA neurosurgery consultation report stated that the Veteran's pain complaints did not fit the normal spinal distribution. There medical evidence is against a finding that the Veteran experiences any neurological manifestations of his service-connected cervical spine disability. Accordingly, a separate rating for neurological manifestations of his cervical spine disability is not warranted. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's cervical spine symptoms, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 20 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for a cervical spine disability inadequate. The Veteran's cervical spine disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's cervical spine disability was manifested by pain and limitation of motion that was analogous to, at worst, forward flexion greater than greater than 15 degrees but not greater than 30 degrees. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disabilities rating assigned for his cervical spine disability. A rating in excess of the currently assigned rating is provided for certain manifestations of spine disabilities, but the medical evidence reflects that those manifestations are not present in this case. The criteria for a 20 percent rating for the Veteran's cervical spine disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's cervical spine disability does not meet the criteria for a rating in excess of 20 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Other Disabilities The Veteran claims service connection for numerous other disabilities. Those include a bilateral arm neurological disability, a bilateral elbow disability, a bilateral knee disability, right foot disability, a left shoulder disability, a headache disability, a urinary disability, sexual dysfunction, hemorrhoids, and memory loss. Some of those disabilities are specifically claimed to be secondary to his service-connected spinal disabilities, while his claims regarding the etiology of the others is unclear. To the extent that the Veteran claims that any of the disabilities are related to his service-connected spinal disabilities, the preponderance of the evidence of record shows that the Veteran does not have any disabilities which are secondary to his cervical and lumbar spine disabilities other than bilateral lower extremity radiculopathy. The Veteran's numerous complaints of bodily pain and other symptoms have been specifically found by neurological examinations to be unrelated to his spinal disabilities. As there is no medical evidence of record that any of these claimed disabilities are related to the Veteran's service-connected spinal disabilities, the Board finds that service connection is not warranted on a secondary basis for those disabilities. With respect to the Veteran's claims regarding the bilateral arm neurological disability, bilateral elbow disability, bilateral knee disability, right foot disability, urinary disability, sexual dysfunction, hemorrhoids, and memory loss, there is no medical evidence of record that provides a diagnosis for any of the claimed disabilities. The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). In this case there is no competent and credible evidence of record that the Veteran has a current diagnosis of a bilateral arm neurological disability, bilateral elbow disability, bilateral knee disability, right foot disability, urinary disability, sexual dysfunction, hemorrhoids, or memory loss. Therefore, the Board finds that service connection is not warranted for the disabilities. With respect to the Veteran's claims regarding the left shoulder and headache disabilities, the medical evidence of record includes relevant diagnoses for both of those disabilities. Specifically, an October 2006 VA outpatient medical report gave an assessment of was chronic shoulder pain with severe limitation of range of motion. While that assessment does not provide a specific diagnosis beyond pain, the examiner stated that the Veteran had a problem in his shoulder joint. In addition, an April 2010 VA neurology note gave a diagnosis of tension headaches. However, the Veteran's service medical records are negative for any diagnosis of a left shoulder or headache disability, and there is no medical evidence of record which relates either of those disabilities to service. In addition, there is no medical evidence of record that a left shoulder disability was diagnosed prior to October 2006, over four years after separation from service, or that a headache disability was diagnosed prior to April 2010, approximately eight years after separation from service. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354 (1991). Accordingly, the Board finds that the competent and credible evidence of record is against that any currently diagnosed left shoulder or headache disability is related to service. The Board finds that the preponderance of the competent evidence is against the Veteran's claims for service connection for a bilateral arm neurological disability, a bilateral elbow disability, a bilateral knee disability, right foot disability, a left shoulder disability, a headache disability, a urinary disability, sexual dysfunction, hemorrhoids, and memory loss. Therefore, the claims are denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for right leg neurologic manifestations of the lumbosacral spine disability is granted. Service connection for a bilateral arm neurological disability is denied. Service connection for a bilateral elbow disability is denied. Service connection for a bilateral knee disability is denied. Service connection for a right foot disability is denied. Service connection for a urinary disability is denied. Service connection for sexual dysfunction is denied. Service connection for hemorrhoids is denied. Service connection for memory loss is denied. Service connection for a left shoulder disability is denied. Service connection for a headache disability is denied. An initial rating of 20 percent, but not higher, for a lumbosacral spine disability is granted. A rating of 20 percent for a cervical spine disability is denied. REMAND With respect to the claims of entitlement to service connection for a bilateral hand disability, a left ankle disability, urolithiasis, and a skin disability, claimed as chronic urticaria, the Veteran's service medical records include complaints or diagnoses related to each of those disabilities. In August 1996 and September 1996 service medical reports, the Veteran stated that his left hand had been bothering him due to having to open many medication bottles. No specific diagnosis was give, but tenderness of the left hand was found on observation. Multiple service medical reports dated from December 1995 to March 1997 show that the Veteran was treated for chronic urticaria. A February 1999 service medical report stated that the Veteran complained of left ankle pain after injuring it. No specific diagnosis was given, but tenderness of the left ankle was found on observation. A November 2001 service medical report gave an assessment of presumed urolithiasis, now resolved. The Veteran complains of current symptoms related to all four of those disabilities. There is no medical evidence of record which opines on whether any currently diagnosed bilateral hand disability, left ankle disability, urolithiasis, or skin disability are related to the Veteran's service. Therefore, the Board finds that a medical examination is needed to determine the nature and etiology of any currently diagnosed bilateral hand disability, left ankle disability, urolithiasis, and skin disability. 38 C.F.R. § 3.159(c)(4) (2012) The Veteran also seeks entitlement to TDIU due to service-connected disabilities. Entitlement to TDIU is warranted if the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2012). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). The claim for TDIU has been previously denied as the Veteran did not meet the percentage criteria. However, the issues covering entitlement to service connection for a bilateral hand disability, left ankle disability, urolithiasis, and skin disability have been remanded for further development. And service connection has been granted for a right leg neurologic disability. Depending on whether some of the service connection claims are granted by the RO while on remand, the Veteran may meet the criteria for entitlement to TDIU. Accordingly, the TDIU claim is inextricably intertwined with these other issues and must be remanded, pending the readjudication of the other claims on appeal. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination with a medical doctor to ascertain the nature and etiology of any bilateral hand disability, left ankle disability, urolithiasis, and skin disability found. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, and the Veteran's reported history, the examiner must provide an opinion as to whether any bilateral hand disability, left ankle disability, urolithiasis, and skin disability found is at least as likely as not (50 percent or greater probability) related to the Veteran's period of service or to any service-connected disability. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed bilateral hand disability, left ankle disability, urolithiasis, and skin disability is due to or aggravated by any service-connected disability. If any bilateral hand disability, left ankle disability, urolithiasis, or skin disability found is attributable to factors unrelated to the Veteran's service or a service-connected disability, the examiner should specifically so state. A complete rationale for all opinions must be provided. 2. Notify the Veteran that it is his responsibility to report for any VA examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the Veteran of any scheduled VA examination must be placed in the claims file. 3. After the above actions have been completed, readjudicate the claim of entitlement to TDIU. If the Veteran does not meet the rating criteria under 38 C.F.R. § 4.16(a), but his service-connected disabilities prevent him from securing or following a substantially gainful occupation, refer the appeal to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of entitlement to TDIU pursuant to 38 C.F.R. § 4.16(b). 4. Then, readjudicate the other remaining issues on appeal. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs