Citation Nr: 1302707 Decision Date: 01/24/13 Archive Date: 01/31/13 DOCKET NO. 09-43 181 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased disability rating in excess of 20 percent for service-connected lumbar strain. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran had active service from August 1977 to October 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In June 2011, the Board remanded the claims for additional development. The case has been returned to the Board for further appellate review. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's lumbar strain is not manifested by forward flexion of the thoracolumbar spine 30 degrees or less or by any incapacitating episodes. CONCLUSION OF LAW The criteria for an increased disability rating in excess of 20 percent for lumbar strain are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5243 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Further, with regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Prior to initial adjudication of the Veteran's claim, a letter dated in April 2007 informed the Veteran of its duty to assist him in substantiating his increased rating claim and the effect of this duty upon his claim. This letter also provided notice of the type of evidence necessary to establish a disability rating or an effective date for the disability on appeal. See Dingess/Hartman, 19 Vet. App. 473. A subsequent letter dated in August 2009 further satisfied the requirements under Vazquez-Flores. Both letters addressed the type of evidence needed to show that the Veteran's lumbar spine disability disorder had worsened. The August 2009 letter also provided notice that should an increase in disability be found, a disability rating would be determined by applying relevant Diagnostic Codes based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. The Veteran was also notified of how the effective date is determined. The duty to notify has been satisfied. The Board also concludes that the duty to assist has been satisfied. VA has obtained records of relevant treatment reported by the Veteran, including service treatment records, records of VA treatment, private medical records, and records from the Social Security Administration (SSA). VA examinations were obtained in association with the Veteran's increased rating claim in July 2007 and July 2011. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nichols, 21 Vet. App. 303, 312 (2007). As directed by the June 2011 remand, the Veteran was afforded a VA examination in July 2011. The Board notes that the examination was adequate as it was predicated on a review of the claims file, as well as a physical examination, and fully addressed the rating criteria that are relevant to rating the Veteran's disability. Therefore, the Board finds that the June 2011 remand directives were substantially completed and an additional remand is not required. See Dyment v. West, 13 Vet. App. 141 (1999 (although under Stegall VA is required to comply with remand orders, substantial compliance, not absolute compliance, is required). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). There is no error or issue that precludes the Board from addressing the merits of this appeal, and there is no assertion to the contrary. LAW AND ANALYSIS Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. 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. 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; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the "present level" of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected lumbar strain is rated as 20 percent disabling under 38 C.F.R. § 4.71a, Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), a 10 percent rating requires thoracolumbar spine forward flexion greater than 60 degrees but not greater than 85 degrees; a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding 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 when forward flexion of the thoracolumbar spine is 30 degrees or less; or with favorable ankylosis of the entire 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, Diagnostic Codes 5235 to 5243 (2012). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are separately evaluated under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, at Note (1). Normal range of motion of the thoracolumbar spine is forward flexion to 90 degrees, extension from zero to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The combined range of motion refers to the sum of the forward flexion, extension, left and right lateral flexion, and left and right rotation. See 38 C.F.R. § 4.71a, General rating Formula for diseases and Injuries of the Spine, Note (2). See also Plate V. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the scheduler criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202, 206-07 (1995) (diagnostic codes that provide ratings solely based on loss of range of motion must consider functional loss and factors of joint disability attributable to pain). The Veteran filed a claim for an increased disability rating in March 2007. The VA treatment records show that the Veteran has complained of limited range of motion and pain. The Veteran was afforded a VA examination in July 2007. He reported that he had had trouble with his low back since his injury in 1981. He indicated that the pain was constant and that it was located in the lumbosacral junction in the midline. He described the pain as dull but with activities, it becomes sharp. He stated that the average pain score as an 8 out of 10 in intensity. The pain is aggravated with prolonged walking, prolonged sitting or riding in a car. Alleviating factors included the use of his pain medications. He complained of occasional numbness in both lower extremities. He did not know of any specific triggers for this numbness. It involved the inner thigh, the anterior knee and the plantar medial foot. He also complained of generalized bilateral lower extremity weakness with no localized or focal areas. He denied any radicular type pain. On physical examination, the Veteran was noticed to have a slight limp while using his cane as well as a slow gait velocity. He did not have any areas of tenderness to palpation in the midline or paraspinal musculature. He did not have any associated muscle spasms or guarding. He did not have deformity of the spine in the coronal or sagittal planes. The Veteran exhibited forward flexion to 50 degrees, limited by pain to 50 degrees. Extension was to 10 degrees, limited by pain and tightness to 10 degrees. Left and right lateral bending was to 15 degrees in each direction, limited by pain to 15 degrees. Left and right lateral rotation was to 15 degrees in each direction because of low back pain in each direction. Sensory testing revealed intact and symmetric sensation to soft touch throughout the lower limbs. There was symmetric motor tone and strength. There was generalized 4+ weakness throughout both lower extremities in all muscle groups with 4+ out of 5 toe flexion/extension, ankle flexion/extension, knee flexion/extension and hip flexion/extension, abduction/adduction. The Veteran was able to do bilateral toe and heel raises as well as squat to approximately 45 degrees in knee flexion. Repetitions of both aggravated both pain and promoted fatigue. Lower extremity reflexes revealed 2+ symmetric patellar and Achilles reflexes. There was negative straight leg raise bilaterally with posterior leg and thigh tightness, but no radicular-type pain. Babinski was negative bilaterally. He did not have any clonus on exam and no Waddell findings. With repetitive motion testing of the thoracolumbar spine, the Veteran demonstrated increasing symptoms of pain as well as fatigue and lack of endurance. He also demonstrated incoordination, needing to maintain balance on nearby objects. No weakness was appreciated. X-rays of the lumbar spine revealed disc deterioration L5-S1, spurs. The diagnosis was lumbar spine L2-S1 degenerative disc disease. The examiner noted the Veteran had findings of degenerative disc disease with limited motion and axial pain. The examiner also noted that the Veteran had some occasional numbness in the lower extremities but that these were in multiple dermatomal regions with cross-over from L2-S1. The examiner reported that the Veteran did not have any radicular symptoms by history or on examination. The Veteran was also provided with a separate VA neurological examination in July 2007. The Veteran described pain and numbness particularly in both buttocks along with numbness in the soles of both feet and the great toes bilaterally. He denied any bladder dysfunction. He claimed that increased activity significantly increased his low back pain and at times his legs will just want to give way on him. He gave no history of a specific weakness in any of the individual muscles of the lower extremities. He did not give a history consistent with dermatomal sensory low in the lower extremities or claudication symptoms. Physical examination revealed that the Veteran walked with a slow limping gait with the aid of a cane. He was able to stand on his heels and toes with support. The examiner noted that the Veteran had markedly reduced range of motion in the lumbosacral spine in all directions secondary to pain. There was normal muscle tone in all four extremities. Muscle strength was virtually 4/5 in all major muscles of the upper and lower extremities with give away secondary to pain. Sensory examination revealed that light touch was intact in all four extremities. The Veteran denied any dermatomal loss to pin in the lower extremities. Vibration sense was intact to the great toes bilaterally. The Romberg was negative. Knee jerks were 2/4, bilaterally. Ankle jerks were 2/4, bilaterally. Plantar responses were downgoing, bilaterally. Straight leg raising and cross straight leg raising was negative, bilaterally. The impression was chronic low back pain without objective evidence of radiculopathy. In a May 2011 private treatment record, it was noted that the Veteran had complaints of low back, leg and hip pain. He reported that the pain went down both of legs. The pain was described as deep and as going down into both of his calves. It was noted that the Veteran has received a diagnosis of peroneal neuropathy on electromyography (EMG). Physical examination of the lower extremities showed hip flexion, quadriceps, ankle dorsiflexion, plantar flexion and extensor hallucis longus (EHL) were all grossly intact. L3 to S1 sensation was grossly intact. Knee jerks and ankle jerks were symmetric. No clonus was present. The Veteran did exhibit some pain with some resistance of movements, but there was no clear focal neurologic deficit. It was noted that an EMG report showed no evidence of acute radiculopathy but there was some peroneal neuropathy that was seen. Following appellate review in June 2011, the Board determined that further examination was warranted. Specifically, the examiner was requested to comment as to whether the disc disease is separate from the Veteran's service-connected lumbar strain. The examiner was also requested to address whether the Veteran had experienced any incapacitating episodes. The Veteran was afforded a VA examination in July 2011. The Veteran complained of a constant dull ache in the lower lumbar area. Aggravating factors included bending, prolonged walking, sitting, sneezing or any twisting motion. The Veteran reported that there was generally no radiation of the pain but occasionally it may radiate to the left leg. He had relief with medication and as well as with resting and elevating his lower extremity. There were no incapacitating episodes of pain in the past 12 months. He reported flare-ups daily up to 2 to 3 hours a day with additional limitation of motion and functional impairment during these flare-ups. There were no associated features with the back pain, but the Veteran did have an independent complaint of subjective weakness and numbness in the bilateral lower extremities where his legs tend to give way and he has to hold onto something. Therefore, he used a cane. There was no bowel or bladder complaints or other associated symptoms. The Veteran was able to walk and transfer. He was also able to eat, groom and bathe himself and perform his toileting. The examiner noted that a recent EMG performed in March 2011 was significant for left peroneal nerve neuropathy. The examiner also noted that the Veteran had x-ray evidence of degenerative disc disease of the lumbar spine as well as MRI evidence of L5-S1 disk herniation in L1-L2, disk bulge. Physical examination revealed that Veteran walked with a help of a cane slowly and steadily. There was slight tenderness at L5-S1 on deep palpation. Forward flexion was to 50 degrees. Extension was to 10 degrees. Lateral flexion was to 15 degrees, bilaterally. Lateral rotation was to 15 degrees, bilaterally. Straight leg raising was positive on the left but not on the right. There was no motor or sensory deficit in the lower extremity and deep tendon reflexes of the lower extremities were 1 to 2+ throughout. The Veteran was unable to perform any motion beyond this range secondary to pain felt in the low back area, occasionally radiating to the left side, subjectively. The examiner noted that the Veteran did not show any worsening pain, fatigability, lack of endurance or incoordination on repetitive motor testing at lower extremity. There was no evidence of ankylosis and there were no new incapacitating episodes in the past 12 months. The assessment was lumbar strain with chronic low back pain. The examiner reported that a claims folder review, to include previously conducted examinations, indicate that the Veteran's complaints are unchanged over the years. The complaints consist of chronic low back pain with subjective radicular symptoms more recently. The examiner stated that there is an additional disability superimposed with a recently diagnosed degenerative disk disease and intervertebral disk syndrome with L5-S1 disk herniation and L1-L2 disk bulge as per MRI findings. The examiner reported that these symptoms are superimposed on the Veteran's chronic low back pain symptoms without objective findings. The examiner felt that it was impossible to differentiate between the symptoms secondary to intervertebral disk syndrome and previously diagnosed lumbar strain without resorting to mere speculation. In light of the July 2011 VA examiner's findings, the Board concludes that the evidence of record is at least in relative equipoise as to whether the Veteran's degenerative disk disease and intervertebral disk syndrome are related to his lumbar strain. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (Medical evidence is required to differentiate between symptomatology attributed to nonservice-connected disability and a service-connected disability). Therefore, the Board attributes all symptoms and limitation of function to the service-connected spine disability. Considering the evidence of record, the Board finds that the overall disability picture does not more closely approximate the criteria for a disability rating in excess of 20 percent under the rating criteria. The Board finds that the Veteran's lumbar spine disability has not resulted in forward flexion limited to 30 degrees or less and there is no finding of favorable ankylosis of the entire thoracolumbar spine. The schedular criteria for an increased rating under the General Rating Formula for Diseases and Injuries of the Spine are not met. The General Rating Formula also directs that neurological manifestations of the spine should be rated separately from orthopedic manifestations. While the record documents the Veteran's complaints of radicular pain into his lower extremities, no objective neurological abnormality arising from the lumbar spine disability has been identified on any of the VA examinations or other clinical evidence of record. Furthermore, there is no evidence of bowel or bladder impairment associated with his lumbar spine disability. Thus, a separate rating for bowel or bladder impairment is not warranted. Id. As the Veteran is diagnosed with intravertebral disc syndrome, the Board has also considered whether a higher disability rating could be assigned under Diagnostic Code 5243. However, the evidence of record fails to show that the Veteran had any incapacitating episodes of back pain that required him to stay in bed as either prescribed or supervised by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Accordingly, a higher disability rating is not warranted under Diagnostic Code 5243. In addition, the Board finds that the Veteran is not entitled to a higher disability rating under the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The July 2007 VA examiner noted that the Veteran demonstrated increasing symptoms of pain, fatigue, lack of endurance an incoordination after repetitive use. However, the examiner did not indicate whether such factors further limited the range of motion of the spine. The July 2011 VA examiner noted that the Veteran did not show any worsening pain, fatigability, lack of endurance or incoordination on repetitive motor testing. Thus, the evidence does not reflect that the Veteran's lumbar strain results in forward flexion limited to 30 degrees, even considering complaints of pain, to warrant a higher evaluation. The Board finds that the Veteran's complaints are adequately contemplated by the Veteran's currently assigned 20 percent disability rating and an increased disability rating under Deluca is not warranted. The Board recognizes the Veteran's statements attesting to his chronic pain and limited range of motion. The Board notes that lay persons can attest to observable symptomatology. In addition, the Veteran's statements describing his symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), Layno v. Brown, 6 Vet. App. 465, 469 (1994), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). These statements, however, must be viewed in conjunction with the objective medical evidence as required by the rating criteria. In this regard, the objective medical evidence, including the VA examination reports, include the information necessary to rate the Veteran's disability in accordance with the rating criteria and the examiners considered the Veteran's reported symptomatology. Thus, when considering the overall evidence of record, including the Veteran's statements, the Veteran's lumbar spine disability does not warrant a disability rating in excess of 20 percent. Based on the above, the Board finds that an increased rating is not warranted at any time during the pertinent appeal period. Thus, staged ratings for the Veteran's disability are also not warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching this decision, the Board considered the doctrine of reasonable doubt; however, the preponderance of the evidence is against the Veteran's claim, and the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim for a higher disability rating is denied. The Board also observes that under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned disability rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, there are higher ratings available under multiple diagnostic codes, but the Veteran's spine disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected lumbar spine disability under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an increased disability rating in excess of 20 percent for a lumbar strain is denied. REMAND Although further delay is regrettable, the Board finds that additional development is required prior to adjudication of the Veteran's claim for entitlement to a TDIU. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veteran contends that he is unemployable due to his service-connected disabilities. In particular, he asserts that his left shoulder condition and lumbar strain place severe restrictions on lifting, sitting and standing for long periods of time and many other restrictions due to side effects of medication and pain. Based upon the above decision, the Veteran is currently service-connected for lumbar strain, rated as 20 percent disabling; left shoulder bicipital tendinosis rated as 20 percent disabling; fractured 10th rib rated as noncompensably (zero percent) disabling; and fracture of the nose also rated as noncompensably disabling. His combined evaluation is 40 percent. 38 C.F.R. § 4.25 (2012). As such, the Veteran does not meet the minimum schedular criteria for TDIU under 38 C.F.R. § 4.16(a). Nevertheless, veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16(b). However, the medical evidence of record is inadequate to adjudicate the Veteran's claim at this time. A June 2007 VA examiner determined that the Veteran's deviated nasal septum has no impact on gainful employment. The examiner also concluded that his status post right tenth rib fracture should not have an impact on gainful employment. A July 2007 VA examiner concluded that the Veteran's shoulder and lumbar spine disabilities should not exclude him from being employable. On the other hand, a July 2011 VA examiner concluded that the Veteran's lumbar spine disability would render him unemployable within his current skill set. The question at issue in this case is whether the Veteran is able to obtain or maintain substantially gainful employment due to his service-connected disabilities. There is no examination addressing whether the combined effect of his service-connected disabilities results in unemployability. Therefore, the Board finds that a VA examination and medical opinion are necessary for the purpose of determining whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination to determine the combined effect of all of his service-connected disabilities (lumbar spine disorder, left shoulder bicipital tendinosis, fractured 10th rib and fracture of the nose) on his employability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to comment on the combined effect of the Veteran's service-connected disabilities (lumbar spine disorder, left shoulder bicipital tendinosis, fractured 10th rib and fracture of the nose) on his ability to engage in any type of full-time employment, including sedentary employment, and whether, in the examiner's opinion, the service-connected disabilities are of such severity to result in unemployability. Although it is the responsibility of the VA rating specialist to determine, based on all the evidence of record--including reports of examination and medical opinions rendered in light of the Veteran's education, experience, and occupational background--whether the case warrants referral to the Director, Compensation and Pension Service, for extraschedular consideration for a TDIU under section 4.16(b), the VA examiner must address the extent of functional and industrial impairment due to all of the Veteran's service-connected disabilities. It is the examiner's responsibility to furnish a full description of the effects of the service-connected disabilities upon the Veteran's ordinary activities which include employment. See 38 C.F.R. § 4.10. This description may include an opinion on such questions as whether a claimant's condition precludes standing for extended periods, lifting more than a certain weight, sitting for eight hours a day, or performing other specific tasks. Moore v. Nicholson, 21 Vet. App. 211, 219 (2007), rev'd on other grounds sub nom. Moore v Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although the examiner is not required to offer an opinion on the general employability of the Veteran, the examiner should, in this case, offer such an opinion as to whether it is at least as likely as not that the Veteran is unable to obtain or maintain substantially gainful employment solely as a result of his service-connected disabilities. The examination report must include a complete rationale for all opinions and conclusions expressed. Note: The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. It should be noted that consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important 'that each disability be viewed in relation to its history [,]' 38 C.F.R. § 4.1 (2012), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. After conducting any additional development as deemed necessary, the RO/AMC should readjudicate the issue of entitlement to a TDIU, to include whether the Veteran is entitled to a TDIU on an extraschedular basis. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. The appellant 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs