Citation Nr: 1320482 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 07-31 349 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral knee disorder, to include as secondary to the service-connected right thoracolumbar strain. 2. Entitlement to service connection for a bilateral shoulder disorder, to include as secondary to the service-connected right thoracolumbar strain. 3. Entitlement to service connection for a chronic headache disability. 4. Entitlement to an initial evaluation in excess of 20 percent for the service-connected right thoracolumbar strain. WITNESSES AT HEARING ON APPEAL Veteran and his wife, S.S. ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1990 to September 1992. This matter comes before the Board of Veterans' Appeals (Board) from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Service connection for shoulder pain, for a knee condition, and for migraines was denied therein. Service connection was granted and an initial evaluation of 20 percent assigned for right thoracolumbar strain secondary to scoliosis. The Veteran perfected an appeal as to each of these determinations. In May 2010, the Veteran and his wife S.S. testified before the undersigned Veterans Law Judge (VLJ) at a hearing held at the RO. The Board remanded each issue comprising this matter for additional development in July 2010 and in March 2012. The migraines issue was recharacterized by the Board at that latter time to one of a chronic headache disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The additional development directed has been completed or at least substantially completed with respect to the right thoracolumbar strain issue. Adjudication thus may proceed if otherwise in order. Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with); aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). No potential problems with adjudication are found at this time. Accordingly, the following determination is made based on review of the Veteran's claims file and Virtual VA "eFolder." As discussed below, the additional development directed has not been completed or even substantially completed with respect to the bilateral knee, bilateral shoulder, and chronic headache disability issues. They are thus addressed in the REMAND portion of the decision below. They are once again REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's right thoracolumbar strain has not manifested forward flexion equal to or less than 30 degrees, favorable ankylosis, or any incapacitating episodes. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 20 percent for right thoracolumbar strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Before addressing the merits, the Board notes that VA has a duty of notification regarding a claim for VA benefits. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. VA must notify the claimant and his representative, if any, prior to initial adjudication by the agency of original jurisdiction (AOJ) of any information and any evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification that an initial evaluation and an effective date will be assigned if service connection is granted for a disability also must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)). None is found. A March 2006 letter informed the Veteran of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. Another March 2006 letter informed him of how an initial evaluation and effective date is assigned if service connection is granted. Both of these letters are dated prior to the initial adjudication by the AOJ, which in this case also is the RO, via the June 2006 rating decision. The purpose that notice is intended to serve was fulfilled in that the benefit sought, which initially was service connection, was granted therein. Dingess, 19 Vet. App. at 473. Additional notification was provided to the Veteran in June 2008, September 2010, and December 2011 letters. The June 2008 letter set forth specific as opposed to generic information regarding evaluation of the Veteran's service-connected right thoracolumbar strain. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (overturning Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008)). In addition to the duty to notify, VA has a duty to assist with respect to a claim for VA benefits. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This includes a requirement to aid the claimant in the procurement of relevant records. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). VA also is required to provide a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran's service treatment records and VA treatment records have been obtained by VA. Some of the VA treatment records were obtained in compliance with the Board's remands. No private treatment records have been obtained by VA. Throughout the pendency of this matter, the Veteran has had many opportunities to identify private treatment records pertinent to his right thoracolumbar strain. This includes responding to the September 2010 and December 2011 letters sent to him in this regard pursuant to the Board's July 2010 remand. He has not done so. It therefore is inferred that either there are no pertinent private treatment records (the Veteran testified that he had chiropractic treatment for his back in the 1990's, but he did not mention any recent treatment) or that he is not going to cooperate in obtaining such records. If the latter is true, that a claimant has an obligation to cooperate is noteworthy. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Wood v. Derwinski, 1 Vet. App. 190 (1991). VA medical examinations concerning the Veteran's right thoracolumbar strain were conducted in April 2006, January 2008, November 2010 (as directed by the Board's July 2010 remand), and February 2013 (as directed by the Board's March 2012 remand). Each examiner reviewed the claims file. There is no indication that any examiner reviewed the "eFolder," but this is of no consequence since it does not contain any medical evidence that is not in the claims file. Each examiner also interviewed the Veteran and undertook a physical assessment of him. That a few of the findings directed in the Board's March 2012 remand, particularly those regarding ankylosis and incapacitating episodes, were not made at the February 2013 VA medical examination is acknowledged. Yet the discussion below reveals that an inference regarding ankylosis readily can be made while incapacitating episodes are irrelevant. As such, the examinations have provided sufficient detail so that the determination made herein is fully informed. They therefore are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). It is significant that the Veteran has not identified any further development necessary for fair adjudication on the merits that has not been completed. The record also does not indicate any further development. Accordingly, the Board finds that no further notice or assistance is required and that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio, 16 Vet. App. at 183. Appellate review therefore may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). Of final note, the individual presiding over a hearing must fully explain the issues and suggest the submission of evidence that may have been overlooked. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The undersigned VLJ identified an increased evaluation for service-connected right thoracolumbar strain as one of the issues on appeal at the outset of the May 2010 hearing. The undersigned VLJ elicited from the Veteran and his wife, S.S., concerning his symptoms and their impact on his life. Information also was elicited from him concerning his treatment. A remand for pertinent private treatment records followed, as noted above. II. Higher Evaluation A. Schedular Evaluations are assigned pursuant to VA's Schedule for Rating Disabilities. Separate Diagnostic Codes identify various disabilities and the criteria for a specific evaluation to be assigned for that disability. The evaluations represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C.A. § 1155. An evaluation is assigned by comparing the extent to which a claimant's disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by his symptoms, with the evaluation criteria. Id.; 38 C.F.R. § 4.10; Schafrath, 1 Vet. App. at 589. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that evaluation of the disability is accurate. 38 C.F.R. § 4.2. If two evaluations are potentially applicable, the higher is assigned if the disability more nearly approximates the criteria required for it. Otherwise, the lower evaluation is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant, however. 38 C.F.R. § 4.3. He thus prevails if the evidence supports a higher evaluation or is in relative equipoise but does not prevail when it is against a higher evaluation. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For initial evaluations, consideration must be given to whether a staged evaluation is or staged evaluations are warranted. Fenderson v. West, 12 Vet. App. 119 (1999). In staged evaluations, two or evaluations are assigned because a disability meets the criteria for one evaluation during one period on appeal but meets the criteria for another evaluation or evaluations during another or other periods on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss in the form of limitation of motion may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion, or weakness. 38 C.F.R. §§ 4.40, 4.59. It also may be due to excess fatigability or incoordination. 38 C.F.R. § 4.45. A higher evaluation for functional loss, to include during flare ups, due to those factors accordingly may be assigned under Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's service-connected right thoracolumbar strain has been evaluated analogously under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5237 addresses lumbosacral strain, which is similar to thoracolumbar strain. It, like other back conditions, is evaluated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (General Formula). Evaluations are to be made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching under the General Formula. For the thoracolumbar spine, a 20 percent evaluation requires forward flexion greater than 30 degrees but not greater than 60 degrees, combined range of motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is assigned when forward flexion is limited to 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine results in a 50 percent evaluation. The maximum 100 percent evaluation is reserved for unfavorable ankylosis of the entire spine. Normal range of motion is from 0 to 90 degrees forward flexion and from 0 to 30 degrees extension, left and right lateral flexion, and left and right lateral rotation for a combined range of motion of 240 degrees. General Formula, Note (2); 38 C.F.R. § 4.71a, Plate V. The General Formula additionally provides for the assignment of separate evaluations under appropriate Diagnostic Codes for any objective neurologic abnormalities associated with a disease or injury of the spine. General Formula, Note (1). This includes, but is not limited to, bowel or bladder impairment. According to Diagnostic Code 5243, intervertebral disc syndrome (IVDS) is evaluated under either the above General Formula or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever results in the higher evaluation. Incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months is needed for a 10 percent evaluation. A 20 percent evaluation is for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months results in award of a 40 percent evaluation. The maximum evaluation of 60 percent is awarded for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. IVDS Formula, Note (1). The probative value of the evidence must be assessed. 38 C.F.R. § 4.6. In other words, the Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any evidence favorable to the Veteran. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert, 1 Vet. App. at 49. This includes the lay evidence in addition to the medical evidence. The competency and credibility of the lay evidence therefore must be addressed. Layno v. Brown, 6. Vet. App. 465 (1994) (noting that competency is "a legal concept determining whether testimony may be heard and considered" whereas credibility is "a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Even though all the evidence has been reviewed, only the most relevant evidence is discussed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). At the April 2006 VA medical examination, the Veteran complained of intermittent back pain rated as 6 or 7 out of 10 which sometimes radiates to his shoulders. He also complained of flare ups lasting 1 to 2 hours three times per week during which his pain is rated as a 10 and he has limited movement and thus limited mobility. He indicated taking over the counter pain medication and having missed 3 days of work within the past 12 months due to incapacitation from his back, with bed rest being prescribed by a physician for each day. The Veteran indicated that he could walk 1/4 mile, does not use a brace or assistive device, and is not unsteady or with a history of falls. He denied bowel and bladder problems, erectile dysfunction, numbness, and weakness. Upon assessment, his gait was slightly antalgic. Mild scoliosis with convexity to the right was noted. The Veteran's back was tender and had muscle spasms. There was no ankylosis. Range of motion was to 60 degrees flexion, to 20 degrees extension, to 15 degrees left lateral flexion and rotation, and to 20 degrees right lateral flexion and rotation with pain at the end points of flexion, extension, and left lateral flexion and rotation. There was no change with repetition. Fatigue, weakness, lack of endurance, and incoordination were not found. The Veteran's upper and lower extremities had normal strength, intact sensation, and hypoactive reflexes. The Veteran indicated in his January 2007 notice of disagreement that his back pain, in addition to other pain, prevents him from getting a good amount of sleep. A June 2007 VA medical examination for some of the other issues on appeal contains his report of limiting his lifting at work, where his is a VA claims adjuster, to 20 pounds or less. In unsigned December 2007 statements, his longtime friends K.W. and C.H. noted that he experiences pain in his body which renders him unable to play with his children. The location of this pain was not specified. The Veteran's supervisor at work finally noted in an unsigned December 2007 statement that the Veteran often works despite pain but sometimes goes home or does not come in due to extreme pain. Once again, the location of this pain was not specified. It further was noted that the Veteran has used countless hours of sick leave. The Veteran reported back stiffness in the morning with cold and damp weather as well as daily back pain rated as 7.5 out of 10 that radiates to the shoulders at the January 2008 VA medical examination. He indicated that he does not use an assistive device, though he bought a brace and takes over the counter pain medication. He also indicated that he has taken 5 days of sick leave from his job as a VA claims adjuster within the past year due to his back. The Veteran denied acute flare ups that have been incapacitating within the past 12 months. He further denied bowel and bladder problems, erectile dysfunction, numbness, and weakness. Upon assessment, his gait and posture were normal. His spinal curvature also was normal. His back was not tender and did not have spasms or ankylosis. Range of motion was to 90 degrees flexion and to 30 degrees extension, left and right lateral flexion, and left and right rotation without pain. There was no change with repetition. Fatigue, weakness, lack of endurance, and incoordination were not found. The Veteran had intact strength, sensation, and reflexes. IVDS was deemed inapplicable. X-rays showed moderately severe rotary lumbar dextroscoliosis. In an April 2010 statement, the Veteran's father C.S. commented that the Veteran had constant back pain during service. His description of the Veteran now did not include reference to back pain or pain in general, but it did reference an inability to play with his children. The Veteran testified at the May 2010 hearing that he experiences back pain 4 or 5 times per week, stiffness, limited range of motion for which he uses sports creams and applies heat and cold. He stated that he gets "shut down completely" by these symptoms in that he is unable to bend or move and that his pain often brings him to tears so that he just has to go to sleep. He additionally stated that he had to transfer positions at his job from one requiring lifting to one that does not. S.S. testified that the Veteran's activities are limited due to his back such that he cannot do much other than sit for short periods. The Veteran complained of back stiffness in the morning, intermittent non-radiating pain, spasms, and decreased motion for which he takes over the counter pain medication and uses heat packs at the November 2010 VA medical examination. He indicated that he had 8 days of incapacitation within the past 12 months and that he still worked full-time as a clerk for VA with no time lost during the past 12 months due to his back. He denied flare ups, weakness, and fatigue. The Veteran also denied urinary incontinence, urgency, retention, and frequency as well as nocturia, fecal incontinence, obstipation, erectile dysfunction, numbness, paresthesias, leg or foot weakness, unsteadiness, and falls. Upon assessment, his gait and posture were normal. Scoliosis was found. The Veteran's back was not tender and did not have spasms, thoracolumbar ankylosis, or cervical ankylosis. Range of motion was to 85 degrees flexion and to 30 degrees extension, left and right lateral flexion, and left and right rotation without objective evidence of pain. There was no change with repetition. Pain with motion, weakness, guarding, and atrophy were not found. The Veteran's strength, sensation, and reflexes in all extremities were normal. It was indicated that he did not have incapacitating episodes due to IVDS. Finally, it was determined that the Veteran's back does not impact his ability to work. At the February 2013 VA medical examination, the Veteran reported back stiffness especially in the morning and pain rated as 7.5 out of 10 for which he uses heat and cold compresses. He also reported flare ups that decrease his mobility. He indicated that he does not have any limitations other than avoidance of lifting anything over 30 pounds. The Veteran denied using a brace or assistive device as well as lower extremity numbness and tingling. Upon assessment, his gait and posture were normal. Scoliosis was found. The Veteran's back was not tender and did not have spasms. Range of motion was to 80 degrees forward flexion and to 25 degrees extension, left and right lateral flexion, and left and right rotation without objective evidence of pain. There was no change with repetition. Functional loss due to pain on movement, guarding, weakened movement, excess fatigability, incoordination, instability, and atrophy from disuse was not found. The Veteran's strength, sensation, and reflexes in his lower extremities were normal. It was indicated that he did not have radicular pain or other symptoms due to radiculopathy, any other neurologic abnormality, or IVDS. X-rays showed scoliosis but did not show degenerative joint disease. It was noted that there was no arthritis. Finally, the examiner determined that the Veteran's back does not impact his ability to work. Given the above, the Board finds that an initial evaluation in excess of 20 percent for the Veteran's service-connected right thoracolumbar strain is not warranted under the General Formula. The criteria for even the next highest evaluation of 40 percent have not been met. Discussion of higher evaluations of 50 percent and 100 percent is thus unnecessary. The Veteran's entire thoracolumbar spine is not favorably ankylosed. Indeed, no part of his thoracolumbar spine is favorably ankylosed. Ankylosis is immobility and consolidation of a joint. Dorland's Illustrated Medical Dictionary 94 (31st ed. 2007); Lewis v. Derwinski, 3 Vet. App. 259 (1992); Nix v. Brown, 4 Vet. App. 462 (1993); Shipwash v. Brown, 8 Vet. App. 218 (1995). In other words, it is stiffening or fixation of a joint. Dinsay v. Brown, 9 Vet. App. 79 (1996). The difference between favorable and unfavorable ankylosis is the position of the ankylosis and whether or not it causes associated difficulties. General Formula, Note (5). At no point has any ankylosis, whether favorable or unfavorable, been found with respect to the Veteran's thoracolumbar spine. Such specifically was not found at the first three VA medical examinations. Ankylosis was not mentioned at the last VA medical examination. However, the Veteran had a significant amount of thoracolumbar motion in all directions initially and with repetition at this examination. He also had a significant but varied amount of thoracolumbar motion in all directions initially and with repetition at each previous VA medical examination. There thus has not been immobility, consolidation, stiffening, or fixation of the thoracolumbar spine at a specific point. Acknowledgement is given to the Veteran's testimony that he gets "shut down completely" such that he is unable to bend or move. He is a lay person because there is no indication that he has a medical background. He is competent to provide the aforementioned testimony because his symptoms and their effects would be personally experienced by him. Layno, 6. Vet. App. at 465. Competent lay evidence may be discounted due to interest, self-interest, bias, inconsistency, inconsistency with other evidence, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). The Veteran's credibility in providing the aforementioned testimony need not be addressed. Even assuming he is credible, his testimony does not suggest ankylosis. He does not indicate that he cannot bend or move all the time. His inability is a product of transient or temporary flare ups, in other words, whereas ankylosis is permanent. Additionally, the Veteran's thoracolumbar spine does not have equal to or less than 30 degrees of forward flexion. His flexion was to 60 degrees initially and with repetition at the first VA medical examination, to a normal 90 degrees initially and with repetition at the second VA medical examination, to 85 degrees initially and with repetition at the third VA examination, and to 80 degrees initially and with repetition at the last VA medical examination. That the flexion at the first VA medical examination was with pain at the end point is of no consequence. Painful motion is not in and of itself functional loss, and it does not constitute limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). At no time has the Veteran's flexion been impacted by weakness, excess fatigability, lack of endurance, incoordination, instability, or atrophy. The Veteran is competent in reporting flare ups to include of pain which decrease his movement and thus his mobility more than normal for the reason specified above. He also is credible to the extent that he has experienced flare ups. It is plausible that an individual with a back condition would experience periods of more severe limitation of motion than usual. That the Veteran has variously reported and denied flare ups, though a possible indication of inconsistency, is understandable since most individuals reflect only upon the recent past in answering questions about symptoms. Nothing from his demeanor at the May 2010 hearing suggested an intent to deceive regarding flare ups. Nevertheless, there is no basis for finding that the Veteran's forward flexion is limited to 30 degrees or less during a flare up. No amount of his additional motion and mobility loss during a flare up was specified at any of the VA medical examinations. The only information he has provided in this regard is that he sometimes becomes unable to bend or move, as noted above. He thus indicates that he sometimes has 0 degrees forward flexion. He is not credible in this regard. At each VA medical examination, his forward flexion was to 60 or more degrees initially and with repetition. He consistently has been found to have ? or more of normal forward flexion not during a flare up, in other words. It is reiterated that painful motion does not constitute limited motion. Mitchell, 25 Vet. App. at 32. While it is plausible that the Veteran does not bend or move during a flare up because doing so causes pain, that he is unable to bend or move whatsoever during a flare up because of pain defies logic. Such an inability would equate to him losing approximately ? or more of his forward flexion during a flare up. Some additional motion and mobility loss during a flare up further is plausible, but a decrease of even ? (the lowest forward flexion found of 60 degrees minus the highest 30 degrees for a 40 percent evaluation = 30 degrees additional loss) is not. A lack of notation where notation would be expected may be considered. Buczynski v. Shinseki, 24 Vet. App. 221 (2011). Treatment for flare ups so severe as to result in such a substantial decrease in range of motion would be expected, but there is no indication of such treatment here. In sum, it appears that the Veteran is motivated by his self-interest in financial gain to exaggerate the severity of his flare ups. The Board next finds that a separate evaluation is not warranted under the General Formula for any objective neurologic abnormality associated with the Veteran's right thoracolumbar strain. A separate evaluation is not warranted for bowel impairment, bladder impairment, or erectile dysfunction. Objective findings in this regard have not been made. The Veteran further consistently has denied bowel and bladder dysfunction as well as erectile dysfunction. He is competent in this regard for the same reason as above. He is credible because there is no significant reason for doubt. With respect to the his extremities, the Veteran sometimes has reported that his back pain radiates to his shoulders and sometimes has reported that it does not radiate. He once again is competent to make these reports for the same reason as above. His credibility need not be addressed. Even assuming he is credible, the Veteran's strength and sensation in each of his extremities consistently has been normal. The only objective finding of neurological abnormality concerning his extremities thus was that his reflexes were hypoactive at the April 2006 VA medical examination. However, this finding is an anomaly since his reflexes were normal at all of the other VA medical examinations. It indeed was indicated at the last VA medical examination that the Veteran did not have radiculopathy. It further was indicated that he did not have any other neurologic abnormality. Turning lastly to the IVDS Formula, the Board finds that it is not applicable. The Veteran has not been diagnosed with IVDS or any similar condition. Assuming IVDS or a similar condition should have been diagnosed, there have not been incapacitating episodes of at least 1 week or more during any 12 month period. The Veteran denied incapacitation once. He twice reported some days of incapacitation. He is competent with respect to these reports for the same reason as set forth above. He is credible with respect to the negative report because there is no significant reason for doubt. Even presuming he is fully credible with respect to the positive reports, only 3 days were characterized by incapacitation in the first report. 8 days were so characterized in the second report. Bed rest prescribed by a physician in relation to these 8 days was not mentioned by the Veteran, as it was for the 3 days, however. There is no indication apart from his reports of bed rest prescribed by a physician. Indeed, there is no indication apart from his reports that he has been treated by a physician for acute symptoms. Use of the IVDS Formula, even if applicable, therefore would result in a noncompensable evaluation. 38 C.F.R. § 4.31. The 20 percent evaluation assigned pursuant to the General Formula thus stands as the higher evaluation. Consideration has been given to reasonable doubt in making the above determinations. However, it does not apply because they were based on the preponderance of the evidence. Consideration also has been given to staged evaluations. None are warranted because the above determinations cover the entire period on appeal. B. Extraschedular The alternative to assigning an initial evaluation schedularly is to assign one on an extraschedular basis. 38 C.F.R. § 3.321(b); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). There are three steps to be taken regarding extraschedular evaluations. Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the evidence presents such an exceptional disability picture that the applicable schedular evaluation criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made. If these criteria are inadequate, it second must be determined whether the Veteran exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral third must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for consideration of an extraschedular evaluation. Here, the Veteran has not argued for an extraschedular evaluation for his service-connected right thoracolumbar strain. There is no indication that this disability cannot be contemplated adequately by the applicable schedular evaluation criteria discussed above. The Veteran's symptoms, which primarily have consisted of pain, stiffness, spasms, and decreased range of motion, specifically are accounted for by these criteria and associated statutes, regulations, and caselaw. Evaluation has been based on these sources. Higher evaluations and separate evaluations exist pursuant to them. As explained above, however, an initial evaluation of 20 percent with no separate evaluations accurately describes the severity of the Veteran's right thoracolumbar strain. The effect this disability has on him is encompassed by the aforementioned evaluation, in other words. This includes his reports and testimony and the reports and testimony of his friends and family of taking pain medication, utilizing sports creams as well as cold and heat, wearing or at least having worn a brace, having difficulty sleeping, having to limit his activities such as lifting, and being unable to walk more than a short distance, play with his children, or do anything much other than sit for a short period. These reports are and the testimony is competent for the same reason as set forth above. The reports are and the testimony is credible because it all is in agreement. Because the applicable schedular rating criteria are adequate, the Board does not find an exceptional right thoracolumbar strain disability picture. Discussion of whether there are related factors such as marked interference with employment or frequent periods of hospitalization accordingly is unnecessary. Yet it is of note is that the Veteran's disability concededly interferes with his employment, notwithstanding the determinations that there has been no impact on his ability to work. His supervisor report that, to the contrary, he has used countless hours of sick leave is highlighted in this regard. So is his report of having to transfer positions. These reports are competent for the same reason set forth above, and they are credible because there is no significant reason for doubt. The employment interference caused by the Veteran's disability does not arise to the level of marked, however, since he has been able to continue working full-time despite experiencing its symptoms. In sum, referral for consideration of the assignment of an extraschedular rating is not warranted. III. Total Disability Evaluation Based on Individual Unemployability Of final note is that "a request for entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by a [V]eteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities . . . as part of a claim for increased compensation." Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case, the Veteran has not contended that his service-connected right thoracolumbar strain is so severe that it has rendered him unable to work. The evidence further does not indicate this to be the case. It is reiterated that he has been able to retain a job notwithstanding the limitations imposed by his service-connected right thoracolumbar strain. Consideration of a TDIU as a component of this matter therefore is not warranted. ORDER An initial evaluation in excess of 20 percent for the service-connected right thoracolumbar strain is denied. REMAND Regrettably, another remand is necessary for additional development with respect to the bilateral knee disorder, a bilateral shoulder disorder, and a chronic headache disability issues on appeal. The Board is cognizant that this is the third remand regarding these issues and that they have been pending for years. The Veteran consequently is assured that this remand would not be directed unless it was essential for fair adjudication. The duty to assist requires that VA medical opinions be adequate. Barr, 21 Vet. App. at 303. Consideration must be given to the Veteran's entire medical history in formulating the opinion. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Ardison v. Brown, 6 Vet. App. 405 (1994). This helps ensure that the factual premises underlying the opinion is accurate, as is required. Reonal v. Brown, 5 Vet. App. 458 (1993). The rationale for the opinion also must be clearly and fully articulated. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl, 21 Vet. App. at 120. All theories of entitlement raised must be addressed in it. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004). A series of VA medical examinations complete with opinions have been undertaken regarding the Veteran's knees, shoulders, and headaches. The last, completed in February 2013, was pursuant to the Board's March 2012 remand. This remand was drafted so as to satisfy the duty to assist. Specifically, the Board called for review of the claims file, interview of the Veteran, and performance of an assessment of him. This was to be followed by the rendering of opinions regarding whether or not each of his diagnosed knee, shoulder, and headache disabilities had its onset during or otherwise is related to his service and whether or not each of his diagnosed knee and shoulder disabilities was caused by or has been aggravated by his service-connected right thoracolumbar strain. A complete rationale was to be provided for each opinion. This was to include addressing the Veteran's competent and credible contentions regarding continuity of his relevant symptomatology since service. There has not been full or even substantial compliance with these directives, as referenced above. Stegall, 11 Vet. App. at 268; Dyment, 13 Vet. App. at 141, aff'd, Dyment, 287 F.3d at 1377. Here, the February 2013 examiner did review the claims file and interview the Veteran. Diagnoses of bilateral knee strain, bilateral shoulder strain, and migraines were made following these actions and assessment of him. It then was opined that each diagnosis was less likely than not incurred during the Veteran's service or otherwise caused by his service, as was requested. The rationale provided was that there is no evidence that he was seen for any of the conditions during service and no evidence of any type to show chronicity shortly after service. Very little rationale was provided in contrast to a complete or fully articulated rationale, in other words. There indeed was only minimal explanation for the conclusion reached. Further, the rationale reveals that the opinion was based at least partially on an inaccurate factual premise due to the failure to consider the Veteran's entire medical history. The Board has deemed his reports of his relevant symptoms beginning during service and continuing thereafter to be both competent and credible. It follows that there is evidence, specifically lay evidence, to show symptoms shortly after service. Of additional note is the lay evidence regarding the contrast in the Veteran before and after service, specifically regarding pain, in the form of statements and testimony from his family and friends. The examiner finally opined that the Veteran's knee and shoulder diagnoses are not related to his service-connected right thoracolumbar strain. The rationale provided was that there is no nexus between thoracolumbar strain and the shoulders or knees. Like above in other words, very little rationale was provided in contrast to a complete or fully articulated rationale. There indeed was no real explanation for the conclusion reached. That conclusion instead simply was restated. Further, it is unclear whether the rationale addressed all theories of entitlement. The lack of a relationship between a diagnosed condition and a service-connected disability could mean that the disability did not cause the condition and that it did not aggravate the condition, but it also could just mean only one or the other. Additional VA medical opinions are needed to cure the deficiencies highlighted above. Additional VA medical examinations are not required concerning unless further assessment is deemed necessary. Any further interview of the Veteran deemed necessary indeed likely can occur via telephone just as efficiently as and quicker than in person. So that appropriate arrangements can be made, remand is required. Efforts must be made to obtain any outstanding private and VA treatment records for association with the claims file or "eFolder" prior to the additional VA medical opinions being rendered so that the Veteran's entire medical history can be considered. Reasonable efforts with respect to records in Federal custody consist of making as many requests as are necessary to obtain them unless it is concluded that they do not exist or that further requests would be futile. 38 U.S.C.A. § 5103A(b)(3); 38 C.F.R. § 3.159(c)(2). When the existence of non-Federal (private) records is discovered, the claimant must be requested to either submit them to VA or provide enough information to identify and locate them along with an authorization for their release to VA. 38 C.F.R. §§ 3.159(c)(1), (e)(2). If information and authorization is provided, reasonable efforts consist of an initial request and one or more follow-up requests if necessary. 38 C.F.R. § 3.159(c)(1). The claimant shall be notified if requested records, whether Federal or non-Federal, cannot be or are not obtained. 38 U.S.C.A. § 5103A(b)(2); 38 C.F.R. § 3.159(e)(1). Paralleling the above discussion with respect to the Veteran's service-connected thoracolumbar strain, there are at least outstanding pertinent private treatment records dated in the 1990's from a chiropractor. The Veteran thus far has not cooperated in obtaining them by either supplying these records or by supplying enough information to identify and locate them along with authorization for their release to VA. He shall be afforded one more chance do to so on remand. If he supplies the information and authorization, an initial request for the records must be made with follow-up requests as well as notification to him and his representative (if any) if they are unsuccessful as necessary. VA treatment records dated into March 2012 have been associated with the claims file or "eFolder." VA treatment records dated thereafter have not been requested. VA treatment records plausibly could be expected to be among the evidence before the Board, and thus the Board has constructive notice of their existence. Bell v. Derwinski, 2 Vet. App. 611 (1992). Requests for them therefore must be made, with notification to the Veteran and his representative (if any) if the requests are unsuccessful. Given the above, a REMAND is directed for the following: 1. Ask the Veteran to either submit any outstanding pertinent private treatment records or provide enough information to identify and locate them along with authorization for their release to VA. If he provides information and authorization, make an initial request for the records. Also make follow-up requests as necessary. Associate all records received with the Veteran's claims file or "eFolder." 2. Make as many requests as necessary to obtain all updated VA treatment records (dated from March 2012 to present) regarding the Veteran. Associate all records received with the Veteran's claims file or "eFolder." 3. If requested treatment records, whether private or VA, ultimately are not received or are received but are incomplete, notify the Veteran and his representative (if any) pursuant to established procedure. Document the claims file or Virtual VA "eFolder" as appropriate regarding this paragraph. 4. After completion of the all of the above development, arrange for another VA medical opinion regarding the Veteran's knees, shoulders, and headaches. The Veteran's claims file and pertinent documents in the Virtual VA "eFolder" shall be made available and reviewed. If deemed necessary, arrangements shall be made for another VA medical examination inclusive of tests, studies, and/or evaluations to further assess the Veteran. For each of the Veteran's knee, shoulder, and headache diagnoses, it next shall be opined as to whether it is at least as likely as not (a 50 percent or greater probability) that the diagnosis: (a) had its onset during his service or (b) is otherwise due to or related to his service. For each knee and shoulder diagnosis, it additionally shall be opined as to whether it is at least as likely as not that the diagnosis: (a) was caused by his service-connected right thoracolumbar strain, or (d) was aggravated (permanently worsened beyond the natural progression of the disorder) by his service-connected right thoracolumbar strain. If aggravation is found, the examiner further shall opine as to: (a) the baseline level of disability prior to the aggravation and (b) the current level of disability. It is noted that this is necessary so that the amount of disability attributable solely to the aggravation may be determined. A clear and complete rationale (explanation) shall be provided for each opinion rendered. This shall include discussion of pertinent medical principles, with a citation for or copy of any literature referenced, as well as the pertinent medical evidence and lay evidence. As such, the reports of the Veteran, his family, and his friends that his symptoms started during service and have continued thereafter shall be addressed. These shall be taken as true, as the Board has found them to be both competent and credible. If an opinion cannot be provided without resort to mere speculation, a complete and clear rationale for why this is so shall be provided. In so doing, it specifically shall be indicated whether or not the inability to render the opinion is because information that is needed cannot be obtained, because more information is needed, because the limits of current medical knowledge have been exhausted, or because of some other reason. Each of the above actions shall be documented fully in a report. A copy of the report shall be placed in the Veteran's claims file or "eFolder." 5. Finally readjudicate the service connection claims remaining on appeal (as are characterized on the title page of this decision/remand). If one or more of these benefits is not granted, furnish the Veteran and his representative (if any) with a supplemental statement of the case (SSOC) and allow them the requisite time period to respond. Place a copy of the SSOC in the Veteran's claims file or "eFolder." No action is required of the Veteran until he is notified by the RO or AMC. However, he is advised that his failure to report for a scheduled VA medical examination may result in denial of the benefit sought. 38 C.F.R. § 3.655 (2012). He also is advised that he has the right to submit additional evidence and argument on the issues remanded herein. Kutscherousky v. West, 12 Vet. App. 369 (1999). This matter must be afforded expeditious treatment. Indeed, the law requires that all matters remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs