Citation Nr: 1341453 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 10-16 254 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial schedular rating in excess of 20 percent for diabetes mellitus, Type II. 2. Entitlement to an initial schedular rating in excess of 30 percent for status post right knee replacement. 3. Entitlement to a schedular rating in excess of 30 percent for service-connected status post left knee replacement. 4. Entitlement to a schedular rating in excess of 20 percent for service-connected lumbosacral strain. 5. Entitlement to an increased schedular rating for orthopedic manifestations of service-connected degenerative joint disease (DJD) of the cervical spine, evaluated as 10 percent disabling until April 8, 2013, and as 20 percent disabling thereafter. 6. Entitlement to a separate compensable rating for radiculopathy of the left upper extremity. 7. Entitlement to a total rating based on individual unemployability due to a single service-connected disability. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran had active military service from January 1964 to August 1987. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The instant matters were previously before the Board in October 2012, at which time they were remanded for further development. On remand, the Veteran was afforded VA examinations in connection with his claims and, based on the results of those examinations, the RO issued in June 2013 a supplemental statement of the case (SSOC) wherein it denied increased evaluations, to include TDIU, for the Veteran's diabetes mellitus, bilateral knee disability, and lumbosacral strain. The RO also issued a June 2013 decision wherein the Veteran's disability rating for his service-connected degenerative joint disease of the cervical spine was increased to 20 percent, effective April 8, 2013. Because less than the maximum available benefit for a schedular rating was awarded for that disability and because the increase was not awarded for the entire claims period, that claim remains properly before the Board. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); AB v. Brown, 6 Vet. App. 35 (1993). Also by way of the June 2013 rating decision, the RO awarded service connection for right Charcot foot, evaluated as 30 percent disabling from March 16, 2010, and, in combination with the Veteran's left Charcot foot, as 100 percent disabling from April 26, 2011. To date, it does not appear that the Veteran has disagreed with any aspect of the RO's decision granting service connection for right Charcot foot. Accordingly, that matter is not currently before the Board. The Board also notes that, as will be discussed in further detail below, the evidence suggests that the Veteran has objective neurologic abnormalities related to his cervical spine disability. However, because the evidence is inadequate to rate such abnormality, the Board finds that the issue of entitlement to a separate compensable rating for radiculopathy of the left upper extremity must be remanded to the agency of original jurisdiction (AOJ) for further development. As such, it has been added as a separate issue, as reflected on the title page of this decision. Regarding entitlement to TDIU, although this issue was initially raised as part of the increased rating matters previously before the Board, because further development is required before the Board can adjudicate that issue, the Board finds that it necessary to now address the matter as a separate issue, as set forth on the title page of this decision. The decision below addresses the question of higher schedular ratings without regard to whether any single disability causes unemployability. FINDINGS OF FACT 1. During the pendency of the Veteran's claim, his diabetes mellitus has been managed by use of oral medication and/or insulin and a restricted diet; regulation of activities has not been shown. 2. The Veteran's knee disabilities, total bilateral knee replacements, have not caused severe painful motion or severe weakness in either affected extremity; the Veteran does not experience ankylosis, or functional losses that equate to limitation of extension worse than 10 degrees. 3. The Veteran's lumbosacral strain has been manifested by painful motion, flare-ups, spasm, and fatigue with functional loss that does not equate to limitation of flexion to 30 degrees or less. 4. Resolving reasonable doubt in favor of the Veteran, the Veteran experiences decreased sensation in the left lower extremity associated with his lumbosacral strain. 5. Prior to April 8, 2013, the Veteran's cervical spine DJD was manifested by painful motion with functional loss equating to no worse than limitation of flexion to 40 degrees or combined range of motion greater than 170 degrees; kyphosis resulting from muscle spasm or guarding has not been shown. 6. Since April 8, 2013, the Veteran's cervical spine DJD has been manifested by painful motion with functional loss equating to no worse than limitation of flexion to 20 degrees; ankylosis has not been shown. CONCLUSIONS OF LAW 1. The criteria for a schedular evaluation in excess of 20 percent for service-connected diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1 - 4.7, 4.119, Diagnostic Code (DC) 7913 (2013). 2. The criteria for a schedular rating in excess of 30 percent for right total knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5055, 5256, 5261, 5262 (2013). 3. The criteria for a schedular rating in excess of 30 percent for left total knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5055, 5256, 5261, 5262 (2013). 4. The criteria for a schedular rating greater than 20 percent for lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2013). 5. The criteria for a separate 10 percent schedular rating for neurological deficits of the left lower extremity associated with lumbosacral strain have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 5235-5243, Note(1) (2013). 6. The criteria for schedular ratings in excess of 10 percent prior to April 8, 2013, or in excess of 20 percent thereafter for cervical spine DJD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For increased rating claims, the VCAA requires only generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that that disability has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). At the outset, the Board notes that VA's General Counsel has held that VCAA notice is not required for downstream issues. VAOPGCPREC 8-2003. Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, 19 Vet. App. at 490. In this case, the issues of entitlement to initial ratings greater than 20 percent for service-connected diabetes mellitus and greater than 30 percent for status post right knee replacement stem from disagreements with downstream elements, and as such, no additional notice is required with respect to those claims because the purpose that the notice is intended to serve has been fulfilled with respect to those claims. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the Veteran was adequately informed of the information and evidence necessary to substantiate the other schedular rating claims decided herein, as well as of VA's duty to assist and of his responsibilities in the adjudication of his claim, via a July 2007 notice letter. The Board finds that this letter complies with the requirements of 38 U.S.C.A. § 5103(a) and Vazquez-Flores and Dingess, both supra, and afforded the Veteran a meaningful opportunity to participate in the development of his claims. Thus, the Board finds that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate the claims decided herein. The evidence obtained or associated with the Veteran's paper claims folder and Virtual VA file includes his service treatment records (STRs), VA treatment records, private treatment records, and statements from the Veteran. The Veteran elected not to have a hearing in connection with his case. He also has not alleged that there is any additional outstanding evidence pertinent to his claims and the Board is also unaware of any such outstanding evidence. In this regard, the Board notes that in its October 2012 remand, the Board referenced the fact that the Veteran had reported to a January 2010 VA examiner that three months earlier he had had a computerized tomography (CT) scan of the cervical and lumbar spine. In remanding the matter, the Board instructed the AOJ to contact the Veteran with a request that he provide further information regarding the CT scan, so as to enable the AOJ to attempt to secure a copy of that report. The Veteran did not respond to the AOJ's request in this regard. The Veteran also failed to sign the necessary authorizations for release of private medical records to VA. Given that "the duty to assist is not always a one-way street," Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), and it is the Veteran who is ultimately responsible for providing private medical evidence to VA, the Board finds that no further assistance in this regard is warranted and that the terms of its prior remand have been complied with. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also finds that the medical evidence of record is adequate for the Board to rely upon in this case. The Veteran has been provided with multiple VA examinations in connection with his claims. Also of record are numerous records from various private physicians. The VA examiners considered the Veteran's reported symptoms, reviewed the medical evidence of record, conducted the appropriate testing when necessary, and made all findings necessary to apply the rating criteria where required. The Board is satisfied that the information contained in the VA examination reports, along with that which is contained in the VA and private records, is sufficient for the Board to evaluate the Veteran's schedular rating claims. Accordingly, the Board has properly assisted the Veteran by affording him an adequate VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). II. Analysis Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Where, as in the case of the Veteran's diabetes mellitus and status post right knee replacement, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where, as in the case of the Veteran's status post left knee replacement and lumbar and cervical spine disabilities, "entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern." Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. For all increased rating claims, staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart, supra. Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7 (2013). A. Diabetes Mellitus The Veteran alleges that his diabetes mellitus is more disabling that initially rated and contends that a rating in excess of 20 percent is warranted. Specifically, in disagreeing with the initial evaluation assigned, the Veteran asserted entitlement to a rating of 40 percent, stating that his diabetes requires him to take two oral medications, regulate his activities, and maintain a restricted diet. The Veteran's diabetes mellitus has been evaluated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. Under DC 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. 38 C.F.R. § 4.119, DC 7913 (2013). A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. Id. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. The maximum 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. A review of the evidence dated during the relevant time period reveals that the Veteran's diabetes has been controlled by a restricted diet and use of an oral hypoglycemic agent and/or insulin. In a January 2006 statement, V.R., M.D. recorded a diagnosis of type II diabetes and recommended the use of 500 milligrams of Metformin, twice daily, in combination with a 2000-calorie diabetic diet for control of the Veteran's diabetes. A VA examination was conducted in December 2007. It was noted that the Veteran's diabetes was being controlled by Metformin and Byetta and a restricted diet. The Veteran was not noted to be restricted in his ability to perform strenuous activities and episodes of ketoacidosis or hypoglycemic reactions were denied. In a letter dated in May 2010, B.L. stated that the Veteran's diabetes treatment regime included the use of an oral hypoglycemic agent and an injectable Glucagon-like peptide (GLP), as well as a restricted diet. It was noted that he Veteran was "unable to comply with the recommendation to exercise at least every other day" on account of his physical limitations, to include his neuropathy, which required the occasional use of a wheelchair. VA treatment records contained in the Veteran's Virtual VA file also indicate that the Veteran was wheelchair bound due to complications of his Charcot foot. A June 2010 VA treatment indicates the use of insulin; however, a February 2013 VA treatment record reveals that the Veteran was taken off insulin for a period of time and in May 2013 it was noted that the Veteran was "doing fine w[ith]out insulin." Another VA examination was conducted in April 2013, the report of which notes that the Veteran's diabetes was being controlled by an oral hypoglycemic agent. A restricted diet was not indicated and it was also noted that the Veteran did not require regulation of activities as part of his medical management of diabetes. It was further reported that the Veteran had to visit his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times a month and that he had had no such episodes requiring hospitalization over the past 12 months. Here, the evidence is clear the Veteran's diabetes mellitus, currently rated as 20 percent disabling, is managed by the use of an oral hypoglycemic agent and a restricted diet. The use of insulin has also been demonstrated at times during the claims period. However, to be entitled to a rating greater than the currently assigned 20 percent, there must be evidence demonstrating a restriction of activities, defined in the rating schedule as "avoidance of strenuous occupational and recreational activities." 38 C.F.R. § 4.119, DC 7913; see Camacho v. Nicholson, 21 Vet. App. 360, 363 -64 (2007). That evidence is lacking in this case. Indeed, neither of the VA examiners has noted a need for regulation of activities; nor do any of the Veteran's private providers indicate that the Veteran has been advised not to undertake certain activities. To the extent that the Veteran is arguing that he has been prescribed an exercise program, which should be considered akin to a restriction of activities, the Board finds that that argument is without merit. Indeed, while the evidence suggests that the Veteran has been advised to maintain a certain level of exercise, the evidence does not suggest that the Veteran has been instructed to avoid certain activities on account of his diabetes mellitus. Further, although the Veteran is unable to perform certain activities due to physical limitations, this does not amount to a restriction of activities as contemplated by the rating criteria because of diabetes mellitus. In sum, the Board finds that the competent and probative evidence is against the Veteran's claim for an increased schedular rating for his diabetes mellitus. The evidence also fails to reveal complications of diabetes for which the Veteran is not already in receipt of service-connected disability benefits. See 38 C.F.R. § 4.119, DC 7913, Note (2). In finding that a rating in excess of 20 percent is not warranted, the Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting a higher schedular rating for the Veteran's diabetes mellitus during any applicable time period. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102 (2013). B. Status Post Right and Left Knee Replacements The Veteran's status post right and left knee replacements have been evaluated as 30 percent disabling under 38 C.F.R. § 4.71a, DC 5055, which pertains to knee replacement and provides for a 100 percent rating for one year following implantation of prosthesis and a minimum 30 percent rating following that one-year period. 38 C.F.R. § 4.71a, DC 5055 (2013). Where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Id. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the rating criteria provide that the disability is to be rated by analogy to DCs 5256, 5261 or 5262. Id. The evidence of record reveals that the Veteran underwent a bilateral knee replacement in December 2003. In May 2007, the Veteran requested an increase in evaluation of his then service-connected left knee DJD, indicating that he had undergone a bilateral knee replacement. A VA pain evaluation dated that same month revealed complaints of low back pain, but was silent for knee pain. The Veteran was afforded a VA examination in December 2007. It was noted that the Veteran was then non-ambulatory due to a recent foot/ankle surgery. He stated that otherwise, he would be able to walk without difficulty for about a mile or stand for three hours. The Veteran reported that both knees were doing well. Examination revealed bilateral knee pain, but no deformity, giving way, instability, stiffness, weakness, or effusion. Episodes of dislocation, subluxation, or locking were not noted. The Veteran was able to achieve a range of motion from 0 to 130 degrees. The examiner noted the Veteran's bilateral knee replacement, but stated that at that time, both knees were doing very well and the Veteran's disability was minimal. The examiner also opined that the Veteran's right knee replacement was at least as likely as not the result of the Veteran's service duties as a paratrooper. Regarding the occupational and recreational effects of the Veteran's bilateral knee replacement, the examiner indicated decreased mobility resulting in mild effects on activities of daily living such as shopping, chores, recreation, and travel, and severe effects on his ability to exercise or play sports. In his January 2009 notice of disagreement (NOD), the Veteran reported that although his knee pain was reduced after undergoing the bilateral knee replacement, he still experienced pain and weakness in both knees every day. He also reported being unable to squat or kneel for any length of time, and indicated that walking down stairs was precarious. In a November 2009 statement, the Veteran asserted entitlement to evaluations of 60 percent, stating that he experienced severely painful motion and weakness in each knee, daily. In a February 2010 statement, A.J., M.D. stated that he had been treating the Veteran since November 2003 for a multitude of medical conditions, to include chronic bilateral knee pain. It was noted that the Veteran continued to have crepitus and pain bilaterally following his knee replacements, which limited him from walking any distance. November 2011 and September 2012 VA treatment records, contained in the Veteran's Virtual VA file, indicate that his knee range of motion was within normal limits. The Veteran was afforded another VA examination in April 2013. It was noted that the Veteran had undergone a right below-the-knee amputation in May 2011, secondary to Charcot foot. The Veteran complained of feeling as though his left knee "pops out" when going up an incline. He also indicated instability and pain, as well as right knee pain with motion. Range-of-motion testing revealed flexion to 130 degrees, bilaterally, with no objective evidence of painful motion, and full extension with no objective evidence of pain. Repetitive testing yielded the same results. The Veteran endorsed flare-ups and described the impact of those flare-ups as occasional pain. The examiner considered the Veteran's functional loss on account of such things as decreased motion, weakness, excess fatigability, incoordination, painful motion, swelling, deformity, interference with sitting, standing and weightbearing, and instability of station, and indicated that the Veteran experienced functional loss/functional impairment due to pain on movement. Weakened movement was also noted for the right knee only and there was evidence of tenderness or pain to palpation. Muscle strength testing revealed active movement against some resistance. Lachman, posterior drawer, and valgus and varus tests were all normal, indicating no anterior, posterior, or medial-lateral instability of either knee. There was also no noted history of left knee patellar subluxation/dislocation and no evidence of shin splints, stress fractures, chronic exertional compartment syndrome, or other tibial or fibular impairment. A right meniscal tear was noted, as were frequent episodes of locking of the right knee joint and of joint pain, bilaterally. Regarding the severity of the Veteran's left and right knee replacements, the examiner opined that the Veteran experienced intermediate degrees of residual weakness, pain, or limitation of motion, bilaterally. The examiner considered the occupational impact of the Veteran's bilateral knee disability and determined that the right and left knee disabilities would prevent any physical job or weightbearing, but would not affect a sedentary job. Upon review of the evidence, the Board finds that the currently assigned 30 percent ratings adequately compensate the Veteran for his left and right knee disabilities. Although the Veteran argues for entitlement to 60 percent ratings, alleging that he meets the criteria for such under DC 5055, objective evidence of severe painful motion or weakness is lacking. See 38 C.F.R. § 4.71a, DC 5055. Notably, although complaints of knee pain have been documented in the Veteran's medical records there was no objective evidence of painful motion during either VA examination. Further, in December 2007, the Veteran himself reported that knees were doing well and he indicated that, save for his recent foot/ankle surgery, he would be able to walk without difficulty for about a mile or stand for three hours. There was also no evidence of weakness at the time of that examination and a pain evaluation conducted several months prior was silent for complaints of knee pain. Although weakened movement was noted in the right knee on examination in April 2013, there is no indication that such weakness was severe. In so concluding that higher schedular ratings are not warranted, the Board finds particularly probative the VA examiner's assessment that the Veteran bilateral knee disability resulted in intermediate degrees of residual weakness, pain, or limitation of motion. Regarding the February 2010 statement from Dr. A.J., who indicated that the Veteran's knee pain and crepitus limited him from walking any distance, the Board finds that without a discussion of the functional impact of the Veteran's "multitude of medical conditions," to include his Charcot foot, or a mention of the fact that the Veteran has at various times been wheelchair bound, the Board cannot conclude that Dr. A.J.'s statement is supportive of a 60 percent rating, as it is not clear that Dr. A.J. considered all relevant evidence regarding the Veteran's functional limitations. Further, a review of the Veteran's VA treatment records dated around the time of Dr. A.J.'s statement indicate that the Veteran's functional limitations were caused by his Charcot foot, for which he had undergone a triple arthrodesis and later underwent a below-the-knee amputation. Indeed, a July 2010 primary care note indicates "functional limitations posted by Charcot joints in feet, with neuropathy." In the instant case, the Board finds that the objective evidence of record outweighs the Veteran's statements regarding painful motion and weakness. The Board does not dispute that the Veteran experiences some degree of painful motion and weakness bilaterally, but finds that it does not rise to the level of a severe disability such that a 60 percent rating is warranted under DC 5055 for the Veteran's right or left knee disability. Notably, despite any alleged painful motion, objective testing reveals that the Veteran has been able to achieve nearly a full range of motion, bilaterally, throughout the appeal period. The VA treatment records dated during the relevant time period also fail to reveal evidence demonstrative of severe painful motion or weakness. Although there are instances where it is noted that the Veteran had difficulty walking or was unable to ambulate on his own without losing balance, those instances are related to the Veteran's Charcot foot and/or subsequent prosthesis for his below-the-knee amputation and not specifically to his knee disabilities. Turning to whether a rating in excess of 30 percent is warranted under DCs 5256, 5261 or 5262 for the Veteran's right or left knee disability as required by DC 5055, the Board has considered the evidence of record but does not find that it supports a higher rating under those alternative DCs. First, DC 5256 pertains to ankylosis of the knee, of which there is no evidence. "Ankylosis is defined as the '[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint.'" Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), quoting Stedman's Medical Dictionary 87 (25th ed. 1990). Clearly neither knee joint remains in a fixed position. Further, the evidence demonstrates full extension and flexion to 130 degrees, bilaterally. Even considering any subjective complaints of pain, the Veteran's range of motion is not analogous to favorable ankylosis, and certainly not to favorable ankylosis anywhere between 10 and 45 degrees, which is required for a rating in excess of 30 percent under DC 5256. 38 C.F.R. § 4.71a, DC 5256 (2013). Under DCs 5260 and 5261, pertaining to limitation of motion, a 30 percent rating is the highest rating under 5260, which is applicable where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260 (2013). Under DC 5261, a 40 percent rating is assigned when extension is limited to 30 degrees. 38 C.F.R. § 4.71a, DC 5261 (2013). As noted above, the Veteran has been able to achieve left and right extension to 0 degrees, which is not even extension limited to a noncompensable degree. Id. Accordingly, a rating greater than 30 percent is not warranted based on actual limitation of motion caused by the Veteran's bilateral knee disability because he is already in receipt of the highest rating available for limitation of flexion and has been able to achieve extension beyond that which would be considered even noncompensable. See 38 C.F.R. § 4.71a, DCs 5260, 5261. The Board notes that, when an evaluation of a disability is based on limitation of motion and/or arthritis, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss a veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013). DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. Although the Veteran has complained of pain and weakness, he has consistently been able to achieve greater degrees of motion than that which would be compensable. In this regard, the Court has affirmed that pain itself does not constitute functional loss and "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' 38 C.F.R. § 4.40, in order to constitute functional loss." Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Thus, an evaluation in excess of the minimum compensable rating on account of pain must be based on demonstrated functional impairment. From a functional standpoint, it has been noted that the Veteran has had pain on movement and weakness. However, given the Veteran's ability to achieve flexion to 130 degrees and extension to 0 degrees, it is clear that his pain does not result in a functional loss equivalent to that which would warrant a rating greater than the currently assigned 30 percent under any analogous DC. There is also no evidence of any impairment of the tibia or fibula to allow for application of DC 5262. Furthermore, a rating in excess of 30 percent is not available under any other potentially applicable DC. In sum, the Board finds that the competent and probative evidence is against the Veteran's claims for increased schedular ratings for his service-connected left or right knee disability. In finding that a rating in excess of 30 percent is not warranted for either knee, the Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting a higher schedular rating for the Veteran's left or right knee disability at any point during the applicable time periods. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra; 38 C.F.R. § 3.102. C. Lumbosacral Strain The Veteran's service-connected lumbosacral strain has been rated during the relevant time period as 20 percent disabling under 38 C.F.R. § 4.71a, DC 5237. Currently, the rating criteria provides for the evaluation of spine disabilities under a General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a (2013). Relevant to the issue currently before the Board, the General Rating Formula provides for a 20 percent evaluation when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, where the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, where there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DCs 5235-5243 (2013). A 40 percent evaluation is assigned where forward flexion of the thoracolumbar spine is 30 degrees or less; or where there is favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. Lastly, a 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. Id. Thus, for the Veteran to be entitled to a higher schedular rating for his lumbosacral strain, the evidence must show that he can achieve no more than 30 degrees of forward flexion of the thoracolumbar spine, or that there is ankylosis. Upon review of the evidence, the Board finds that the Veteran is not entitled to a schedular rating greater than the currently assigned 20 percent under the General Rating Formula for his lumbosacral strain. Evidence relevant to this determination consists of the report of an April 2007 CT scan showing multi-level spondylosis and hypertrophy of the facets. In May 2007, the Veteran presented with complaints of low back pain. Triggering factors were noted be lifting, weather, riding in cars/airplanes. Notably, VA examinations conducted in October 2007 and January 2010 contain no range-of-motion findings with respect to the lumbar spine, as it was noted that the Veteran was wheelchair bound at the time of those examinations and unable to complete certain aspects of the examinations. As indicated above, the Veteran was wheelchair bound due to certain complications of other disabilities. There is no evidence to suggest that the Veteran was wheelchair bound on account of his low back disability. Indeed, the October 2007 VA examination report states specifically that the Veteran was wheelchair bound due to a recent foot/ankle surgery. Regarding his low back disability, the Veteran endorsed symptoms of paresthesia, decreased motion, and pain. He denied radiating pain, flare-ups, and incapacitating episodes and the examiner found no evidence of intervertebral disc syndrome. Relevant muscle strength was normal and there was no evidence of atrophy or loss of muscle tone. Reflexes were present and a sensory examination was normal. The January 2010 VA examination report notes a history of fatigue, weakness, stiffness, decreased motion, and pain. Spasms and incapacitating episodes were denied; however, spasms of the thoracic sacrospinalis were noted. Relevant muscle strength was active against some resistance, sensory examination was normal, and relevant reflexes were present. In February 2010, Dr. A.J. submitted a statement wherein he reported that the Veteran suffered diffuse pain along the lower lumbar region and had a decreased range of motion associated with spasms. It was noted that the Veteran had undergone several procedures to alleviate lumbar pain, to include lumbar facet injections, epidural steroid injections, and radiofrequency lesioning. Dr. A.J. indicated that the Veteran's flexion was limited to 30 degrees and his extension to less than 10 degrees with reproduction of pain. In September 2012, however, it was noted in a VA treatment record, contained in his Virtual VA file, that the Veteran's trunk range-of-motion was within normal limits in all planes. A VA examination was conducted in April 2013. The examiner noted the Veteran's complaints of low back pain, daily, with increased severity overnight. Flare-ups were denied. Range-of-motion testing revealed flexion to 80 degrees; extension to 20 degrees; right lateral flexion to 20 degrees; left lateral flexion to 20 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. There was no objective evidence of painful motion and repetitive testing yielded the same results. In terms of functional loss, the VA examiner noted less movement than normal, weakened movement, incoordination, pain on movement, deformity, instability of station, disturbance of locomotion, and interference with sitting, standing, and/or weightbearing. There was no tenderness upon palpation of the lumbar paravertebral muscles. Guarding or muscle spasm was noted, but it was noted severe enough to result in abnormal spinal contour. Muscle strength testing showed active movement against some resistance and there was no evidence of muscle atrophy. Reflexes were present, but sensory examination revealed some decreased sensation to the left thigh/knee, lower leg/ankle, and foot/toes. The examiner found no signs or symptoms due to radiculopathy, but also indicated involvement of the sciatic nerve, stating that the left side was mildly affected. Intervertebral disc syndrome was not noted. At the outset, the Board acknowledges that Dr. A.J.'s February 2010 statement could potentially support a higher rating, as he indicated that the Veteran was able to achieve no more than 30 degrees of forward flexion, which would meet the criteria for a 40 percent rating. The Board finds reason, however, to question the probative value of Dr. A.J.'s report. Notably, Dr. A.J. provides no details with regard to when he conducted any range-of-motion testing on the Veteran; nor does he indicate that his findings were based in fact upon objective testing, as opposed to estimation. Such detail is important where, as here, the evidence indicates that the Veteran was wheelchair bound at or around the time that the Dr. A.J. wrote his statement. Indeed, Dr. A.J. makes no mention of the fact that the Veteran was wheelchair bound. Dr. A.J. also submitted no supporting evidence, such as treatment records recording any range-of-motion findings, despite indicating that he had been treating the Veteran since 2003. (The Veteran was also requested to sign the necessary authorizations for release of information to VA so as to enable VA to procure these records, but failed to do so.) Given that the Board cannot discern from Dr. A.J.'s statement how he arrived at the conclusion that the Veteran was limited to 30 degrees of flexion and the fact that his statement contains no indication of whether that was a recent finding nor a discussion of the fact that the Veteran was wheelchair bound, the Board finds reason to the question the accuracy of such findings and will, therefore, not rely on them in this case. Turning to the other evidence of record, the Board notes that while it shows that the Veteran is unable to achieve a full range of thoracolumbar motion, see 38 C.F.R. § 4.71a, Plate V, he is able to achieve flexion to at least 80 degrees, with no evidence of pain. This does not demonstrate that his thoracolumbar motion is limited to 30 degrees of flexion, the criteria for a 40 percent evaluation under the General Rating Formula. The Board also acknowledges that Veteran's complaints of back pain and has considered application of the factors described in 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca, supra, but finds that these additional considerations cannot support a rating in excess of the currently assigned 20 percent. This is so because, as discussed above, the Court has affirmed that "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' 38 C.F.R. § 4.40, in order to constitute functional loss." Mitchell, supra. Given the Veteran's ability to achieve flexion to 80 degrees, with no objective evidence of pain, it is clear that any subjective pain did not result in a functional loss equivalent to that which would warrant a rating greater than 20 percent under the General Rating Formula. The Board also finds that the Veteran's complaints of pain have been accounted for by his 20 percent schedular rating, as forward flexion to 80 degrees would not qualify him for even the minimum 10 percent rating under the General Rating Formula. Further, examination of the Veteran has failed to reveal any additional functional impairment with repetitive testing. From a functional standpoint, it has been noted that the Veteran had less movement than normal, weakened movement, incoordination, pain on movement, deformity, instability of station, disturbance of locomotion, and interference with sitting, standing, and/or weightbearing; however, he has clearly been able to achieve a greater range of motion than that required for a 40 percent disability rating, even taking into account the DeLuca factors, at all times since filing his claim for increased compensation. Moreover, as demonstrated by the range-of-motion findings of record, there is no evidence of ankylosis, as the Veteran's thoracolumbar spine does not appear to be fixed or immobile. See Dinsay, supra. Accordingly, as the evidence reveals that the Veteran's flexion is not limited to 30 degrees or less, even with consideration of functional losses, the Board finds that a schedular rating greater than the currently assigned 20 percent is not warranted under the General Rating Formula. Further, as there is no indication of intervertebral disc syndrome, the Board finds no basis upon which to consider whether the Veteran is entitled to a rating greater than 20 percent based on incapacitating episodes. See 38 C.F.R. 4.71a, DC 5243. The General Rating Formula also requires associated objective neurologic abnormalities to be evaluated separately under an appropriate DC. In the instant case, the Board finds that, when reasonable doubt is resolved in the Veteran's favor, the clinical evidence of record suggests involvement of the sciatic nerve associated with the Veteran's lumbar spine disability resulting in decreased sensation in the left lower extremity. Although the April 2013 VA examination report is somewhat unclear as to whether the Veteran indeed has radiculopathy, the examiner indicated an abnormal sensory examination and noted involvement of the sciatic nerve. Based on the April 2013 VA examination report, the Board finds that the criteria for a separate 10 percent rating is warranted under 38 C.F.R. § 4.124a, DC 8520, which provides for a 10 percent rating for mild incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, DC 8520 (2013); see 38 C.F.R. § 4.124a, DCs 8510-8719 (introduction) (providing that when the involvement is wholly sensory, the rating should be for the mild, or at most, moderate degree). D. DJD of the Cervical Spine As noted in the introduction, the Veteran's service-connected DJD of the cervical spine was evaluated as 10 percent disabling until April 8, 2013; a 20 percent has been assigned from April 8, 2013. Relevant to rating disabilities of the cervical spine, the General Rating Formula for spine disabilities provides for a 10 percent evaluation when forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or, when the combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or, where there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, when vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, DCs 5235-5243. A 20 percent evaluation is assigned when forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, where the combined range of motion of the cervical spine is not greater than 170 degrees; or, where there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent evaluation is assigned where forward flexion of the cervical spine is 15 degrees or less; or where there is favorable ankylosis of the entire cervical spine. Id. A 40 percent evaluation is assigned for unfavorable ankylosis of the entire cervical spine. Id. Lastly, a 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. At the outset, the Board notes that range-of-motion testing was unable to be conducted during an October 2007 VA examination due to the fact that the Veteran had recently undergone foot surgery and was wheelchair bound. Evidence submitted by the Veteran in connection with his claim pre-dates his claim for increase by well more than one year and thus is not relevant to the matter currently before the Board. A VA spine examination was conducted in January 2010. The Veteran related that he had undergone a CT scan of the cervical spine three months prior, "which showed 'more narrowing of the discs and spondylosis.'" (As noted above, attempts were made to obtain a copy of this CT report, but the Veteran failed to respond to VA's request for information.) It was noted that the Veteran was wheelchair bound at the time and unable to walk. (As discussed above, the evidence demonstrates that the Veteran was wheelchair bound due to complications of Charcot foot and lower extremity neuropathy.) Regarding symptoms of his cervical spine disability, the Veteran reported decreased motion, stiffness, weakness, and pain. He described the pain to be mild to moderate, occasionally sharp in nature, and occurring daily, lasting for hours. There was no evidence of cervical spine ankylosis, but kyphosis was noted, as was spasm, guarding, and painful motion of the cervical sacrospinalis. Atrophy, tenderness, and weakness were not observed. There was also no evidence of neurological symptoms related to the cervical spine, as all relevant reflexes, senses, and muscular movements were present. Range-of-motion testing revealed flexion from 0 to 40 degrees; extension from 0 to 30 degrees; lateral flexion to 30 degrees, bilaterally; and lateral rotation to 70 degrees, bilaterally. There was no objective evidence of pain on active motion and additional limitations following repetitive motion testing were not noted. It was indicated that the examination was limited due to the fact that the Veteran was wheelchair bound and unable to stand. In his February 2010 letter, Dr. A.J. indicated that the Veteran's most recent CT scan revealed extensive multi-level spondylosis with extensive multi-level moderate bilateral neural foramina narrowing, most severe at C3-C6. In appealing his cervical spine rating to the Board, the Veteran asserted entitlement to a 40 percent rating, stating that he suffered from headaches, limited range of motion, spasms, and tenderness. A September 2011 VA treatment record contained in the Veteran's Virtual VA file indicates that he Veteran presented with complaints of neck pain. He reported increased neck pain with sitting and cervical rotation, bilaterally. Range-of-motion testing revealed all relevant ranges of motion to be within normal limits, but it was noted that the lateral rotation produced pain, bilaterally. Another VA examination was conducted in April 2013. The Veteran reported pain and decreased motion, but denied flare-ups. Range-of-motion testing showed flexion to 30 degrees, without pain; posterior flexion to 30 degrees, without pain; right lateral flexion to 40 degrees, without pain; left lateral flexion to 25 degrees, without pain; and lateral rotation to 60 degrees, bilaterally, without pain. Repetitive testing yielded the same results. Functional impairment was noted to be less movement than normal, weakened movement, and pain on movement. Also indicated were localized tenderness or pain on palpation and guarding or muscle spasms of the cervical spine, not resulting in an abnormal gait or spinal contour. Relevant muscle strengths were active against some resistance, and there was no evidence of atrophy. Sensory examination was normal, but reflex testing revealed an absence of relevant reflexes. The examiner indicated the presence of radicular pain or other signs or symptoms due to radiculopathy, to include moderate to severe pain, mild paresthesia and/or dysesthesia, and mild numbness of the left upper extremity. Nerve root involvement was noted to be C5-C6. X-rays showed a mild loss of lordotic curvature within the cervical spine with moderate diffuse degenerative changes noted within the middle to lower cervical spine. Facet atrophy was presented, but there was no evidence of abnormal alignment or acute fracture. The examiner also indicated no intervertebral disc syndrome. Regarding the Veteran's orthopedic manifestations of his cervical spine DJD, the Board finds no basis upon which to assign rating greater than 10 percent prior to April 8, 2013. In this regard, there are no documented range-of-motion findings during the relevant time period prior to the January 2010 VA examination, at which time the Veteran was able to achieve flexion to 40 degrees and had a combined range of motion of 270 degrees. While these range-of-motion findings represent less than a full range of cervical spine motion, see 38 C.F.R. § 4.71a, Plate V, they do not indicate that his cervical motion was limited to 30 degrees of flexion or to a combined range of motion of 170 degrees, the criteria for 20 percent evaluation under the General Rating Formula. Moreover, range-of-motion testing conducted in September 2011 revealed all relevant ranges of motion to be within normal limits. The Board notes that although there is some suggestion that the Veteran has kyphosis, as well as muscle spasm and guarding, there is no indication that the Veteran's kyphosis resulted from his muscle spasm or guarding. Indeed, while muscle spasm was noted on examination, a history of muscle spasm was denied. Further, the April 2013 VA examiner specifically indicated that the Veteran's guarding and muscle spasm did not result in spinal contour. Based on this evidence, the Board cannot assign a rating greater than the currently assigned 10 percent for the Veteran's cervical spine DJD The Board also acknowledges the Veteran's complaints of neck pain and has considered application of the factors described in 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca, supra, but finds that these additional considerations cannot support a rating in excess of 10 percent. This is so because, as discussed above, the Court has affirmed that "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' 38 C.F.R. § 4.40, in order to constitute functional loss." Mitchell, supra. Given the Veteran's ability to achieve flexion to 40 degrees, with no objective evidence of pain, it is clear that any subjective pain did not result in a functional loss equivalent to that which would warrant a rating greater than 10 percent under the General Rating Formula for Diseases at any time prior to the April 8, 2013, VA examination. The April 8, 2013, VA examination, however, demonstrates that the criteria for a 20 were met, as evidenced by the Veteran's ability to achieve only 30 degrees of flexion at that time. The examination report does not support the assignment of rating greater than 20 percent, as the Veteran's ability to achieve 30 degrees of flexion, without pain, in addition to some range of motion in all directions, clearly does not demonstrate ankylosis, as there is no indication that the Veteran's cervical spine is fixed or immobile. See Dinsay, supra. Further, examination of the Veteran failed to reveal any additional weakness, fatigability, incoordination, restricted range of motion, or functional impairment with repetitive testing. From a functional standpoint, it has been noted that the Veteran had less movement than normal and pain on movement; however, he has clearly been able to achieve a greater range of motion than that required for a 30 percent disability rating, even taking into account the DeLuca factors as of the April 8, 2013, VA examination. Accordingly, as the evidence reveals that from April 8, 2013, the Veteran has had a demonstrated range of cervical motion and his flexion has not been limited to at least 15 degrees, even with consideration of functional losses, the Board finds that a rating greater than the currently assigned 20 percent is not warranted under the General Rating Formula for Diseases is not warranted at any point since April 8, 2013. As the Veteran's disability is rated under DC 5243, which pertains to intervertebral disc syndrome, the Board has also considered whether he is entitled to ratings greater than those assigned based on incapacitating episodes. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. 38 C.F.R. 4.71a, DC 5243. Note 1 of that DC provides that, for purposes of evaluations under DC 5243, 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. Id. at Note (1). Notably, the evidence of record does not indicate that the Veteran indeed has intervertebral disc syndrome of the cervical spine, despite the fact that he is now rated under DC 5243. The April 2013 VA examiner specifically stated that intervertebral disc syndrome was not present. In any event, the Veteran has not alleged, nor does the evidence of record suggest, that he experiences incapacitating episodes, such that a physician has prescribed bed rest, on account of his cervical spine disability. Accordingly, the Board can find no basis upon which to assign ratings greater than those currently assigned at any point during the claims period. See 38 C.F.R. 4.71a, DC 5243. ORDER Entitlement to an initial schedular rating in excess of 20 percent for diabetes mellitus, Type II, is denied. Entitlement to an initial schedular rating in excess of 30 percent for status post right knee replacement is denied. Entitlement to a schedular rating in excess of 30 percent for service-connected status post left knee replacement is denied. Entitlement to a schedular rating in excess of 20 percent for service-connected lumbosacral strain is denied. Entitlement to a schedular rating in excess of 10 percent for orthopedic manifestations of service-connected DJD of the cervical spine prior to April 8, 2013, or in excess of 20 percent thereafter is denied. Entitlement to a separate 10 percent schedular rating for neurological deficits of the left lower extremity associated with lumbosacral strain is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND As stated above, the General Rating Formula requires associated objective neurologic abnormalities to be evaluated separately under an appropriate DC. In the instant case, the Board finds that the clinical evidence of record suggests that the Veteran has radiculopathy of the left upper extremity, as demonstrated by the April 2013 VA examiner's findings of moderate to severe pain, mild paresthesia and/or dysesthesia, and mild numbness of the left upper extremity and indicated nerve root involvement of C5-C6. Curiously, however, when asked to indicate the severity of the Veteran's radiculopathy and the side affected, the VA examiner stated that neither side was affected. Given the apparent inconsistencies in the April 2013 VA examiner's findings, the Board finds it necessary to remand the issue of entitlement to a separate compensable rating for neurologic manifestations of his cervical spine disability for the Veteran to be afforded a VA examination for the specific purpose of indentifying all associated neurologic abnormalities. In this regard, the Board notes that the Veteran and his private physician have both suggested that the Veteran also suffers from headaches related to his cervical spine disability. The Veteran's assertion should be considered as part of the matter being remanded. The Board also finds that the issue of entitlement to TDIU based on a singular service-connected disability requires further development. That matter was previously remanded in connection with the Veteran's increased rating claims in light of the Court's holding in Bradley v. Peake, wherein the Court stated that VA should potentially consider whether TDIU is warranted for a particular service-connected disability even when a schedular 100-percent rating is already in effect for combined service-connected disabilities in order to determine the veteran's eligibility for special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). 22 Vet. App. 280, 294 (2008). (Because of this, the decision above with respect to the diabetes, knees, lumbosacral spine, and cervical spine was limited to the question of higher schedular ratings without regard to whether any extraschedular award based on TDIU should be made.) In the instant case, the Veteran has been in receipt of a combined 100 percent schedular evaluation since May 22, 2007, and has variously been in receipt of SMC under section 1114(s) during the pendency of his appeal. However, the Veteran has not been in receipt of SMC under section 1114(s) throughout the entire pendency of his claim. Based on private medical evidence submitted along with the Veteran's VA Form 9, which suggested that the Veteran would be unable "to obtain employment under which his training commences" on account of certain service-connected disabilities, the Board, in its October 2012 remand, requested that the VA examiner(s) provide an opinion as to whether the Veteran is unemployable due to any single service-connected disability at issue, such that an award of TDIU could be made for a single service-connected disability. A review of the April 2013 VA examination reports reveals that the VA examiner, although finding that the Veteran's back, neck, and knee disabilities would impact his ability to engage in physical employment, indicated no unemployability on account of the Veteran's orthopedic disabilities, finding that those disabilities would not preclude him from engaging in sedentary employment. The VA examiner also found that the Veteran's diabetes mellitus would have no occupational impact. It does not appear, however, that the examiner elicited from the Veteran any information regarding his occupational and educational history. Without such information, it cannot be said that the examiner's opinion was based on all relevant evidence and his conclusion regarding employability was not fully formed. Accordingly, the case is REMANDED to the AOJ for the following action: 1. The AOJ should schedule the Veteran for a VA examination in connection with the issue of entitlement to separate compensable ratings for any neurologic abnormalities associated with the Veteran's cervical spine disability, to specifically include radiculopathy of the left upper extremity and headaches. (Advise the Veteran that failure to appear for an examination as requested, and without good cause, could adversely affect his appeal. See 38 C.F.R. § 3.655 (2013).) The claims folder, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. All necessary tests and studies should be conducted and the examiner should review the results of any testing and include them in the report. The examiner should identify any neurological symptoms related to the service-connected cervical spine disability and fully describe the extent and severity of those symptoms. With regard to any associated objective neurological abnormalities, the examiner should identify each nerve affected, or seemingly affected, and describe the degree of disability as "mild," "moderate," "moderately severe," "severe," or "complete paralysis." If the examiner finds that the Veteran does not have radiculopathy of the left upper extremity, the examiner must fully discuss his/her findings in this regard and provide reasons for why he/she disagrees with the April 2013 VA examiner's notation of C5-C6 nerve root involvement. The examiner should also determine whether the Veteran's alleged headaches are in any way associated with his cervical spine disability. If headaches are found to be associated with the Veteran's cervical spine disability, the examination should include findings regarding the severity and frequency of the Veteran's headaches. A complete rationale for all opinions provided, to include citation to pertinent evidence of record and/or medical authority, as appropriate, should be set forth in detail and explained in the context of the record. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record (i.e., additional facts are required). 2. An examination should also be conducted with regard to the issue of entitlement to TDIU based on a single service connected disability. The examiner must take a detailed history regarding the Veteran's employment and education and vocational attainment. The examiner should then review the Veteran's claims folder, including a copy of this remand, and provide a definite opinion as to whether any of the following disabilities alone renders him unable to secure or follow substantially gainful employment consistent with the Veteran's education and occupational experience: (1) status post right knee replacement; (2) status post left knee replacement; (3) lumbosacral strain with associated neurologic symptoms; (4) diabetes mellitus; or (5) cervical spine DJD with any associated neurologic symptoms. A complete rationale for all opinions provided, to include citation to pertinent evidence of record and/or medical authority, as appropriate, should be set forth in detail and explained in the context of the record. The examiner's opinion must include a discussion of the Veteran's previous employment history. If the examiner feels that the requested opinions with respect to each separate disability cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record (i.e., additional facts are required). 3. The AOJ must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request, especially with respect to the VA examiner eliciting from the Veteran a detailed occupational and educational history and discussing the occupational impact of each service-connected disability separately. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, the AOJ should readjudicate the issue of entitlement to separate compensable ratings for any identified neurologic abnormality associated with the Veteran's cervical spine disability, to specifically include upper extremity radiculopathy and/or headaches. The AOJ must also specifically consider whether a rating of TDIU is warranted as part of its readjudication of the remanded matter, which must include consideration of whether TDIU is warranted for any single disability. If it is determined that any service-connected disability alone renders the Veteran unemployable, the AOJ must consider whether the Veteran is entitled to SMC under 38 U.S.C.A. § 1114(s) for any period when the benefit is not already in effect. If a benefit sought on appeal is not granted, the Veteran and his representative must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs