Citation Nr: 1724944 Decision Date: 06/29/17 Archive Date: 07/10/17 DOCKET NO. 10-37 029 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for thoracolumbar spine, degenerative disc disease (low back disability). 2. Entitlement to an initial evaluation in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent beginning February 4, 2011 for radiculopathy, right lower extremity. 3. Entitlement to an initial evaluation in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent beginning February 4, 2011 for radiculopathy, left lower extremity. 4. Entitlement to an evaluation in excess of 20 percent disabling for hypertension. 5. Entitlement to an increased rating in excess of 20 percent for a right ankle disorder prior to November 17, 2014 and in excess of 10 percent thereafter. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shana Z. Siesser, Counsel INTRODUCTION The Veteran served on active duty from November 1980 to October 1988. These matters originally came to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO). A February 2004 rating decision denied the Veteran's claim of service connection for a lumbar spine disorder. He appealed this decision and a December 2009 rating decision granted his service connection claim and assigned a 20 percent rating for degenerative disc disease of the thoracolumbar spine, along with 10 percent ratings for radiculopathies of the bilateral lower extremities. In a January 2010 rating decision, the RO continued the Veteran's 20 percent rating for hypertension. An August 2012 rating decision granted the Veteran's claims for an earlier effective date of July 26, 2004 for the grant of service connection and the assignment of 10 percent ratings for radiculopathies of the bilateral lower extremities and granted increased ratings of 20 percent, effective February 4, 2011. In a February 2013 rating decision, the RO denied the Veteran an increased rating in excess of 20 percent for a right ankle disorder. The claims for increased ratings for increased evaluations of the spine, radiculopathies, and hypertension were previously before the Board in March 2013, at which time they were remanded for further development. The Veteran testified at a personal hearing before the undersigned Veterans Law Judge sitting at the RO in July 2013 regarding his lumbar spine disorder, bilateral radiculopathies, and hypertension. A transcript of the hearing is included in the file. A November 2014 rating decision decreased the rating for a right ankle disorder to 10 percent, effective November 17, 2014. The issues of an increased rating for hypertension and a right ankle disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. At worst, the Veteran's lumbosacral strain was manifested by forward flexion to 35 degrees with no additional functional limitation due to pain. 2. Prior to February 4, 2011, the Veteran's service-connected radiculopathies of the right and left lower extremities were manifested by mild incomplete paralysis of the sciatic nerves. 3. Since February 4, 2011, the Veteran's service-connected radiculopathies of the right and left lower extremities have been manifested by moderate incomplete paralysis of the sciatic nerves. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for a lumber spine disorder have not been met. 38 U.S.C.A. §§ 1155, 5100, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1-4.7, 4.10, 4.71a, Diagnostic Code 5237 (2016). 2. The criteria for entitlement to an initial rating for a radiculopathy of the right lower extremity in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent thereafter have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.327, 4.1, 4.2, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8520 (2016). 3. The criteria for entitlement to an initial rating for radiculopathy of the left lower extremity in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent thereafter have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.327, 4.1, 4.2, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8520 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2016). In a claim for an increased rating, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was provided with the relevant notice and information. He has not alleged any notice deficiency during the adjudication of that claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA's duty to assist under the VCAA includes helping claimants to obtain pertinent records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (c). The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159 (c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159 (c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Appropriate VA medical inquiry was accomplished, and the VA medical examination reports are factually informed, medically competent, and responsive to the issues under consideration. Monzingo v Shinseki, 26 Vet. App. 97 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran appeared at a Board hearing before the undersigned Veterans Law Judge (VLJ) in July 2013. A VLJ who conducts a hearing must comply with 38 C.F.R. 3.103 (c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) the duty to fully explain the issue or issues on appeal and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the Veteran was assisted at the Board hearing by an attorney. During the Veteran's hearing, the VLJ and the Veteran's representative asked the Veteran questions to ascertain the basis of the claims. They also asked questions regarding current treatment. The hearing focused on the elements necessary to substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103 (c)(2) nor identified any prejudice in the conduct of the Board hearing. As such, the Board finds that the VLJ complied with the duties set forth in 38 C.F.R. 3.103 (c)(2), consistent with Bryant, and that any error in notice provided during the Veteran's hearing constitutes harmless error. Finally, the Board finds that the AOJ sufficiently complied with the remand directives of the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Increased rating claims Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2016). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21 (2016). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3. A veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue (i.e., an increased rating claim), the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Lumbar spine disorder Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 20 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if 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, Diagnostic Codes 5235-5243. A 40 percent evaluation is warranted if the forward flexion of the thoracolumbar spine is 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted if there is unfavorable ankylosis of the entire spine. Id. There are several notes set out after the diagnostic criteria, with the following applying to this case: For purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of thoracolumbar spine is to 240 degrees. Also, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Each range of motion should be rounded to the nearest 5 degrees. Id. Also, Note 1 after the General Rating Formula states that one should also evaluate any associated objective neurological abnormalities, including but not limited to bladder impairment, separately, under the appropriate diagnostic code. Id. The record reflects that the Veteran has complained of low back pain throughout the course of this period on appeal. However, as discussed above, to warrant a 40 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show that the Veteran's back disability results in forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The Veteran submitted a March 2005 evaluation from a private physician. The report noted that that Veteran presented with low back pain after a twisting injury two years prior. Since that time, the pain had gotten progressively worse. An examination of the back showed normal lordosis, no tenderness of the lumbar paraspinals, but tenderness of the LS triangle and the lumbosacral area. Range of motion was normal in flexion, extension, and lateral flexion. A May 2005 MRI of the lumbar spine showed a mild symmetrical bulge of the disc at the 4-5 level which with degenerative changes of the facets results in a mild degree of spinal stenosis. Treatment records from 2006 through 2009 showed he had on and off back pain that radiated to his hips. He had normal lordosis, tenderness of the bilateral lumbar paraspinals, LS triangle, no spasm, and normal posture. The records noted decreased spinal motion in flexion and extension but lateral flexion was within normal limits and he had a normal gait. In an October 2009 VA examination, the Veteran reported progressively worsening pain in his back since service. He reported symptoms of fatigue, decreased motion, stiffness, numbness, weakness, spasms, pain, parasthesias, and unsteadiness. His posture was normal with an antalgic gait. He had lumbar flattening but no other abnormal spinal curvatures or ankylosis. A physical examination showed spasm on the right and bilateral guarding, pain with notion, and tenderness. Range of motion testing showed flexion to 40 degrees, extension to 10 degrees, left lateral flexion to 10 degrees, right lateral flexion to 15 degrees, and bilateral rotation to 10 degrees with objective evidence of pain on active range of motion. The Veteran was able to perform repetitive use testing with a loss of an additional 5 degrees of flexion and extension due to pain. X-rays of the lumbar spine were normal. The examiner diagnosed thoracolumbar spine degenerative disc disease with bilateral radiculopathy. He opined that it had significant effects on the Veteran's usual occupation in that it caused increased absenteeism due to pain and decreased mobility. The Veteran underwent a VA examination in February 2011. He reported symptoms of fatigue, decreased motion, stiffness, numbness, weakness, spasms, pain, parasthesias, and unsteadiness. He complained of severe flare-ups nightly, precluding sleep. The examiner noted no hospital admissions or physician-prescribed bed rest during the prior 12 months. A physical inspection of the spine showed normal posture and head position, but with an antalgic gait. He had no abnormal spinal curvatures and no ankylosis. Range of motion testing showed flexion to 80 degrees, extension to 20 degrees, bilateral flexion to 25 degrees, and bilateral rotation to 20 degrees with objective evidence of pain on active motion. The Veteran was able to perform repetitive motion testing with objective evidence of pain, but no additional limitations. Muscle tone was normal with no atrophy. X-rays were normal. The examiner noted that the Veteran was presently employed but had lost 8 days at work due to "not feeling right" and had to leave his prior job as a police officer due to back, knee, and ankle pain. The Veteran appeared at a Board hearing in July 2013. He testified that he has back pain and has difficulty bending, sitting, or walking long distances. He contended that his disabilities affected his employment as he was restricted in which assignments he felt he could undertake. The Veteran was afforded a VA examination in May 2014. He reported persistent, worsening low back pain for the past three years. His pain was aggravated by prolonged sitting, bending, and lifting. The pain radiates to his lower extremities. The Veteran described acute flare-ups of pain monthly, requiring one to two days of rest. Range of motion testing showed flexion to 45 degrees with pain at 40 degrees, extension to 15 degrees with pain at 15 degrees, bilateral flexion to 20 degrees with pain at 20 degrees, and bilateral rotation to 30 degrees with pain at 20 degrees. The Veteran was able to perform repetitive use testing with no additional limitations. Functional impairment included less movement than normal, weakened movement, excess fatigueability, pain on movement, and interference with sitting, standing, and/or weight-bearing. Guarding, pain, and localized tenderness of the lower lumbar midline were noted but there was no muscle spasm. No ankylosis was found. The examiner further stated that the Veteran did not have IVDS of the thoracolumbar spine. An x-ray of his lumbosacral spine was normal. The examiner concluded that the Veteran has "marked decreased ROM of the lumbar spine associated with pain. On this examination, the Veteran has evidence of weakness, easy fatigability, and interference with sitting, standing, or weight bearing due to the lumbar spine condition. The Veteran reports that with a flare-up or repetitive use, he is unable to quantify or describe how much, if any, loss of motion there is in terms of degrees without mere speculation. For the reasons given, this Veteran would have a severe impairment in performing physical labor due to his lumbar spine condition. This condition would also mildly impair the Veteran from performing sedentary labor as his pain is aggravated by prolonged sitting." Review of the evidence of record reveals that the Veteran's lumbar spine symptomatology does not approximate a 40 percent disability rating. With respect to favorable ankylosis of the entire thoracolumbar spine, the objective medical evidence of record is pertinently absent any indication that ankylosis exists. "Ankylosis" is immobility and consolidation of a joint due to a disease, injury, surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Medicine 68 (4th Ed. 1987)]. Neither the medical or lay evidence of record suggests that the Veteran's lumbar spine is immobile. On the contrary, the record shows that the Veteran has maintained motion, albeit limited motion, throughout the course of the appeal. Specifically, the competent evidence of record demonstrates that the Veteran has maintained forward flexion to 35 degrees or more throughout the entire period on appeal. The Board has also addressed the provisions of 38 C.F.R. § 4.40 and 4.45 (2016). See DeLuca, supra; Mitchell, supra. The Board recognizes the Veteran's complaints of significant pain and functional loss as a result of his lumbar spine disability, specifically that his flexion was to 35 degrees at the October 2009 VA examination after repetitive use testing. Therefore, although the Board recognizes that the Veteran has pain on motion and functional limitations, there are no clinical findings that would warrant an increased evaluation under 38 C.F.R. § 4.40 and 4.45. The Board further finds that the current 20 percent rating adequately compensates the Veteran for any functional impairment attributable to his lumbar spine disability. See 38 C.F.R. §§ 4.41, 4.10 (2016). As the Veteran was not noted to have a diagnosis of IVDS or physician-prescribed episodes of bedrest, a rating under Diagnostic Code 5243 based on incapacitating episodes is not warranted. The Board finds the Veteran to be competent and credible to describe his symptoms as he has personally experienced them, but finds that the objective medical evidence is more probative in assigning a rating in accordance with the schedular criteria. Therefore, the Board cannot grant an increased rating for the Veteran's lumbosacral spine disability. Bilateral radiculopathies of the lower extremities The Veteran's right and left lower extremity radiculopathies are evaluated under Diagnostic Code 8520, which provides ratings for paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Mild incomplete paralysis is rated 10 percent disabling. Moderate incomplete paralysis is rated 20 percent disabling. Moderately severe incomplete paralysis is rated 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve, in which the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost, is rated 80 percent disabling. A note preceding the Schedule of Ratings for Diseases of the Peripheral Nerves provides that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve. The note further states that when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2014); 38 C.F.R. §§ 4.2, 4.6. The VA's Adjudication Manual does provide guidance in evaluating the severity of nerve paralysis. According to the Manual, "mild" incomplete paralysis is demonstrated by subjective symptoms or diminished sensation. M21-1, Part III, Subpart iv, 4.G.4.b. "Moderate" incomplete paralysis is manifested by the absence of sensation confirmed by objective findings. Id. "Severe" incomplete paralysis is manifested when more than sensory findings are demonstrated, such as atrophy, weakness, and diminished reflexes. Id. A separate evaluation may be assigned for symptoms that are separate and distinct, do not overlap, and are attributed to different lower extremity nerves. M21-1, Part III, Subpart iv, 4.G.4.d. This means that separate evaluations are warranted when symptoms arise from any of the five nerve branches listed in the table in M21-1, Part III, Subpart iv, 4.G.4.c. Treatment records from 2007 show the Veteran experienced back pain with pain and numbness radiating down his legs. At the October 2009 VA examination, the Veteran complained of intermittent radiating pain down both legs. A sensory examination was normal. A detailed reflex examination showed hypoactive knee and ankle jerk, bilaterally. A motor examination was normal with normal tone and no muscle atrophy. At the February 2011 VA examination, the Veteran complained of numbness, decreased motion, stiffness, weakness, spasms, and pain radiating down both legs with numbness and tingling in the legs and feet. A reflex examination showed absent knee and ankle jerk bilaterally. A sensory examination of the right leg showed decreased sensation to the pain/pinprick of the toes and absent sensation to light touch of the toes and absent pain/pinprick and light touch sensation of the left leg with dysesthesias, manifested as numbness/tingling in the toes. A motor examination of the right lower extremity was normal, but the left lower extremity showed active moment only against some resistance. There was no evidence of imbalance, tremor, or fasciculations and no joint function was impacted. The Veteran appeared at a Board hearing in July 2013. He testified that his radiculopathies had increased in severity. Specifically, he testified that he had pain radiating down his legs and increased difficulty walking. The Veteran stated that his right leg is worse than his left. At a May 2014 peripheral nerves examination, the Veteran reported shooting pains down both legs that can last for hours, as well as numbness and tingling in his feet 3 to 4 times weekly. The examiner noted severe intermittent pain of the right lower extremity and moderate intermittent pain on the left, mild parasthesias bilaterally, and mild numbness bilaterally. Muscle strength testing showed decreased muscle strength of the right ankle; however, this was noted to be due to his right ankle disorder and not his radiculopathy. A reflex examination was normal but a sensory examination showed decreased sensation to light touch of the right foot/toes and absent sensation on the left. No trophic changes were noted. The examiner concluded that the Veteran has mild incomplete paralysis of the bilateral sciatic nerves. An August 2014 treatment record shows the Veteran complained of periodic numbness of the feet. After a review of the evidence of record, the Board finds that prior to February 4, 2011, a rating in excess of 10 percent is not supported by the evidence. A 10 percent rating contemplates a mild disability that is predominantly sensory, including pain and decreased sensation, which was nature of the Veteran's right and left lower extremity disabilities during that period. While purely sensory symptoms may be rated as moderate in some cases, the evidence does not establish that the Veteran had a moderate disability during this period to warrant a rating in excess of 10 percent. From February 4, 2011, the Veteran's overall disability was no greater than moderate in nature. The Veteran's sensory symptom of pain was present, along with decreased and absent sensation to the toes and feet and motor weakness. Thus, the disability was more than sensory in nature, but the increased impairment was found to be no greater than moderate. At no point during the period on appeal did the Veteran have moderately severe incomplete paralysis of the bilateral lower extremities. The May 2014 VA examiner specifically noted that the Veteran had mild incomplete paralysis of the bilateral sciatic nerves, despite findings of severe and moderate intermittent pain. Consequently, a rating in excess of 20 percent is denied. The Board has considered the Veteran's lay statements regarding the severity of his radiculopathies and finds him to be competent and credible as to the sensations he experiences. However, the objective findings of the VA examiners, which included consideration of the Veteran's statements, are more probative in assigning ratings in accordance with the Schedule. Therefore, the preponderance of the evidence is against granting an increase in the ratings that are currently assigned. Extraschedular evaluations The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321 (b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321 (b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations noted above are adequate. The Veteran is in receipt of both orthopedic and neurologic ratings for his left arm, which the symptoms of which are contemplated by the schedular criteria and additional higher ratings are available. The Board has noted when the Veteran's symptoms span different ratings under the criteria. The Board discussed why the Veteran's symptoms did not reach the next higher level of symptoms associated with an increased rating for each disability. As such, the diagnostic criteria reasonable describe and contemplate the severity and symptomatology of the Veteran's back and leg disorders. As the rating schedules are adequate to evaluate the disabilities, referral for extraschedular consideration is not in order. Finally, the Board notes that under Johnson v. McDonald, 762 F.3d. 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER Entitlement to an initial evaluation in excess of 20 percent for thoracolumbar spine, degenerative disc disease is denied. Entitlement to an initial evaluation in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent thereafter for radiculopathy, right lower extremity is denied. Entitlement to an initial evaluation in excess of 10 percent prior to February 4, 2011 and in excess of 20 percent thereafter for radiculopathy, left lower extremity is denied. REMAND Regarding the claim for an increased rating for his service-connected hypertension, the Veteran's most recent VA examination was in February 2011. His blood pressure readings at that examination were 124/82, 142/84, and 138/82. VA treatment records from October 2016 show that the Veteran had elevated readings of 153/99 and 162/102. The Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. 38 C.F.R. § 3.327; Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994) (finding that a 23-month-old VA examination was too remote in time where evidence of worsening symptoms was submitted in the interim). Therefore, remand for a VA examination is necessary prior to adjudication. Regarding his claim for an increased rating for a right ankle disorder, remand is necessary to afford the Veteran a hearing before the Board. In the Veteran's July 2014 substantive appeal (VA Form 9), he requested a hearing before the Board at the RO regarding his claim for an increased rating for a right ankle disorder. To date, no hearing has been scheduled. Because the RO schedules Travel Board hearings, a remand of this matter to the RO is warranted. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA treatment records for the Veteran dated from January 2017 to the present. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of all manifestations associated with his service-connected hypertension. The Veteran's claims file, to include a copy of this Remand, should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished. After a review of the evidence, to include the private treatment records, VA examination reports and treatment records, and with consideration of the Veteran's lay statements regarding his symptoms, the examiner should address the extent of the Veteran's hypertension in accordance with VA rating criteria. A complete rationale should be provided for any opinion or conclusion expressed. 3. Schedule a Board hearing at the RO in accordance with the Veteran's request on his July 2014 substantive appeal. Notify the Veteran of the date and time of the hearing in writing. After the hearing is conducted, or in the event the Veteran withdraws his hearing request or fails to report for the hearing, the claims file should be returned to the Board in accordance with appellate procedures. 4. After all development has been completed, re-adjudicate the claims of entitlement to a compensable initial disability rating for hypertension and entitlement to service connection for bilateral hearing loss. If any benefit sought on appeal is not granted to the fullest extent, issue the Veteran and his representative a SSOC and provide a reasonable opportunity to respond before the case is returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs