Citation Nr: 1753524 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 06-28 275 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased rating for bilateral pes planus and lower extremity sciatica, rated as 10 percent disabling prior to April 18, 2016, and as 50 percent disabling thereafter. 2. Entitlement to a rating in excess of 20 percent for a lumbar spine disability, to include on an extraschedular basis. 3. Entitlement to an increased rating for neurogenic bladder secondary to the service-connected lumbar spine disability, rated as 20 percent disabling since October 1, 2015. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from January 1985 to October 1985 and active duty training from April 1992 to August 1992 and in August 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which, in pertinent part, continued the noncompensable rating assigned for bilateral pes planus and the 20 percent rating assigned for the lumbar spine disability. The Veteran testified before the Board in February 2007 (resulting in an inaudible transcript) and, as a result, he testified again before the Board in January 2008. In February 2009, the Board denied the Veteran's claims for increased ratings for bilateral pes planus and a lumbar spine disability. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court) and in April 2011, the Court issued a Memorandum Decision in which it set aside the Board's February 2009 decision and remanded the claims for further adjudication. The claims were remanded most recently in February 2012 and January 2015. The issue of entitlement to a TDIU on an extraschedular basis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to April 18, 2016, the Veteran's pes planus was moderate, without evidence of marked deformity, accentuated pain on use, indication of swelling on use, or characteristic callosities. 2. Since April 18, 2016, the Veteran's pes planus has been pronounced. 3. Throughout the appeal period, the Veteran's lumbar spine disability has been manifested by moderate limitation of motion of the spine, with forward flexion of the thoracolumbar spine to greater than 30 degrees, with no evidence of ankylosis or incapacitating episodes having a total duration of greater than four weeks. 4. Throughout the appeal period, the Veteran's lumbar spine disability has been manifested by neurological impairment that approximates no more than mild incomplete paralysis in the right lower extremity. 5. Throughout the appeal period, the Veteran's lumbar spine disability has been manifested by neurological impairment that approximates no more than mild incomplete paralysis in the left lower extremity. 6. Throughout the appeal period, the Veteran's neurogenic bladder has necessitated the use of absorbent material to be changed less than two times per day. 7. Since April 18, 2016, the Veteran's service-connected disabilities have precluded gainful employment. CONCLUSIONS OF LAW 1. Prior to April 18, 2016, the criteria for a rating in excess of 10 percent for the Veteran's pes planus have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 4.7, 4.10, 4.71a, Diagnostic Codes 5276 (2017). 2 Since April 18, 2016, the criteria for a rating in excess of 50 percent for the Veteran's pes planus have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 4.7, 4.10, 4.71a, Diagnostic Codes 5276 (2017). 3. The criteria for a rating in excess of 20 percent for orthopedic manifestations of a lumbar spine disability have not been met. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5292, 5293 (2003) 5237, 5243 (2017). 4. The criteria for a separate 10 percent rating for neurological manifestations of the right lower extremity have been met. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 3.321 (b), 4.25, 4.26, 4.71a, Diagnostic Code 8520 (2017). 5. The criteria for a separate 10 percent rating for neurological manifestations of the left lower extremity have been met. 38 U.S.C.A. § 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 3.321 (b), 4.25, 4.26, 4.71a, Diagnostic Code 8520 (2017). 6. Prior to October 1, 2015, the criteria for a separate 20 percent rating for neurogenic bladder have been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107(2012); 38 C.F.R. § 3.102, 3.159, 4.115b, DC 7518 (2017). 7. Since October 1, 2015, the criteria for a rating in excess of 20 percent for neurogenic bladder have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107(2012); 38 C.F.R. § 3.102, 3.159, 4.115b, DC 7518 (2017). 8. Since April 18, 2016, the criteria for assignment of TDIU are met. 38 U.S.C. § 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. § 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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. The Board will consider entitlement to staged ratings to compensate for times since filing the claims when the disabilities may have been more severe than at other times during the course of the claims on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. § 4.2, 4.6. Pes Planus Under Diagnostic Code 5276, a 10 percent rating is warranted for unilateral or bilateral pes planus that is moderate, characterized by weight-bearing line over or medial to great toe, inward bowing of the tendo Achilles, and pain on manipulation and use of the feet. A 30 percent rating is warranted for severe bilateral pes planus, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, an indication of swelling on use, and characteristic callosities. A maximum 50 percent rating is warranted for pronounced bilateral pes planus, manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a. The Board notes that the Veteran has been rated for both his pes planus and his lower extremity radiculopathy. However, the Board has separated those ratings according to the conclusions of law stated above because they affect separate functions of his body and result in different disabilities. With regard to the Veteran's pes planus, specifically, the Board finds that increased ratings are not warranted during the appeal period. Prior to April 18, 2016, the Veteran was shown to suffer from arch pain for which he used arch supports. He reported pain on walking and use. However, his flat feet were described as mild in degree on 2003 VA examination. That finding comports with the Veteran's testimony, lay statements, and treatment records demonstrating that the Veteran did not suffer from severe pes planus during this time period, or objective evidence of marked deformity, pain on manipulation and use accentuated, an indication of swelling on use, or characteristic callosities. Since April 18, 2016, the Veteran has been in receipt of the highest rating available for pes planus under the rating schedule. The Board finds that the Veteran does not demonstrate other symptoms outside of those contemplated by the rating schedule, and as shown on April 2016 VA examination, that would warrant extraschedular consideration. Lumbar Spine Disability The regulations for rating disabilities of the spine were revised during the pendency of the Veteran's appeal, effective September 26, 2003. 68 Fed. Reg. 51454 (Aug. 27, 2003). Where the law or regulations governing a claim are changed while the claim is pending, the version most favorable to the claimant applies from the effective date of the change, while the previous version of the regulation applies prior to the date of change. Karnas v. Derwinski, 1 Vet. App. 308 (1991); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003 (Nov. 19, 2003), 69 Fed. Reg. 25179 (2004). The amended rating criteria can be applied only for periods from and after the effective date of the regulatory change. The Board can apply only the prior regulation to rate the veteran's disability for periods preceding the effective date of the regulatory change. VAOPGCPREC 3-00 (Apr. 10, 2000), 65 Fed. Reg. 33422 (2000). Prior to September 26, 2003, a 10 percent rating was warranted for slight limitation of motion of the lumbar spine, a 20 percent rating was warranted for moderate limitation of motion of the lumbar spine, and a 40 percent rating was warranted for severe limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002). Prior to September 26, 2003 degenerative disc disease was rated under Diagnostic Code 5293 for intervertebral disc syndrome. The Rating Schedule, provided for a noncompensable rating for postoperative, cured intervertebral disc syndrome. A 10 percent rating was warranted upon a showing of mild intervertebral disc syndrome, while a 20 percent rating contemplated moderate intervertebral disc syndrome with recurring attacks. A 40 percent rating required severe intervertebral disc syndrome with recurring attacks with intermittent relief. A 60 percent rating, the highest rating assignable, for pronounced intervertebral disc syndrome, required persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, with little intermittent relief. 38 C.F.R. § 4.71, Diagnostic Code 5293 (effective before September 26, 2003). Effective September 26, 2003, the regulations for rating disabilities of the spine were revised, and the diagnostic codes were reclassified. These reclassified diagnostic codes include spinal diagnoses that are rated pursuant to the spinal criteria (5235-5242) and 5243 (intervertebral disc syndrome). 68 Fed. Reg. 51454 (Aug. 27, 2003). The code for intervertebral disc syndrome (Diagnostic Code 5243), permits evaluation under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5239, 5243. The September 2003 regulation revisions set forth a General Rating Formula for 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 as follows: Unfavorable ankylosis of the entire spine (100 percent), unfavorable ankylosis of the entire thoracolumbar spine (50 percent), unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine (40 percent), for forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine (30 percent), for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent), for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height (10 percent). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine . When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Normal combined range of motion of the thoracolumbar spine is 240 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. In this case, under the pre-September 26, 2003 spinal criteria, the Board finds that an increased rating is not warranted. The evidence of record does not demonstrate "severe" limitation of motion of the spine. Specifically, the Veteran has been shown to be limited at most to 35 degrees on repetitive testing. However, that being the most restricted limitation of motion, the remainder of the evidence of record demonstrates the ability to forward flex significantly further, specifically, to 85 degrees in 2002, 55 degrees in 2004, 45 degrees in 2010, and 60 degrees in 2016. Notably, on 2004 VA examination, the Veteran demonstrated "Waddell's" findings, indicative of symptom exaggeration. When taking into account the findings of back flexion throughout the appeal period, the Board finds that severe limitation of motion of the spine was not shown. The Board has taken into consideration the Veteran's lay statements with regard to his back pain, but based upon the VA examinations and treatment records of record, a more severe back disability has not been demonstrated. In that regard, the Board finds that the medical records are of more probative value than the Veteran's statements, when taking into account the 2004 finding of symptom exaggeration as well as the 2016 finding that the medical findings either supported or did not support the Veteran's reported symptom presentation. A higher rating is not warranted pursuant to the post- September 26, 2003 spinal criteria, as flexion limited to 30 degrees or ankylosis of the spine was not demonstrated. Nor has incapacitation necessitating bedrest by a physician for 4 weeks or more been demonstrated during any given year. The Board has determined that the Veteran is not entitled to higher ratings for the musculoskeletal claims decided above. Consideration has been given to the provisions of 38 C.F.R. § 4.40 and 4.4 and DeLuca, 8 Vet. App. at 202. The Board also finds that an extraschedular rating is not warranted in this case. In that regard, the Board finds that all the symptomatology and impairment caused by the Veteran's lumbar spine disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's lumbar spine disability has manifested in painful movement and limitation of motion due to pain, and during flare-ups. The schedular criteria for rating the lumbar spine disability specifically provide for ratings based on the presence of painful motion, whether or not such pain radiates; limitations of motion of the spine including due to pain and other orthopedic factors that result in functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, Mitchell); and other clinical findings such as muscle spasm, guarding, abnormal gait, and abnormal spinal contours; and on the basis of incapacitating episodes. All the symptomatology and functional impairment described above result from the limitation motion of the lumbar spine, to include as due to pain, stiffness, muscle spasm, and all the symptoms described by the Veteran are contemplated in the schedular rating(s) assigned under the General Rating Formula for Spine Disabilities either directly as limitation of motion or muscle spasm or tenderness or antalgic gait, or indirectly as orthopedic factors that limit motion and function. See 38 C.F.R. §§ 4.40, 4.45, 4.59 4.71a. Neurological Impairment Next, 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 . Under 38 C.F.R. § 4.124a , disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. 38 C.F.R. § 4.124a, DC 8520. Diagnostic Code 8620 refers to neuritis of the sciatic nerve, and DC 8720 refers to neuralgia of the sciatic nerve. In this case, the Board finds that separate 10 percent ratings are warranted for the left and right lower extremities throughout the appeal period, as the Veteran has provided testimony that he has suffered from numbness, pain, and tingling in the lower extremities for many years. Moreover, on September 2017 VA examination, he was determine to suffer from mild radiculopathy in the right and left lower extremities. The Board notes that the records are inconsistent with regard to whether he was diagnosed with radiculopathy in the lower extremities at various times during the appeal period, however, the 10 percent rating may also takes into account sensory symptoms that are not always objectively demonstrated on examination. Given the Veteran's consistent report of radiating symptoms to his lower extremities, the Board finds that the separate ratings for mild radiculopathy are appropriate. The Board notes that on 2016 VA examination, he was assessed to suffer from severe radiculopathy in the left lower extremity. However, the Board places less probative weight on that finding, as the remainder of the records do not demonstrate such a severe finding. Rather, he has not been shown to suffer from more than mild sensory impairment of the left lower extremity in the remainder of the records both prior to and subsequent to this examination. The Board finds that higher ratings are not warranted for this reason. Finally, the Board finds that a separate rating pursuant to the ratings for external popliteal nerve are not warranted, as the Veteran has not been shown to suffer from separate manifestations related to that nerve that would differ from those for which he is already rated, and thus pyramiding of ratings must be avoided. With regard to the higher 60 percent rating under the old spinal rating criteria, the Board does not find evidence of pronounced intervertebral disc syndrome with persistent symptoms of sciatic neuropathy to include muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, with little intermittent relief. While ankle reflexes have been shown to be diminished bilaterally, other more severe symptoms that align with a severe rating were not shown by the probative medical evidence, such as muscle spasm, motor deficit, or more than mild sensory deficit. Neurogenic Bladder The Veteran's diagnosed neurogenic bladder has been rated according to DC 7542, which directs that the disability be rated as a voiding dysfunction. Voiding dysfunction is rated based upon urine leakage, frequency, or obstructed voiding. Urine leakage contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. A 20 percent rating for urine leakage contemplates the wearing of absorbent materials, which must be changed less than two times per day. A 40 percent rating is warranted for the wearing of absorbent materials, which must be changed two to four times per day. A 60 percent rating is warranted for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a . The Veteran has been noted to suffer from bladder incontinence since 2000. The etiology of his bladder incontinence has been disputed on VA examinations, however, because it cannot be ruled out that the Veteran's service-connected lumbar spine disability and neurological impairment has been the cause of his incontinence, and he is in fact in receipt of service connection for neurogenic bladder beginning in 2015, the Board finds that the current 20 percent rating is warranted throughout the appeal period. A rating in excess of 20 percent is not warranted, however, as the VA examinations of records and pertinent treatment records do not demonstrate that the Veteran's absorbent materials must be changed two to four times per day. TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. Since April 18, 2016, the Veteran has met the schedular criteria for a TDIU. In that regard, the Board notes that although the April 2016 VA examiner found that the Veteran's service-connected disabilities did not impact sedentary employment, his service-connected disabilities were determined to impact his ability to complete employment with physical labor requirements. In September 2017, a VA examiner determined that the Veteran's lower extremity neuropathy impacted his ability to stand or walk for any distance or time, affecting his ability to work. Moreover, on October 2010 VA examination, the examiner concluded that the Veteran's back disability would make it difficult for him to maintain gainful employment in a physical or sedentary environment. On a VA Form 21-8940 submitted in October 2016, the Veteran reported that he had 4 years of college, work experience in "mechanical" and as a substitute teacher. The evidence of record reflects that the Veteran has not been gainfully employed since April 2006. The Veteran has reported that his low back and related impairments prevented him from continuing to work as a substitute teacher in that he could not sit for prolonged periods of time or carry out his duties. Given the positive opinions stated above, the Board finds that a TDIU is granted from April 18, 2016. For the period prior to that date, the issue must be referred to the Director of Compensation and Pension Services. ORDER Prior to April 18, 2016, a rating in excess of 10 percent for the Veteran's pes planus is denied. Since April 18, 2016, a rating in excess of 50 percent for the Veteran's pes planus is denied. A rating in excess of 20 percent for a lumbar spine disability, including on an extrashedular basis, is denied. A separate 10 percent rating for radiculopathy of the left lower extremity is granted, subject to the laws and regulations governing monetary benefits. A separate 10 percent rating for radiculopathy of the right lower extremity is granted, subject to the laws and regulations governing monetary benefits. Prior to October 1, 2015, a 20 percent rating for neurogenic bladder is granted, subject to the laws and regulations governing monetary benefits. Since October 1, 2015, a rating in excess of 20 percent for neurogenic bladder is denied. Since April 18, 2016, a TDIU is granted. REMAND The Veteran meets the schedular consideration of a TDIU since April 18, 2016. However, prior to that date, when considering the above grants, the Veteran's combined rating is 60 percent. In light of the above, the Board finds that the Veteran's claim of entitlement to TDIU should be referred to the Director of the Compensation and Pension Service for consideration of a TDIU on an extraschedular basis. Accordingly, the case is REMANDED for the following action: 1. Refer the issue of entitlement to TDIU to the Director of the Compensation and Pension Service for extraschedular consideration. 2. If the benefit sought on appeal is not granted, issue a supplemental statement of the case and provide the Veteran and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration as warranted. The appellant 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 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 (2012). ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs