Citation Nr: 1754035 Decision Date: 11/27/17 Archive Date: 12/07/17 DOCKET NO. 12-04 172 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a compensable initial rating for lumbosacral strain with degenerative joint disease (low back disability). 2. Entitlement to a compensable initial rating for right acromioclavicular joint tendonitis (right shoulder disability). REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from January 1998 to April 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction of the Veteran's claims file rests with the RO in Denver, Colorado. The Veteran testified at a hearing before the undersigned Veterans Law Judge in July 2014. A transcript of that hearing is associated with the claims file. The issue of entitlement to a compensable initial rating for a right shoulder disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT Since the initial grant of service connection, the Veteran's low back disability has been manifested by flexion to 90 degrees, extension to 30 degrees, right and left flexion to 30 degrees, and right and left rotation to 30 degrees, but has shown symptoms of painful motion with X-ray examinations documenting degenerative arthritis. CONCLUSION OF LAW The criteria for a 10 percent initial rating, but no higher, for a service-connected low back disability have been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5237 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). Prior to the initial adjudication of the Veteran's claim, a letter dated in June 2010 satisfied the duty to notify provisions. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, VA medical treatment records, and identified private treatment records have been obtained. 38 U.S.C. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). In addition, the Veteran was most recently provided with a VA examination addressing the severity of his low back disability in March 2017. Review of the March 2017 examination report reflects that it is adequate in this case, as it was based on a review of the claims file, clinical examination, and interview of the Veteran. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examination provided was adequate in this case, as it provides subjective and objective findings sufficient to rate the severity of the Veteran's low back disability under the appropriate rating criteria. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board has considered the applicability of principles set forth in a recent Court case Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the United States Court of Appeals for Veterans Claims (Court) held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 (2017) states that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." In the March 2017 VA examination, the VA examiner found that it was not medically appropriate to perform passive range of motion testing on the spine. The examiner was able to determine that there was no evidence of pain when the spine was used in non-weight bearing. Although the examiner was not able to conduct passive range of motion testing, the Board finds that the March 2017 VA examination complies with the Correia requirements. The Board observes that the Veteran was scheduled for another VA spine examination in June 2017, and that he failed to report for that examination. However, because the Veteran presented for the March 2017 VA examination and because that examination is adequate, as discussed above, remand is not required for a new VA examination. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the Veteran's Board hearing, the Veteran was assisted at the hearing by an accredited representative. The representative and the Veterans Law Judge (VLJ) solicited information regarding any outstanding evidence pertinent to the claim on appeal. The hearing focused on the evidence necessary to substantiate the Veteran's claim. No pertinent evidence that might have been overlooked and that might substantiate the claim decided herein was identified by the Veteran or the representative. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Accordingly, any error in notice or assistance by the VLJ at the July 2014 Board hearing constitutes harmless error. Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran contends that he is entitled to a compensable initial disability rating for his service-connected low back disability. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2017); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In a November 2010 rating decision, service connection for a low back disability was granted, and a noncompensable rating was assigned, effective April 11, 2010, under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5237 provides that lumbosacral or cervical strain is to be rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The General Rating Formula states that a 10 percent rating is for application when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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. 38 C.F.R. § 4.71a, General Rating Formula. A 20 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent disability rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent disability evaluation is for application when there is unfavorable ankylosis of the entire thoracolumbar spine, and a maximum 100 percent evaluation is warranted when there is unfavorable ankylosis of the entire spine. Id. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. Id. at Note (1). Diagnostic Code 5003, for degenerative arthritis (also applicable to traumatic arthritis under Code 5010), provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010. With any form of arthritis, painful motion is an important factor. It is the intent of the rating schedule to recognize actually painful, unstable or mal-aligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no compensable limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where a compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. Intervertebral disc syndrome (IVDS) (preoperatively or postoperatively) will be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. These criteria specify that any associated neurologic abnormalities, including but not limited to bowel or bladder impairment, are to be separately rated under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). According to the Formula for Rating IVDS Based on Incapacitating Episodes, a 10 percent rating contemplates incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent rating contemplates incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. In October 2010, the Veteran underwent a VA examination. The Veteran reported low back pain which radiates to his mid-thighs with monthly flare-ups associated with strenuous activity. He described the flare-ups as lasting from a few hours to two or three days with pain reported at 10/10. He indicated that alleviating factors included stretching and anti-inflammatory medication. The examiner remarked that, during flare-ups, there was "no additional limitation due to pain, weakness, fatigue, or lack of endurance following repetitive motion." The Veteran stated that the flare-ups did not affect his daily activity, but that they did impact occupational and recreational activity due to pain and lack of endurance. He noted that he lost two weeks of work during the past 12 months due to low back pain. He also stated that he could walk two miles and run one mile when there was no flare-up. He could also sit and stand for two hours. He denied a history of unsteadiness or falls. He stated that he was attending school to obtain a degree in business administration. Physical examination showed normal posture and gait. Range of motion showed forward flexion to 90 degrees, extension to 30 degrees, right and left lateral bending to 30 degrees, and right and left lateral rotation to 30 degrees. On active and passive range of motion, there was no spasm, weakness, or tenderness. After repetitive motion testing, there was no additional loss in range of motion due to pain, fatigue, weakness, or lack of endurance. Lower extremity strength was 5/5 and sensation was completely intact. Deep tendon reflexes were symmetrical, bilaterally. X-rays of the spine showed mild degenerative joint disease. The diagnosis was lumbosacral strain with no functional impairment and mild degenerative joint disease. In his February 2011 notice of disagreement, the Veteran reported that he experienced daily back pain and that there were some days that he could not get out of bed due to pain. He also stated that he had back spasms a couple of times per week. VA treatment records from September 2010 through February 2017 note complaints of and treatment for back pain. They show that there was normal range of motion of the back. In May 2011, the Veteran reported "horrible flares" every seven to eight months. He also noted pain going down the left posterior thigh but denied numbness and weakness as well as urinary and bowel incontinence. A 2011 magnetic resonance imaging scan (MRI) of the lumbar spine showed spondylolytic change within the lumbar spine with a posterior broad-based disc protrusion with ligamentum flavum and facet overgrowth and mild right-sided neural foraminal narrowing at L5-S1; posterior broad-based disc protrusion with bilateral annual tears involving the lateral recess portion of the disc, bilaterally, at L4-L5; and posterior broad-based disc protrusion with ligamentum flavum and facet overgrowth at L3-L4. In May 2015, he indicated that his low back pain radiated into his buttock then down the back of the leg to the foot with occasional tingling in the left toes. He reported that these symptoms happened weekly for the prior three months. The diagnosis was chronic back pain with left-sided sciatica. A June 2016 computed tomography (CT) scan of the abdomen and pelvis revealed minimal degenerative change of the lumbosacral spine. During a July 2014 hearing before the Board, the Veteran testified that he did not believe that his prior VA examination was adequate because he experienced pain during range of motion testing. He indicated that he had constant pain in his back. He stated that he never bends over because his back locks up which would incapacitate him for a week or two. He described flare-ups of back symptoms where his back goes out. He noted that one such episode occurred in August 2010 and that it lasted for approximately 15 days. He indicated that he was unable to leave his house for over one week. He described symptoms such as tight muscles and muscle spasms during the flare-ups which caused him to stand in a leaned over position and limp. He reported other such incidents in November 2010, May 2011, July 2012, October 2012, November 2012, January 2013, August 2013, December 2013, January 2014, May 2014, and June 2014. He stated that he missed classes during several of the incidents, which impacted his grades. He indicated that his definition of incapacitation during those episodes meant that there were stretches of days where he was basically stuck in his room and limping or crawling to the bathroom in tears. In December 2014, the Veteran underwent a VA peripheral nerves examination. He reported constant low back pain with bilateral leg pain radiating from the low back. He noted that the pain started in his lower back and shoots down both the front and back of both thighs. He noted that he experienced the radiation of pain when the low back is flared which occurs on a daily or weekly basis. He indicated that the shooting pain lasts only for a few seconds and that he also experienced tingling in the second through fifth digits on the left foot on one occasion. He denied urinary and bowel problems as well as numbness and tingling in the right foot. He also denied lower extremity weakness. The examiner reported that the Veteran experienced mild intermittent pain in the bilateral lower extremities and mild numbness in the left lower extremity. There was no constant pain in the lower extremities, paresthesias or dysthesias in the lower extremities, or numbness in the right lower extremity. Strength was normal in the lower extremities and reflexes were 1+ and symmetric in the bilateral lower extremities. A sensory examination was normal in the bilateral upper anterior thighs, in the bilateral thighs and knees, and in the right lower leg and ankle. Sensation was decreased in the left lower leg and ankle and the right and left feet and toes. There were no trophic changes attributable to peripheral neuropathy and the Veteran's gait was normal. The examiner found that the right and left sciatic nerves, external popliteal nerves, musculocutaneous nerves, anterior tibial nerves, internal popliteal nerves, posterior tibial nerves, anterior crural nerves, internal saphenous nerves, obturator nerves, external cutaneous nerves, and ilio-inguinal nerves were all normal. An electromyography (EMG) was not performed, but the examiner remarked that EMG and nerve conduction testing were set up in January for full assessment, but the Veteran cancelled both scheduled appointments. The Veteran stated that his low back disorder caused him to miss school. The examiner noted that the Veteran's physical examination did not follow the appropriate lumbar dermatome, which was why EMG and nerve conduction testing was required to determine whether he had radiculopathy due to his low back disability. However, the Veteran cancelled the scheduled testing on two occasions. The examiner remarked that the Veteran's October 2010 X-ray showed mild disc narrowing at L4-L5 and L5-S1 as well as degenerative joint disease, and that these findings would not cause any bilateral lower extremity radiculopathy. Accordingly, the examiner concluded that the Veteran's symptoms were due to a different pathopsychology, and his lower extremity radiculopathy was not related to or aggravated by his service-connected low back disability. In March 2017, the Veteran underwent another VA spine examination. The Veteran reported daily pain, that he could not stand up straight, and that his muscles were so tight that he was often hunched over. He noted that he was unable to sit for more than 30 minutes and that he experienced difficulty standing for prolonged periods. He explained that he constantly stretched throughout the day and that he had palpable muscle knots that bulge out which he must push back in. He also indicated that he could not run anymore and no longer worked as a nurse because he could not lift patients. He stated that he had not worked since the prior June. He also described a shooting pain in the left leg which lasted for a few seconds. He reported that the pain went down his leg and caused his middle three toes to go numb. Range of motion of the thoracolumbar spine showed forward flexion to 90 degrees with pain, extension to 30 degrees with pain, right and left lateral flexion to 30 degrees with pain, and right and left lateral rotation to 30 degrees with pain. The examiner remarked that there was pain on examination, but that the pain did not result in functional loss. There was not evidence of pain with weight bearing and there was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of function or range of motion after three repetitions. The examiner acknowledged that the Veteran was not being examined immediately after repetitive use over time, but that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner also found that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examiner reported that it was not medically appropriate to perform passive range of motion testing on the spine and that there was no evidence of pain when the spine was used in non-weight bearing. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength was 5/5 in the bilateral lower extremities and there was no muscle atrophy. Reflexes were 2+ and symmetric in both legs. Sensory examination showed normal sensation to light touch in the right and left upper anterior thighs, thighs and knees, and lower legs and ankles. There was decreased sensation in the right and left feet and toes. A straight leg raising test was negative, bilaterally. The examiner remarked that the Veteran did not have radicular pain or any other signs or symptoms of radiculopathy and there was no ankylosis of the spine. The examiner reported that there were no other neurologic abnormalities or findings related to a thoracolumbar spine condition and there was no evidence of intervertebral disc syndrome. The diagnosis was lumbar strain with degenerative joint disease and degenerative disc disease. The examiner noted that the Veteran's low back condition impacted his ability to work in that heavy lifting and repetitive bending may be limited. With regard to the Veteran's reports of pain radiating down the lower extremities, the examiner noted that the Veteran's neurologic examination was largely unremarkable. His deep tendon reflexes were mildly reduced, which was deemed normal for the Veteran. Additionally, the decreased sensation found on examination is not consistent across examinations, as his clinical examinations were documented as normal, and was only documented to be present during VA examinations. Further, the examiner noted that the fine touch reduction is not in a dermatomal distribution and, therefore, is not consistent with radiculopathy. The examiner indicated that it was also not deemed to be related to the low back disability. With regard to radiculopathy, the examiner stated that the Veteran's subjective symptoms did not have objective correlates to support a diagnosis of radiculopathy, as the Veteran complained only of low back pain when the right leg was raised during straight leg raising testing "which does not represent a positive test." Further, when the legs were raised as part of a concomitant knee examination, the Veteran offered no complaint. Additionally, the previous MRI and CT scans documented only mild degenerative disease without frank disc herniation and without evidence of neurologic compromise, which does not support radiculopathy. Accordingly, the examiner concluded that the cumulative data in the claims file did not support a finding of radiculopathy. After consideration of the pertinent evidence of record, the Board concludes that an initial disability rating of 10 percent, but no greater, is warranted for the Veteran's low back disability under Diagnostic Code 5003. The medical evidence of record reflects X-ray evidence of degenerative joint disease of the lumbar spine as early as October 2010. Additionally, the medical evidence shows that thoracolumbar spine limitation of motion is noncompensable under the General Rating Formula for Diseases and Injuries of the Spine, but that the Veteran experienced painful motion on range of motion testing. As such, a 10 percent initial disability rating is warranted for the Veteran's low back disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, an initial evaluation greater than 10 percent is not warranted for the Veteran's low back disability. The evidence demonstrates that, throughout the appeal period, the Veteran had forward flexion to 90 degrees with pain, extension to 30 degrees with pain, right and left lateral flexion to 30 degrees with pain, and right and left lateral rotation to 30 degrees with pain. Additionally, the competent medical evidence does not demonstrate muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour; reversed lordosis; or abnormal kyphosis. Although the Veteran has provided lay statements and testimony that he experienced flare-ups producing muscle spasm which caused him to stand in a hunched over position, he does not possess the medical training to competently assess whether the flare-ups caused abnormal gait, abnormal spinal contour, reversed lordosis, or abnormal kyphosis. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). To the extent that he believes a higher rating is warranted, the Board places greater probative weight on the findings from the clinicians and examiners who have greater expertise than the Veteran in evaluating the disabling characteristics of a thoracolumbar spine disability - including the accurate measure of motion with a goniometer and whether his muscle spasm has been severe enough to result in abnormal gait or spinal contour. Accordingly, an initial rating greater than 10 percent is not warranted for the Veteran's thoracolumbar spine disability under the pertinent rating criteria. Id. The Board has also considered whether the Veteran is entitled to an increased evaluation for his low back disability under the regulations for intervertebral disc syndrome. However, there is no medical evidence of a finding of intervertebral disc syndrome. Thus, an initial rating greater than 10 percent is not warranted under the rating criteria for intervertebral disc syndrome. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes; see Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Additionally, the Board has considered whether a separate evaluation is warranted for any neurological component of the Veteran's thoracolumbar spine disability. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Toward that end, the Veteran has regularly reported that his low back pain radiated to his bilateral lower extremities and occasionally caused numbness and tingling in the left lower extremity. However, both the December 2014 and the March 2017 VA examiners concluded that the evidence of record did not support a finding of radiculopathy associated with the Veteran's low back disability. The December 2014 VA examiner explained that the Veteran's physical examination did not follow the appropriate lumbar dermatome and that the October 2010 X-ray findings did not correlate with bilateral lower extremity radiculopathy. The examiner further observed that the Veteran was scheduled for EMG and nerve conduction testing on two different occasions to rule out a finding of radiculopathy, but that he failed to appear for both scheduled appointments. The March 2017 VA examiner observed that the Veteran's neurologic examination was unremarkable and that the Veteran's reports of decreased sensation were inconsistent across examinations and regularly normal during clinical examinations. The examiner also observed that the fine touch reduction was not in a dermatomal distribution and was not consistent with radiculopathy, and that the Veteran's subjective symptoms did not have objective correlations sufficient to support a diagnosis of radiculopathy. Last, the examiner remarked that the previous MRI and CT scans showed only mild degenerative disease without frank disc herniation or evidence of neurologic compromise, which did not support a finding of radiculopathy. The Board finds the opinions provided by the December 2014 and March 2017 VA examiners to be adequate and entitled to great probative weight, as they were based upon clinical examination of the Veteran and a thorough review of the evidence in the claims file. In the absence of any competent medical evidence documenting radiculopathy or bowel or bladder impairment associated with the Veteran's low back disability, a separate evaluation is not warranted for a neurologic component of the Veteran's service-connected low back disability. Last, the Board has considered whether there is any additional functional loss not contemplated in the current rating assigned for the Veteran's low back disability. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board acknowledges the Veteran's subjective complaints of pain and muscle spasms during flare-ups. However, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell, 25 Vet. App. at 36-38. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. In this case, the competent medical evidence of record does not show that it does. More specifically, the medical evidence of record does not show decreased range of motion with repetitive range of motion testing of the lumbar spine or additional limitation of joint function due to pain, fatigue, weakness, lack of endurance, or incoordination during the October 2010 or March 2017 VA examinations. Further, none of the VA treatment records document treatment for the Veteran's reported flare-ups sufficient to rate their severity. In that regard, the VA treatment records note that the Veteran reported a history of flare-ups, but he does not appear to have sought medical treatment during any of these episodes. In light of the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected low back disability is not warranted based on functional impairment. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca, 8 Vet. App. at 204-06. Based on the foregoing, an initial evaluation of 10 percent, but no greater, is warranted for the Veteran's low back disability. There is no evidence of record that would warrant a rating in excess of 10 percent at any time during the period pertinent to this appeal. 38 U.S.C. § 5110 (2012); see also Hart, 21 Vet. App. at 509. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected low back disability, the evidence shows no distinct period of time during which any of the Veteran's low back disability has varied to such an extent that a rating greater or less than 10 percent would be warranted. Cf. 38 C.F.R. § 3.344 (2017) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected low back disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b) (2017). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). As discussed at length above, the Veteran's lumbar spine symptomatology is contemplated by the rating criteria for a 10 percent rating. The Veteran's low back disability does not more nearly approximate the symptoms set forth for a rating of a 20 percent, or any symptoms of similar severity, duration or frequency as those set forth for those ratings. Accordingly, referral for extraschedular ratings for a low back disability is not warranted. Under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extra-schedular 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, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms of record that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Johnson, 762 F.3d 1362. Last, the Board acknowledges the Veteran's reports that his low back disability impacts his employability. During his March 2017 VA examination, the Veteran stated that he could no longer work as a nurse because he could not lift patients, and that he had not worked since the previous June. However, the Veteran does not contend, and has not presented any evidence suggesting, that he cannot work at all due to his service-connected low back disability. Accordingly, the issue of entitlement to a total disability rating based upon individual unemployability (TDIU) has not been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to an initial rating of 10 percent, but no greater, for the Veteran's low back disability is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The issue of entitlement to a compensable initial rating for a right shoulder disability was remanded by the Board in May 2017 to afford the Veteran a new VA examination to evaluate the severity of his right shoulder disability. The record reflects that the Veteran was scheduled for such a VA examination in June 2017, and that he failed to report for the examination. A July 2017 note in the claims file reflects that the QTC informed the RO that the Veteran was called prior to his examination to inform him of the date and time of the examination, and that the Veteran responded that he would attend the examination. However, the Veteran failed to report for the June 2017 VA examination. QTC indicated that the Veteran was called about his failure to report for the examination, but that there was no response. Another July 2017 note in the file reflects that the RO contacted the Veteran to determine why the Veteran failed to report for his scheduled examination. The note indicates that the Veteran stated that he did not remember the examination, that he had car issues, that his parents both died, and that he had posttraumatic stress disorder (PTSD). The RO asked the Veteran if they could reschedule him for a new VA examination, but the Veteran responded that he was unsure. Based on the Veteran's statement that he did not report for the scheduled VA examination in June 2017, in part, because both of his parents died, the Board finds that he has provided good cause under 38 C.F.R. § 3.655(a) (2017) for his failure to report. In that regard, the Board finds that the record does not contain sufficient contemporaneous for rating purposes or sufficient evidence for adjudication of the claim for an increased rating for a right shoulder disability. The Veteran was lasted afforded a VA examination to evaluate the severity of his right shoulder disability in October 2010, which is over 7 years ago. Subsequent VA treatment records and the Veteran's testimony indicate that his right shoulder symptomatology has worsened. The Board determines that it is necessary to reschedule the Veteran for the examination in order to rate the severity of his right shoulder disability. See 38 C.F.R. § 3.159(c) (2017). The Veteran is cautioned, however, that failure to report for any scheduled examination without good cause may result in the denial of his claim. 38 C.F.R. § 3.655 (2017). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA examination to assess the current severity of his service-connected right shoulder disability. The Veteran's claims file and a copy of this Remand must be reviewed by the examiner. All pertinent symptomatology and findings must be reported in detail. Any diagnostic tests deemed necessary for an accurate assessment must be conducted. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, in detail. The examiner must test and report the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for both the right and left shoulders. If pain on motion of the right shoulder is shown, the examiner must state at what degree the pain begins. The same range of motion studies must then be repeated after repetitions. The examiner must indicate whether there is any favorable or unfavorable ankylosis of the right shoulder. The examiner must state whether there is any functional loss caused by the Veteran's right shoulder disability, including whether there is any functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of the joint. Additionally, an opinion must be stated as to whether any pain found in the right shoulder could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional limitation of motion due to pain on use or during flare-ups. The examiner must also state whether there is any evidence of dislocation of the right shoulder, nonunion with loose movement, or malunion of the right shoulder. Finally, the examiner must describe all functional limitations resulting from the Veteran's right shoulder disability. 2. Notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). 3. A copy of the notification letter advising the Veteran of the date, time, and location of the scheduled examination must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report, the claims folder must indicate whether the notification letter was returned as undeliverable. Additionally, any correspondence to or from the Veteran regarding the scheduling or rescheduling of the VA examinations requested must be associated with the claims file. 4. When the above development has been completed, readjudicate the issue on appeal. If any benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran, and afford the Veteran an adequate opportunity to respond, prior to returning the issue to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs