Citation Nr: 1759935 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 10-14 831 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial increased disability rating in excess of 10 percent prior to September 2, 2010 and from December 1, 2010 to December 18, 2012; in excess of 20 percent from December 19, 2012 to August 31, 2016; and in excess of 40 percent beginning September 1, 2016 for lumbosacral strain (back condition). 2. Entitlement to an initial compensable disability rating prior to December 19, 2012, and in excess of 20 percent thereafter, for bilateral lower extremity radiculopathy associated with a back condition. 3. Entitlement to an initial disability rating in excess of 10 percent for status post multiple sprains of the right ankle (right ankle condition). 4. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD). 5. Entitlement to an initial disability rating in excess of 50 percent for headaches. 6. Entitlement to service connection for a left hand condition, to include as secondary to a back condition. 7. Entitlement to service connection for a condition of the bilateral upper extremities, to include as secondary to a left hand condition. 8. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include adjustment disorder with depressed mood, including as secondary to service-connected disabilities. 9. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from January 16, 2009 to September 1, 2010, and from December 1, 2010 to December 18, 2012. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD N.S. Pettine, Associate Counsel INTRODUCTION The Veteran had initial active duty for training from November 1987 to May 1988, and active service from January 1991 to March 1991, from June 2003 to May 2004, and from October 2007 to January 2009-including service in the Southwest Asia theater of operations. The Veteran had additional service in the Army National Guard from May 1988 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction of the Veteran's claims file now resides with the North Little Rock, Arkansas RO. In November 2012, the Board granted an increased 30 percent initial disability rating for headaches. It then remanded all of the pending issues-including the headaches claim-for further development. Thereafter, in a March 2013 rating decision, the Veteran was awarded: (1) a 20 percent rating for his back condition, effective December 19, 2012; (2) a 10 percent rating for GERD, effective December 19, 2012; and (3) service connection for right and left lower extremity radiculopathy. Regarding the radiculopathy claims, the Veteran was assigned initial 20 percent ratings, effective December 19, 2012. Then, via an August 2013 rating decision, the Veteran was awarded 10 percent ratings for his back condition, effective January 16, 2009 to September 2, 2010, and from December 1, 2010 to December 19, 2012. Additionally, the Veteran was awarded a 10 percent rating for his right ankle condition, effective January 16, 2009, as well as an earlier effective date of January 16, 2009 for his 10 percent rating for GERD. A separate August 2013 rating decision increased the Veteran's rating for headaches from 30 percent to 50 percent, effective January 16, 2009. Subsequently, in July 2014, the Board again remanded the case for further development. Thereafter, via a July 2017 rating decision, the rating for the Veteran's back condition was increased to 40 percent, effective September 1, 2016. Regarding the Veteran's increased rating claims, as the above-discussed rating decisions did not constitute full grants of the benefits sought for the entire appeal period, the increased rating issues remain in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Lastly, Note 1 to the general rating formula for diseases and injuries of the spine provides that associated objective neurological abnormalities are to be rated separately under the appropriate diagnostic code. See 38 C.F.R. § 4.71a. As the record reveals that the Veteran suffers from neurological abnormalities of both of his lower extremities due to his back, the Board has also added this issue to the title page and will rate these disabilities for the entire claim period. The issues of (1) an increased initial rating for a right ankle condition; (2) an increased initial rating for headaches; (3) service connection for a left hand condition; (4) service connection for a condition of the bilateral upper extremities; and (5) entitlement to a TDIU from January 16, 2009 to September 1, 2010, and from December 1, 2010 to December 18, 2012 are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to September 2, 2010, forward flexion of the Veteran's thoracolumbar spine was not limited to between 30 and 60 degrees. Additionally, the combined range of motion of the thoracolumbar spine was not less than 120 degrees. Lastly, the evidence does not demonstrate that the Veteran had muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 2. Beginning December 1, 2010 through August 31, 2016, the evidence of record demonstrates that forward flexion of the Veteran's thoracolumbar spine was limited to between 30 and 60 degrees and that he had guarding and muscle spasms resulting in abnormal spinal contour. 3. From September 1, 2016 onward, the evidence of record does not demonstrate that the Veteran suffered from unfavorable ankylosis of either the entire thoracolumbar spine or the entire spine. 4. Prior to September 2, 2010, the symptoms of the Veteran's bilateral lower extremity radiculopathy most nearly approximated mild incomplete paralysis of the sciatic nerve. 5. From September 2, 2010 onward, the symptoms of the Veteran's bilateral lower extremity radiculopathy most nearly approximated moderately severe incomplete paralysis of the sciatic nerve. 6. Beginning September 1, 2016, the Veteran displayed symptoms associated with GERD that were productive of considerable impairment of health. 7. The evidence of record demonstrates that the Veteran currently suffers from adjustment disorder with mixed anxiety and depressed mood that is due to his service-connected back condition and associated bilateral lower extremity radiculopathy. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent prior to September 2, 2010 for a back condition have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5010-5237 (2017). 2. The criteria for an initial disability rating of 20 percent, but no higher, for a back condition have been met, effective from December 1, 2010 through August 31, 2016. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5010-5237 (2017). 3. The criteria for an initial disability rating in excess of 40 percent, beginning September 1, 2016, for a back condition have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5010-5237 (2017). 4. The criteria for the assignment of separate 10 percent ratings, but no higher, for bilateral lower extremity radiculopathy prior to September 2, 2010 have been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, 4.123, 4.124, 4.124a, DC 8520 (2017). 5. The criteria for the assignment of 40 percent ratings, but no higher, for bilateral lower extremity radiculopathy have been met beginning September 2, 2010. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, 4.123, 4.124, 4.124a, DC 8520 (2017). 6. The criteria for the assignment of a 30 percent rating, but no higher, for GERD have been met, effective September 1, 2016. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.73, DC 7399-7346 (2017). 7. The criteria for service connection for an acquired psychiatric disorder other than PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating for Back Condition As indicated above, the Board finds that the Veteran is entitled to the following initial ratings for his back condition: (1) 10 percent prior to September 2, 2010; (2) 20 percent from December 1, 2010 to August 31, 2016; and (3) 40 percent from September 1, 2016 onward. Accordingly, the Board will grant the Veteran's claim in part and deny it in part. A. Prior to September 2, 2010 Regarding the time period prior to September 2, 2010, the Board finds that a disability rating in excess of 10 percent is not warranted. Accordingly, the Veteran's claim to this extent will be denied. As indicated in the Findings of Fact section, the Veteran is not entitled to a rating higher than 10 percent for this time period because: (1) forward flexion of the thoracolumbar spine was not limited to between 30 and 60 degrees; (2) the combined range of motion of the thoracolumbar spine was not less than 120 degrees; and (3) the evidence does not demonstrate that the Veteran had muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour. This criteria is required in order to assign the next-highest rating of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine, for which the Veteran's back condition is rated pursuant to Diagnostic Code 5010-5237. See 38 C.F.R. § 4.71a. Indeed, during a February 2009 VA general medical examination, the Veteran displayed a normal posture and gait and the examiner noted that there was normal lumbar lordosis and no muscle spasm. During initial range of motion testing, the Veteran extended backwards to 35 degrees, flexed forwards to 95 degrees, flexed laterally to 40 degrees either side, and rotated 35 degrees to either side. Pain was only present during rotation and lateral flexion to the right side. After 3 repetitions, there was no additional limitation in range of motion. After diagnosing the Veteran with a lumbosacral strain, the examiner commented that the Veteran did not have spasms, weakness, or tenderness and that the Veteran only had a slight additional limitation during flare-ups. A review of the Veteran's VA treatment records currently associated with the claims file does not paint a more severe disability picture for the time period prior to September 2, 2010 than that painted by the February 2009 VA examination. In making this determination, the Board has considered whether there was any additional functional loss not contemplated in the 10 percent rating for the Veteran's back condition. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Although the Veteran did display pain on motion during the February 2009 VA examination and in treatment records for the time period prior to September 2, 2010, pain itself is not functional loss, but can cause functional loss to the extent that it affects the normal working movements of the body such as excursion, strength, speed, coordination, or endurance. Mitchell v. Shinsekil, 25 Vet. App. 32, 37-44 (2011). B. From December 1, 2010 through August 31, 2016 Comparatively, for the time period from December 1, 2010 through August 31, 2016, the Board finds that the Veteran has satisfied the above-discussed criteria for a 20 percent rating. Accordingly, the Board will grant the Veteran's claim to this extent. Principally, the Board is assigning an earlier effective date for the assignment of the 20 percent rating for the Veteran's back condition. In support of this determination, the Board notes that during a June 2012 VA back examination, the Veteran's forward flexion was limited to 50 degrees with objective evidence of pain beginning at 45 degrees. This satisfies the criteria for a 20 percent rating pursuant to Diagnostic Code 5010-5237 under the General Rating Formula for Diseases and Injuries of the Spine. The Board has determined that the results of the June 2012 VA back examination are an accurate illustration of the Veteran's entire disability picture for the time period following his period of convalescence. Specifically, in a November 2011 VA treatment record, the Veteran complained of increasing back pain since his surgery on September 2, 2010. During this particular incident of treatment, the Veteran reported muscle spasms in his back and legs resulting in falls. However, in addressing why the next higher rating of 40 percent is not warranted, the Board notes that the record is devoid of evidence demonstrating favorable ankylosis of the entire thoracolumbar spine or the limitation of forward flexion to 30 degrees or less. This criteria is required for the assignment of a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. Accordingly, to this extent, the Veteran's claim is denied. Similar to the time period prior to September 2, 2010, in making this determination, the Board has considered whether there was any additional functional loss not contemplated in the 20 percent rating for the Veteran's back condition. See DeLuca, 8 Vet. App. at 206; 38 C.F.R. §§ 4.40, 4.45, 4.59. Although the Veteran did display pain during this time period with loss of endurance and coordination, the Board will not assign the next-higher 40 percent rating for the back condition pursuant to these additional limitations. Rather, as these symptoms were intertwined with the Veteran's bilateral lower extremity radiculopathy, the Board will incorporate them into its assignment of ratings for those separate service-connected disabilities. C. From September 1, 2016 Onward Lastly, as indicated above, the Board finds that the Veteran is not entitled to the next higher ratings of 50 percent or 100 percent at any time during the claim period. Accordingly, to this extent, the Veteran's claim is denied. In support of this determination, the Board notes that the record is devoid of evidence of unfavorable ankylosis at any time during the claim period. In order to warrant the assignment of a 50 percent or a 100 percent rating for a condition of the thoracolumbar spine under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show either (1) unfavorable ankylosis of the entire thoracolumbar spine, or (2) unfavorable ankylosis of the entire spine. The Veteran's back condition was not productive of unfavorable ankylosis at any time during the claim period. Additionally, although the Board must consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination when deciding an appropriate rating, this rule is not applicable where a veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis or incapacitating episodes. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). As the Veteran has not displayed unfavorable ankylosis of the entire thoracolumbar spine or the entire spine at any time during the claim period, the Board may not assign a rating higher than 40 percent. Accordingly, the Board will deny the Veteran's claim. Increased Ratings for Bilateral Lower Extremity Radiculopathy As indicated above, the Board finds that the Veteran's bilateral lower extremity radiculopathy warrants the following ratings throughout the claim period: (1) 10 percent prior to September 2, 2010, and (2) 40 percent from September 2, 2010 onward. For all of the ratings discussed below, the Board will assign them pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, paralysis of the sciatic nerve, as the Board finds it to be the most appropriate code to evaluate the Veteran's disability picture. A. Prior to September 2, 2010 In support of its determination to assign 10 percent disability ratings for bilateral lower extremity radiculopathy prior to September 2, 2010, the Board finds that for this time period, the Veteran's disabilities were best classified as mild incomplete paralysis of the sciatic nerve. For this time period during the appeal, the Veteran made subjective complaints of pain in his lower extremities. Additionally, during the February 2009 VA back examination, he reported transient numbness in his legs when sitting on hard surfaces. However, the Board cannot assign the Veteran the next higher rating of 20 percent for moderate incomplete paralysis for this time period. Specifically, there were no objective manifestations of radiculopathy in either lower extremity during this time period. For example, the Veteran did not display any loss of muscle strength, muscle atrophy, decreased reflexes, or decreased sensation during objective testing of each leg. Accordingly, to this extent, the Veteran's claim is denied. B. From September 2, 2010 Onward Comparatively, for the time period from September 2, 2010 to July 30, 2015, the Board finds that the Veteran's bilateral lower extremity radiculopathy warrants the assignment of 40 percent ratings as, during this time period, the Veteran's disability is best classified as moderately severe incomplete paralysis of the sciatic nerve. In support of this determination, the Board notes that, in a November 2011 VA treatment record, the Veteran reported experiencing so much lower back pain and weakness of the right leg that he was barely functioning. Additionally, this November 2011 treatment record noted that the Veteran wore an ankle brace due to problems of foot drop. Further, the Veteran's VA treatment records documented that the Veteran experienced problems with incoordination and falling due to leg weakness after his back surgery on September 2, 2010. Accordingly, the Board will assign 40 percent ratings effective the date of his back surgery in September 2010. In addressing why ratings higher than 40 percent are not warranted, the Board finds that, for any time during the claim period, the Veteran's bilateral lower extremity radiculopathy cannot be classified as severe incomplete paralysis or complete paralysis. In support of this determination, the Board notes that the record is devoid of evidence of marked muscular atrophy-criteria required for a 60 percent rating under Diagnostic Code 8520. Additionally, regarding the criteria for complete paralysis under Diagnostic Code 8520, while the Veteran has used ankle braces for foot drop during the claim period, he has not displayed (1) a lack of any active movement of muscles below the knees, (2) weakened flexion of the knees, or (3) loss of flexion below the knees at any time during the claim period. Accordingly, to this extent, the Veteran's claim is denied. Increased Rating for GERD As stated above in the Conclusions of Law section, the Board finds that the Veteran is entitled to an increased initial disability rating of 30 percent for service-connected GERD beginning September 1, 2016. Accordingly, to this extent, the Veteran's claim will be granted. However, the Board finds that, prior to September 1, 2016, the evidence of record does not support a rating higher than 10 percent. Likewise, the Board also finds that the Veteran is not entitled to a 60 percent rating for any time during the claim period. Thus, to this extent, the claim will be denied. As an initial matter, the Board acknowledges that GERD is not listed in the rating schedule. Accordingly, the Veteran's disability will be rated by analogy to hiatal hernia by using the hyphenated diagnostic code of 7399-7346. See 38 C.F.R. § 4.27. Unlisted diseases, injuries, or residual conditions are rated by analogy with the first two digits selected from that part of the rating schedule that most closely identifies the part or system of the body involved; the last two digits will be "99" for all unlisted conditions. Accordingly, in this case 7399 refers to disabilities of the digestive system, while 7346 refers to the diagnostic code for hiatal hernia. Pursuant to Diagnostic Code 7346, a 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Comparatively, a 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Lastly, a 10 percent rating is assigned for two or more of the symptoms listed in the criteria for a 30 percent rating but with less severity. As indicated above, the Board finds that the Veteran first displayed evidence indicative of a 30 percent rating during a September 1, 2016 VA esophageal conditions examination. During this examination, the examiner noted that the Veteran took medications daily for his GERD. Additionally, the examiner marked that the Veteran displayed dysphagia, pyrosis, reflux, and substernal pain as a result of his GERD. One month after the September 2016 VA examination, in an October 2016 VA treatment record, the Veteran reported difficulty swallowing solid foods and regurgitation of liquids. Later, in a February 2017 VA treatment record, the Veteran's spouse reported the recent onset of frequent unpredictable vomiting and nausea. Thus, in light of the above evidence, the Board finds that the Veteran's GERD warrants the assignment of a 30 percent rating beginning September 1, 2016-the date of the VA esophageal conditions examination-as this was the first time during the appeal where the Veteran's GERD could be classified as productive of considerable impairment of health. Prior to September 1, 2016, the Veteran's GERD manifested primarily by periods of intermittent mild reflux, nausea, vomiting, and abdominal discomfort. As the Veteran's symptoms were not persistently recurrent and he did not display dysphagia prior to September 1, 2016, the Board cannot assign a 30 percent rating at any point during this time period. Likewise, the Board also cannot assign the next-higher rating of 60 percent for any period during the claim period as the record is devoid of evidence of material weight loss or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Accordingly, to this extent, the Veteran's claim will be denied. Service Connection for an Acquired Psychiatric Disorder other than PTSD As indicated above, the Board finds that service connection for an acquired psychiatric disorder other than PTSD is warranted. Accordingly, the Board will grant the Veteran's claim. Generally, establishing service connection requires competent evidence of: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Additionally, relevant to the instant case, service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To substantiate secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Regarding the Veteran's acquired psychiatric disorder claim, the Board finds that all 3 requirements for secondary service connection have been met during the claim period. Firstly, during a September 1, 2016 VA examination, the Veteran was diagnosed with adjustment disorder with mixed anxiety and depressed mood. The examiner then stated that it was possible to differentiate the symptoms between the adjustment disorder and the already-service-connected PTSD. Accordingly, the Veteran satisfies the current disability criterion for secondary service connection. Next, the examiner then opined that the adjustment disorder was at least as likely as not secondary to the Veteran's chronic pain in his back and legs. As the Veteran is already service-connected for a back condition and bilateral lower extremity radiculopathy, the second and third requirements for secondary service connection have also been satisfied. Therefore, the Board will grant the Veteran's claim. ORDER A disability rating in excess of 10 percent prior to September 2, 2010 for a back condition is denied. A disability rating of 20 percent, but no higher, for a back condition is granted from December 1, 2010 to August 31, 2016. A disability rating in excess of 40 percent beginning September 1, 2016 for a back condition is denied. A disability rating of 10 percent, but no higher, for right lower extremity radiculopathy is granted, effective from January 16, 2009 to September 1, 2010. A disability rating of 10 percent, but no higher, for left lower extremity radiculopathy is granted, effective from January 16, 2009 to September 1, 2010. A disability rating of 40 percent, but no higher, for right lower extremity radiculopathy is granted, effective September 2, 2010. A disability rating of 40 percent, but no higher, for left lower extremity radiculopathy is granted, effective September 2, 2010. A disability rating of 30 percent, but no higher, for GERD is granted, effective September 1, 2016. Entitlement to service connection for an acquired psychiatric disorder other than PTSD-adjustment disorder with mixed anxiety and depressed mood-is granted. REMAND Although the Board regrets the additional delay, further development is required prior to adjudication of the Veteran's claims for: (1) an increased initial rating for a right ankle condition; (2) an increased initial rating for headaches; (3) service connection for a left hand condition; (4) service connection for a condition of the bilateral upper extremities; and (5) entitlement to a TDIU from January 16, 2009 to September 1, 2010, and from December 1, 2010 to December 18, 2012 Right Ankle In Correia v. McDonald, the Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 4.59 required that VA joint examinations must, where possible, include range of motion results 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. 28 Vet. App. 158 (2016). Since the July 2014 Board remand, the Veteran was afforded an additional VA examination regarding his right ankle in September 2016. During this examination, range of motion testing was conducted on the Veteran's right ankle and the examiner also commented that the Veteran had no evidence of pain with weight-bearing. However, the examination report does not indicate that the Veteran's left ankle was tested. A November 2016 addendum indicated that the Veteran's active and passive ranges of motion were the same and that no flare-ups were noted. But, the addendum also did not indicate whether the Veteran's left ankle was tested. In light of this uncertainty, the Board will remand the Veteran's right ankle condition claim so that a new VA examination may be obtained. Headaches Regarding the Veteran's headaches, he currently is in receipt of an initial 50 percent disability rating under Diagnostic Code 8100. This is the maximum schedular rating assignable for that condition and the Veteran contends that he is entitled to an even higher rating. Accordingly, the Board must consider whether he is entitled to an extraschedular rating. Such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, and is found inadequate, then the second inquiry is whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. The "governing norm" for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. See 38 C.F.R. § 3.321(b)(1). In this case, the Board first finds that the rating criteria do not adequately address the Veteran's disability picture. Specifically, a September 2016 VA headaches examination report stated that the Veteran had daily headaches which caused him to get dizzy and vomit. Additionally, the Veteran reported that he got 4 to 5 migraines a month which could last more than 5 days and up to 9 days. The examiner marked constant head pain, pulsating or throbbing pain, pain on both sides of the head, nausea, vomiting, sensitivity to light and sound, and changes in vision as current symptoms. Relatedly, in an August 2017 VA ophthalmology note, the Veteran reported that his migraines affected his vision in his left eye. Moving to the second step of the extraschedular inquiry, the Board finds that the Veteran's headache disability picture causes marked interference with employment, warranting the case to be referred to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. Specifically, the September 2016 VA examiner commented that the Veteran's headaches were so severe and frequent that the Veteran could not function in an economic environment. Accordingly, the Board will refer the claim to Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating for headaches is warranted for any time during the claim period. Left Hand and Bilateral Upper Extremities Regarding the Veteran's left hand and bilateral upper extremity service connection claims, following the July 2014 Board remand, in November 2016, a VA clinician remarked that the Veteran's left hand injury was not related to or aggravated by his back condition with radiculopathy or related to falls. However, the clinician did not provide any rationale for his conclusion and, accordingly, is inadequate for adjudicative purposes. See, e.g., Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, the Board will remand these issues to determine whether the Veteran experienced any injury to the left hand and bilateral upper extremities that were caused or aggravated by a history of falls as documented in an August 2013 VA treatment record. Pursuant to this VA treatment record, the Veteran's falling issues were caused by his back condition and lower extremity radiculopathy. Additionally, the AOJ should also obtain an opinion as to whether an injury to the left hand or wrist caused or aggravated a separate disability to the upper extremities. TDIU A decision on the Veteran's TDIU claim would be premature at this point as it is dependent upon the outcome of remanded issues. Where a pending claim is inextricably intertwined with other claims currently on appeal, the appropriate remedy is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records and associate them with the claims file-particularly those dated since October 2017. If no such records exist, the claims file should be annotated to reflect as such and the Veteran notified as such. 2. Refer the issue of entitlement to an initial disability rating in excess of 50 percent for headaches to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. 3. After Item (1) has been completed to the extent possible, schedule the Veteran for a VA examination with an appropriate clinician to determine the current nature and severity of his service-connected right ankle condition. The Veteran's claims file should be made available to and be reviewed by the examiner in conjunction with the examination. Any disability benefits questionnaires (DBQs) deemed relevant by the examiner should be completed. All indicated tests and studies should be performed and the results reported in detail. Additionally, the examiner should record the results of range of motion testing for pain on both active and passive motion, and in weight-bearing and non-weight-bearing. Additionally, range of motion should be tested for the opposite undamaged joint, if applicable. If the examiner is unable to conduct the required testing or concludes that any of the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also comment on the degree to which the Veteran's service-connected right ankle condition affects his overall occupational and social functioning and his ability to obtain and retain substantially-gainful employment. A report of the examination should be prepared and associated with the Veteran's claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why this is so. 4. After Item (1) has been completed to the extent possible, schedule the Veteran for an examination to determine the nature and etiology of a left hand condition and/or a condition of the bilateral upper extremities. The claims file, including a copy of this remand, must be made available to and reviewed by the clinician. The clinician should then address the following: (a) Please identify any disabilities of the left hand, left wrist, and/or upper extremities. Please note that although the Veteran may not meet the criteria for a certain diagnosis at the present time, diagnoses made prior to and since the date of the filing of the claim satisfy the criteria for a "current" diagnosis. (b) For each disability identified, please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by the Veteran's service-connected back condition, including a series of falls that occurred in 2011. (c) For each disability identified, please state whether it is at least as likely as not (50 percent probability or more) that the disability was aggravated beyond its natural progression by the Veteran's service-connected back condition, including a series of falls that occurred in 2011. (d) For each disability identified, please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by the Veteran's service-connected lower extremity radiculopathy, including a series of falls that occurred in 2011. (e) For each disability identified, please state whether it is at least as likely as not (50 percent probability or more) that the disability was aggravated beyond its natural progression by the Veteran's service-connected lower extremity radiculopathy, including a series of falls that occurred in 2011. (f) If and only if the above prompts are supportive of a grant of service connection for a left hand or wrist disability, please state whether it is at least as likely as not (50 percent probability or more) that the Veteran suffered from a separate disability of either upper extremity that was caused by the Veteran's left hand or wrist disability. (g) If and only if the above prompts are supportive of a grant of service connection for a left hand or wrist disability, please state whether it is at least as likely as not (50 percent probability or more) that the Veteran suffered from a separate disability of either upper extremity that was aggravated beyond its normal progression by the Veteran's left hand or wrist disability. If the Veteran's left hand, left wrist, or upper extremities were worsened beyond normal progression (aggravated) by a service-connected condition, please attempt to quantify the degree of aggravation beyond the baseline level that is attributable to the service-connected condition. In offering any opinion, the clinician should consider medical and lay evidence dated both prior to and since the filing of the claim for service connection. A complete rationale for any opinions rendered must be provided. 5. After completing the requested actions, and any additional action deemed warranted, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, if in order. The Veteran 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). ______________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs