Citation Nr: 1739694 Decision Date: 09/15/17 Archive Date: 09/29/17 DOCKET NO. 08-07 592 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a disability rating for impairment of the sciatic nerve of the right lower extremity (associated with service-connected back disability) in excess of 10 percent for the period prior to December 17, 2014, and in excess of 20 percent thereafter. 2. Entitlement to separate compensable rating for neurological symptoms secondary to a service-connected back disability, with specific attention to neurological impairment of the left lower extremity. 3. Entitlement to separate compensable ratings for impairment of the external popliteal (common peroneal) nerve, musculocutaneous (superficial peroneal) nerve, anterior tibial (deep peroneal) nerve, internal popliteal (tibial) nerve, and posterior tibial nerve of the right lower extremity (associated with service-connected back disability). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran served on active duty from June 1962 to September 1982. This matter is on appeal from a June 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified before a Veterans Law Judge (VLJ) in June 2011. In July 2014, the Board sent the Veteran a letter informing him that the VLJ who had conducted that hearing was no longer employed at the Board and asked him to indicate whether he wanted to attend a new hearing. He was informed that he had 30 days from the date of the letter to respond, and if he did not respond within that time period, the Board would assume that he did not want another hearing and proceed accordingly. As no response was received, the Board will proceed in adjudicating the merits of the appeal. The issues on appeal arise primarily from an underlying claim of entitlement to an increased rating for a back disability; that claim was denied by the Board in October 2014. However, the Board remanded issues concerning entitlement to increased or separate ratings for any associated neurological abnormalities, as is prescribed under the General Rating Formula for Diseases and Injuries of the Spine, contained in 38 C.F.R. § 4.71a. The remanded issues returned to the Board and were again addressed in an August 2015 Board decision that essentially recharacterized the issues as entitlement to increased ratings for right lower extremity neurological impairments (as explained in the body of that decision) and entitlement to separate compensable ratings for other neurological manifestations secondary to the service-connected spine disability. The August 2015 decision granted an increased 20 percent rating for the right lower extremity for the portion of the period on appeal from December 17, 2014 onward. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court), specifically challenging the denial of further increases of ratings for neurological deficits of the right lower extremity and the denial of a separate compensable rating for neurological deficits of the left lower extremity. In January 2017, the Court issued a memorandum decision that vacated the August 2015 Board decision and remanded the matters for readjudication consistent with the instructions outlined in the memorandum decision. All prior Board actions and decisions in this case have been issued by VLJs other than the undersigned; the case has now been reassigned to the undersigned VLJ for final appellate review. At this time, the Board notes that evidence of record (featuring, in particular, a December 2014 VA examination report) identifies six different peripheral nerves as involved in the Veteran's neurological deficits of the right lower extremity at issue in this appeal. The Veteran is currently in receipt of a rating for impairment of the sciatic nerve of the right lower extremity, and this appeal also features the issue of whether further separate compensable ratings may be warranted for additional neurological symptoms secondary to the service-connected back disability. As discussed below, the Board finds that the evidence of record is adequate to (1) complete final appellate review of the existing rating for impairment of the right sciatic nerve, (2) grant entitlement to a separate compensable rating for left lower extremity neurological impairment, and (3) identify five additional nerves of the right lower extremity with impairment that may potentially be separately compensable. No other manner of neurological impairment associated with the service-connected back disability is suggested in this case. The Board finds, however, that the evidence of record is not fully adequate to support sufficiently informed appellate review determining whether any (and if so, which) impairment of the additional nerves of the right lower extremity may warrant separate compensable ratings. The Board finds that all of these matters are encompassed by the scope of the issues on appeal and, to ensure clarity and effectiveness in this adjudication and in the needed additional development, the Board has recharacterized the issues on appeal to recognize and address these matters separately as reflected on the title page of this decision. The Board notes that the portion of the August 2015 decision that awarded an increased 20 percent rating for the right lower extremity neurological deficits was not challenged by the Veteran and has been effectuated by a December 2015 RO rating decision. Although the January 2017 Court memorandum decision somewhat broadly states that it vacated the August 2015 Board decision, the Board interprets the entirety of the of the Court's decision as not disturbing the award of the increased rating that was favorable to the Veteran and which the Veteran did not challenge. Accordingly, the Board now revisits this appeal from a position of assuming the Veteran's already-established entitlement to a 20 percent rating for the right lower extremity neurological deficits for the period from December 17, 2014 onward; the Board's analysis focuses upon the questions of entitlement to further or additional increased ratings. Furthermore, the Board recognizes that the August 2015 Board decision addressed an issue listed as "Entitlement to a separate compensable rating for neurological symptoms secondary to a service-connected back disability," but the focus of the adjudication of that issue by the Board in August 2015 and by the Court in January 2017 was the Veteran's contentions concerning neurological impairment specifically of the left lower extremity. The Board has recharacterized the issue accordingly, as reflected on the title page of this decision. The Board notes that the neither the Veteran nor the Court's January 2017 memorandum decision raised any concerns directing attention to any neurological symptoms beyond those of the lower extremities; the Board's analysis in this decision is accordingly focused upon the contentions featuring the lower extremities. The Board also notes that the Veteran separately appealed part of the October 2014 Board decision to the Court; that separate appeal to the Court concerned the issue of entitlement to an increased rating for the primary back disability itself (as distinguished from the secondary neurological impairment). In September 2015, the parties filed a Joint Motion for Remand, asking the Court to vacate the October 2014 Board decision, and to remand the issue to the Board for additional consideration. The Court granted the Joint Motion for Remand later that month, and the claim returned to the Board. The Board then again decided (with a partial grant) the remaining portion of the back disability rating claim on appeal in a November 2015 final decision. The Board notes that the back disability is now rated as 20 percent disabling from February 15, 2006 to March 12, 2012, and 40 percent disabling from March 12, 2012 onward under 38 C.F.R. § 4.71a, Diagnostic Code 5295-5242 (addressing degenerative arthritis of the spine). That aspect of the appeal has been resolved and is no longer a matter pending before the Board; accordingly, it will not be further discussed in this decision. In addition to the pertinent August 2015 Board decision discussed above, the Board issued another separate August 2015 decision under a different docket number addressing the Veteran's appeal on the matter of entitlement to a clothing allowance. That separate Board decision remanded the clothing allowance issue to a separate agency of original jurisdiction for additional development, and that issue has not yet been re-certified to the Board. Accordingly, the clothing allowance issue shall not be addressed by the Board in this decision nor in any separate Board decision at this time. The issue of entitlement to separate compensable ratings for impairment of the external popliteal (common peroneal) nerve, musculocutaneous (superficial peroneal) nerve, anterior tibial (deep peroneal) nerve, internal popliteal (tibial) nerve, and posterior tibial nerve of the right lower extremity (associated with service-connected back disability) is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to December 17, 2014, the neurological symptoms associated with impairment of the Veteran's sciatic nerve of the right lower extremity (resulting from his service-connected back disability) featured some numbness and pain generally limited to the right foot/ankle, and mildly diminished muscle strength and reflex responsiveness but with generally normal motor functioning; incomplete paralysis to a "moderate" level has not been shown for this period. 2. For the period from December 17, 2014 onward, the neurological symptoms associated with impairment of the Veteran's sciatic nerve of the right lower extremity (resulting from his service-connected back disability) featured diminished muscle strength, absent sensory functioning in the toes, and incomplete paralysis to a "moderate" level; incomplete paralysis to a "moderately severe" level has not been shown. 3. For the entire period on appeal, the neurological symptoms in the Veteran's left lower extremity resulting from his service-connected back disability were characterized by pain and some slight loss in motor strength approximating "mild" incomplete paralysis; incomplete paralysis to a "moderate" level has not been shown. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for impairment of the sciatic nerve of the right lower extremity for the period prior to December 17, 2014 have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.6, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 2. The criteria for a rating in excess of 20 percent for impairment of the sciatic nerve of the right lower extremity for the period from December 17, 2014 onward have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.6, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 3. The criteria for a separate 10 percent rating, but no higher, for neurological symptoms of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.6, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Board typically considers only those factors contained wholly in the rating criteria, it is appropriate to consider factors outside the specific rating criteria when appropriate in order to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). The Veteran's disability of the right leg associated with lumbar spine disability is currently rated under Diagnostic Code 8520 for paralysis of the sciatic nerve (following the Board's recharacterization of the matter in August 2015, a determination not objected to by the Court's January 2017 memorandum decision). The Board notes that Diagnostic Code 8520's rating criteria are identical to those for Diagnostic Code 8620 for neuritis of the sciatic nerve and Diagnostic Code 8720 for neuralgia of the sciatic nerve. See 38 C.F.R. § 4.124a. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe paralysis; a 60 percent rating is warranted for severe paralysis, with marked muscular atrophy; and a maximum 80 percent rating for complete paralysis (the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost). The terms "mild," "moderate," and "severe" under applicable diagnostic codes are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The term "incomplete paralysis," with these and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type 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 wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. See "note" at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124a. VA's Adjudication Procedures Manual M21-1, Part III, Subpart iv, Chapter 4, § G(4)) defines 'mild' incomplete paralysis as demonstrating subjective symptoms or diminished sensation; 'moderate' incomplete paralysis as featuring the absence of sensation confirmed by objective findings; and 'severe' incomplete paralysis as featuring more than sensory findings (such as atrophy, weakness, and diminished reflexes). The Board notes that the VA Adjudication Procedures Manual M21-1 is not binding upon the Board. The Board, in its consideration of appeals, "is bound by applicable statutes, regulations of the Department of Veterans Affairs, and precedent opinions of the General Counsel of the Department of Veterans Affairs, but not by Department manuals, circulars, or similar administrative issues." 38 C.F.R. § 19.5; see also 38 U.S.C.A. § 7104(c). However, this does not prevent the manual, and the definitions contained therein, from serving as a benchmark when evaluating the degree of severity of neurological impairment. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In February 2006, the Veteran submitted a claim seeking, in pertinent part, increased ratings for his service-connected back disability ("Back strain"), and for paresthesia on the lateral side of his right foot ("Nerve paralysis"). The neurological disability was rated at the time as 10 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8523 (addressing incomplete paralysis of the anterior tibial nerve). As discussed in the introduction section of this decision, the neurological disability has been recharacterized during the course of this appeal as a right lower extremity disability rated under 38 C.F.R. § 4.124a, Diagnostic Code 8520, with a 20 percent rating in effect from December 17, 2014 (and a 10 percent rating in effect prior to that date). The Board's award of the increased 20 percent rating was not disturbed by the Court's January 2017 memorandum decision. As discussed in the introduction section of this decision, the Board has previously issued decisions resolving the matter of rating the Veteran's primary back/spine disability (resolved in an October 2014 Board decision and, following an appeal to the Court of part of that decision, a subsequent November 2015 Board decision). That aspect of the claim is no longer on appeal. In its October 2014 decision, the Board remanded the issues of whether any separate ratings were warranted based on neurological abnormalities, to include the issue of entitlement to a rating in excess of 10 percent for right lateral fifth toe paresthesia. In the remand, the Board noted that it was unclear whether the 10 percent rating the Veteran received for his right foot would be a separate and distinct rating from any other neurological disorder. In this regard, the Board notes that rating the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Based on the evidence of record, the Board has determined that the 10 percent rating the Veteran receives for his right foot neuropathy under Diagnostic Code 8523 is better rated under Diagnostic Code 8520, which addresses incomplete paralysis of the sciatic nerve and manifests in symptoms of the entire lower extremity. (This determination to recharacterize the disability and change the applied Diagnostic Code was previously made and explained in the Board's now-vacated August 2015 decision, and the Court's January 2017 memorandum decision did not disturb or otherwise present any objection with this aspect of the Board's decision.) The question of whether further separate ratings may be warranted for involvement of other nerves in addition to the sciatic nerve is a matter subject to a need for further development, as discussed in the remand section of this decision, below. Having recharacterized the Veteran's neurological pathology, the Board has found (in a portion of the August 2017 Board decision that has not been disturbed by the January 2017 Court memorandum decision) that a 20 percent rating is warranted for neurological symptoms in the right lower extremity under 38 C.F.R. § 124a, Diagnostic Code 8520 for the period from December 17, 2014 onward. The Board finds that no further increased rating is warranted for the disability during the period for consideration in this appeal. Specifically, a May 2006 VA examination report shows that the Veteran stated that he felt neurological pain in the right ankle and bottom of the foot intermittently which made it difficult to walk. In the neurological evaluation for the Veteran's right lower extremity, the examiner found that his motor function was within normal limits and sensory function was "abnormal with findings of right 5th toe digital nerve." For both lower extremities, the Veteran's reflex results "reveal[ed] knee jerk 1+ and ankle jerk 1+," indicating diminished (hypoactive) reflex responses. While motor functioning was normal in both lower extremities, sensory functioning was abnormal in the right foot. The Veteran testified at his Board hearing in June 2011 that he had numbness, tingling, and pain in both of his feet, which he claimed limited some of his walking ability. A March 2012 VA examination report shows that the Veteran described a constant burning pain in the right 5th toe since 1982, with intermittent numbness, tingling, and pricking sensation in the toe; episodes of the intermittent symptoms last for 20 to 30 minutes and affect prolonged standing and walking. The Veteran exhibited normal muscle strength, sensory functioning, and reflexes. The examiner opined that the Veteran did not have radicular pain or neurologic abnormalities as a result of his back condition. Regarding the Veteran's service-connected paresthesia, she found that it affected his ability to work due to "limits from prolonged standing and walking." The examiner characterized the Veteran's muscle strength testing as normal with respect to his hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe flexion. On sensory examination, she opined that the Veteran's upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were normal bilaterally. The examiner also found no radiculopathy. Next, a March 2013 VA examination report shows that the Veteran stated that he still experienced paresthesia in the right foot. The examiner found that the Veteran's paresthesia affected his ability to work by limiting his walking, standing, and sitting and requiring him to be dependent on a cane to walk. Regarding Appellant's back condition, he determined that the Veteran had all normal reflexes of the knee and ankle bilaterally. On physical examination, muscle strength was mildly diminished (4/5) bilaterally (for strength testing of the knees, ankles, and great toes), but his reflex examination was normal bilaterally. There was no muscle atrophy present. Sensory functioning was decreased in the right foot toes, but was normal in both lower extremities otherwise; specifically, the examiner opined that the Veteran's sensory examination was normal bilaterally for his upper anterior thigh, thigh/knee, lower leg/ankle, and left foot/toes, except for decreased sensory findings for the Veteran's right foot/toes. Regarding radiculopathy, the Veteran had right-sided involvement of the sciatic nerve. The examiner also found that the Veteran did not have constant or intermittent pain, paresthesias or dysesthesias, or numbness for his left lower extremity. The examiner did note the presence of moderate paresthesias in the right lower extremity, but there was otherwise no finding of significant incomplete paralysis. The Board notes that moderate paresthesias or dysesthesias are not synonymous with moderate incomplete paralysis as contemplated by a rating in excess of 10 percent under Diagnostic Code 8520. For the period prior to December 17, 2014, the neurological symptoms associated with impairment of the Veteran's sciatic nerve of the right lower extremity are shown to have featured some numbness and pain generally limited to the right foot/ankle, and mildly diminished muscle strength and reflex responsiveness, but with generally normal motor functioning. The Board finds that incomplete paralysis to a "moderate" level has not been shown for this period. Therefore, a rating in excess of 10 percent for the right lower extremity neurological impairment is not warranted for the period prior to December 17, 2014. As noted in the Board's August 2015 grant of a 20 percent rating effective from December 17, 2014, the Veteran's symptoms appeared to have worsened by the time of his most recent VA examination in December 2014. Specifically, the December 2014 VA examination report shows that the Veteran continued to complain of numbness and "stinging" pain. He reported that during episodes of flare-up, which occur twice a month, he has to sit because the right foot pain worsens when he puts weight on it. Upon examination, his muscle strength was normal bilaterally in all respects. His reflexes were slightly diminished ("1+") in the bilateral ankles, and normal ("2+") in the knees. While sensory functioning was decreased in the left foot, it was absent in the right foot. The examiner found that the Veteran had moderate constant and intermittent pain and moderate paresthesia and/or dysesthesias for the right lower extremity, which he determined were attributable to a peripheral nerve condition. The examiner characterized the examination findings as revealing "Moderate" incomplete paralysis of the right sciatic nerve; the examiner reported normal findings for the left sciatic nerve. As discussed in the award of an increased rating in the Board's August 2015 decision, there is evidence of incomplete paralysis to a 'moderate' level in the right lower extremity. Accordingly, a 20 percent rating for neurological symptoms in the right lower extremity has been awarded from the date of the December 2014 VA examination. (Again, the Board considers the August 2015 establishment of this 20 percent rating to have been undisturbed by the January 2017 Court memorandum decision that otherwise vacated the August 2015 Board decision. That increase has already been implemented by the RO and the Board will not repeat the order of that established increase in this decision.) The Board finds that the evidence does not demonstrate incomplete paralysis that is "moderately severe" in degree. With regard to the right lower extremity, the Court's January 2017 memorandum decision discusses that the Board's August 2015 decision "noted that the appellant's neurological symptoms were characterized by both sensory as well as nonsensory symptoms," noting "[s]pecifically, the Board detailed that for the period prior to December 17, 2014, the appellant suffered from diminished muscle strength and pain; and for the period after December 17, 2014, the appellant suffered from diminished muscle strength and a loss of sensory functioning in [] his toes." The Court identified a problem in that "[t]he Board, however, failed to further discuss the sensory and nonsensory symptoms the appellant experiences even though the M21-1MR instructs an adjudicator to find incomplete paralysis severe for peripheral nerve disabilities that are manifested by sensory plus other nonsensory symptoms. See M21-1MR, pt. III, subpt. iv, ch. 4, § G(4)(b)." The Court explained: "Although VA's adjudication manual is not binding on the Board, the Board's finding that the appellant's symptoms were merely mild or moderate, without further discussing [] the appellant's sensory and nonsensory symptoms, frustrates judicial review because the Board's findings appear[] inconsistent with VA's instructions to adjudicators regarding how to determine the severity of peripheral nerve disabilities. See Patton v. West, 12 Vet.App. 272, 282 (1999)('The [Board] cannot ignore provisions of the Manual M21-1 . . . that are favorable to a veteran when adjudicating that veteran's claim.' (internal citations omitted))." Significantly, as noted by the Court's January 2017 memorandum decision, the Board is not bound by the guidance contained in VA's M21-1 adjudication manual. Further significantly, however, the guidance contained in VA's M21-1 adjudication manual has been revised to clarify the meaning of the guidance pertaining to this case, and the pertinent revision/clarification of the guidance has recently been recognized by the Court after the issuance of the January 2017 memorandum decision in this case. In June 2016, VA amended the M21-1 adjudication manual "to further clarify the intent of VA's policy," and the relevant portion of the M21-1 adjudication manual now explains: Important: This provision does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength. M21-1, Part III, subpt. iv, Ch. 4, § G(4)(b). In Miller v. Shulkin, 28 Vet. App. 376 (2017), the Court recently noted the significance of this revision in a precedential decision affirming a Board decision denying a rating in excess of 10 percent for a peripheral nerve disability under the provisions of 38 C.F.R. § 4.124a. See Miller v. Shulkin, 28 Vet. App. 376, 380 (2017). In light of this expressly clarified intent of the pertinent M21-1 guidance, the Board is compelled to conclude that the concerns raised by the Court's January 2017 memorandum decision have been resolved. The memorandum decision's attention was focused upon an interpretation that "the M21-1MR instructs an adjudicator to find incomplete paralysis severe for peripheral nerve disabilities that are manifested by sensory plus other nonsensory symptoms." However, this is now not a correct characterization of the referenced guidance: VA's express clarification of the pertinent guidance in the revision of the adjudication manual is clear in dispelling the concern raised in the January 2017 memorandum decision, and the adjudication manual does not "instruct[] an adjudicator to find incomplete paralysis severe for peripheral nerve disabilities that are manifested by sensory plus other nonsensory symptoms." Thus, although it may have previously been the case that "the Board's findings appear[] inconsistent with VA's instructions to adjudicators regarding how to determine the severity of peripheral nerve disabilities," that finding of the January 2017 memorandum decision does not contemplate the recent pertinent clarification of the meaning of the referenced VA instructions. Again, the Board notes that the Court has more recently (after the issuance of the January 2017 memorandum decision) acknowledged the significance of this revision in a precedential affirmance of a Board decision denying a rating in excess of 10 percent for a peripheral nerve disability under the provisions of 38 C.F.R. § 4.124a. See Miller v. Shulkin, 28 Vet. App. 376, 380 (2017). As the Board has found that the pertinent provisions of the VA adjudication manual do not conflict with the Board's findings regarding the characterization of the severity of peripheral nerve disability in this case, the Board finds that it has satisfied the January 2017 memorandum decision's instruction that the Board "cannot ignore provisions of the Manual M21-1 . . . that are favorable to a veteran when adjudicating that veteran's claim." The Board has reached its decision in this case with consideration of the M21-1 guidance as discussed above. Turning attention now to the Veteran's left lower extremity, the Court's January 2017 memorandum decision concluded "that the Board provided an inadequate statement of reasons or bases for denying the appellant a compensable rating for the neurological symptoms he experienced in his left lower extremity." The Court discussed that "[t]he Board noted that the appellant suffered from 'at most mild symptoms' in his left lower extremity," and that "DC 8520 provides a 10% disability rating for incomplete paralysis exhibited through mild symptoms. 38 C.F.R. § 4.124a (2016)." The Court found that "[i]t is unclear based on th[e] Board's findings why the appellant was not entitled to a 10% rating. Remand is required for the Board to provide an adequate statement of reasons or bases for its findings regarding the mild neurological symptoms the appellant experienced in his left lower extremity." Upon further appellate review of this case, the Board finds that the Veteran's left lower extremity was noted to have slightly diminished reflex response in a May 2006 VA examination report, no notable deficits documented in a March 2012 VA examination report, slightly diminished strength documented in a March 2013 VA examination report, and diminished reflexes together with diminished sensation shown in a December 2014 VA examination report. The Veteran testified at his Board hearing in June 2011 that he had numbness, tingling, and pain including in his left foot, which he claimed limited some of his walking ability. Resolving reasonable doubt in the Veteran's favor, the Board finds that a separate 10 percent rating for mild incomplete paralysis of the left lower extremity under Diagnostic Code 8520 is warranted because the evidence of record reasonably demonstrates a mild degree of impaired neurological function (albeit with inconstant and varying mild manifestations at different times) throughout the period for consideration in this appeal. The Board has also resolved reasonable doubt in the Veteran's favor by selecting Diagnostic Code 8520 as appropriate for application in this case because: (1) it is the most favorable to the Veteran of the available lower extremity peripheral nerve Diagnostic Codes in this case, (2) this preserves consistency with the Board's determination in the August 2015 decision that Diagnostic Code 8520 was the most appropriate for rating the right lower extremity impairments on the basis of a similar anatomical extent of the manifestations (and that Board determination has not been disturbed by the Court), and (3) because the Court's January 2017 memorandum decision itself suggests the applicability of Diagnostic Code 8520 for the left lower extremity ("DC 8520 provides a 10% disability rating for incomplete paralysis exhibited through mild symptoms .... It is unclear ... why the appellant was not entitled to a 10% rating"). The Board notes that in resolving reasonable doubt in the Veteran's favor in this case, the Board is assigning a compensable rating for the left lower extremity despite the fact that the December 2014 VA examination report that identifies the incomplete paralysis of nerves in the right lower extremity actually specifies that there was no paralysis of the left lower extremity in clinical testing. No rating in excess of 10 percent for the left lower extremity is warranted as the evidence does not indicate more than mild incomplete paralysis of any left lower extremity nerve. The Board notes that the pertinent manifestations suggestive of left lower extremity neurological impairment are so mild as to have been characterized by the December 2014 VA examiner as "normal" when that examiner declined to characterize the impairment as representing any incomplete paralysis whatsoever of any left lower extremity nerve. No medical report, finding, or opinion of record suggests that the Veteran's left lower extremity neurological function has been more than mildly impaired. The December 2014 VA examiner did not clearly explain why the noted deficits of the left lower extremity did not constitute even a mild degree of incomplete paralysis, and the Board is resolving reasonable doubt in the Veteran's favor to resolve the conflicting indications and conclude that the Veteran's left lower extremity symptoms throughout the period for consideration approximate 'mild' incomplete paralysis of the left sciatic nerve (with evidence as early as the May 2006 VA examination report showing diminished reflex responsivity in the left lower extremity). The preponderance of the evidence weighs against finding more than mild incomplete paralysis, and no rating in excess of 10 percent for the left lower extremity neurological impairment is warranted for any portion of the period on appeal. Finally, the Board determines that there is no basis for a separate compensable rating for any other neurological disorder secondary to the service-connected back disability (aside from the lower extremity deficits raised by the Veteran and discussed by the Board in this decision). As discussed in the Board's August 2015 decision, the Veteran has not indicated any notable bladder or urinary incontinence; the Court's January 2017 memorandum decision presents no concerns regarding these points for consideration. In considering the appropriate disability ratings, the Board has also considered the Veteran's statements that his neurological symptoms are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his neurological symptoms according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's neurological pathology has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent findings and opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Based on evidence of record, the Board reiterates the prior determination that the Veteran's prior 10 percent rating for paresthesia in the right foot is to be recharacterized as a 10 percent rating for paralysis of the right sciatic nerve under Diagnostic Code 8520, and that a 20 percent rating for such symptoms is warranted from December 17, 2014 onward. However, no higher ratings for right sciatic nerve impairment are warranted in this case. Furthermore, with attention to the discussion in the Court's January 2017 memorandum decision, and resolving reasonable doubt in the Veteran's favor, a new separate 10 percent rating for neurological symptoms in the left lower extremity is warranted under Diagnostic Code 8520. No further increased or separate compensable ratings for left lower extremity neurological disorders are warranted for any period on appeal, and the appeal is denied to this extent. Neither the Veteran nor his/her representative before the Board has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER A rating in excess of 10 percent for impairment of the sciatic nerve of the right lower extremity for the period prior to December 17, 2014 is denied. A rating in excess of 20 percent for impairment of the sciatic nerve of the right lower extremity for the period from December 17, 2014 onward is denied. A separate 10 percent rating, but no higher, for neurological symptoms in the left lower extremity is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Significantly, the December 2014 VA examination report is the most specifically detailed medical evidence of record documenting clinical findings describing the neurological impairments of the Veteran's right lower extremity. This examination report includes a checklist for identification of each individual nerve manifesting impairment in this case. The examiner completed the checklist with markings that indicate "Moderate" incomplete paralysis of the sciatic nerve, which the Board has discussed in the decision section above and in the prior August 2015 Board decision as the basis of the award of an increased 20 percent rating for the right lower extremity impairment. However, the December 2014 VA examination report's checklist also marks "Moderate" incomplete paralysis of five other nerves of the right lower extremity: "External popliteal (common peroneal) nerve," "Musculocutaneous (superficial peroneal) nerve," "Anterior tibial (deep peroneal) nerve," "Internal popliteal (tibial) nerve)," and "Posterior tibial nerve." Paralysis of these nerves may be rated under 38 C.F.R. § 4.124a, Diagnostic Codes 8521, 8522, 8523, 8524, and 8525, respectively. The Board has considered whether the impairment attributable to impairment of these nerves may be contemplated in the rating already assigned under Diagnostic Code 8520 for paralysis of the sciatic nerve such that separate ratings for the other nerves could potentially be prohibited as pyramiding. 38 C.F.R. § 4.14. However, the evidence in this particular case does not allow the Board (limited to its lay sensibilities and reliant upon competent medical evidence) to make this determination with adequately informed clarity. The Board takes judicial notice of the fact (without relying upon the information for any binding determination in this case) that the identified nerves involve branches of the sciatic nerve such that some degree of overlapping symptomatology / impairment may be suggested. However, it is not clear that assignment of separate ratings for multiple nerve involvement is necessarily inappropriate in this case. The Board observes that it is a matter of public record that the Court, albeit in a non-precedential manner, has noted that there are situations where, for example, "compensating the appellant's sciatic nerve symptoms separately [from external popliteal (common peroneal) nerve symptoms] would appear to not run afoul [of] the rule against pyramiding. 38 C.F.R § 4.14 (2015)." Defazio v. McDonald, 2015 U.S. App. Vet. Claims LEXIS 1304 (U.S. App. Vet. Cl. Sept. 28, 2015) (non-precedential). The medical evidence currently of record does not make clear whether any manifestations of impairment attributable to one or more of the other peripheral nerves may be compensably distinct from the manifestations contemplated by the rating already assigned for the sciatic nerve impairment. The Board finds that a remand is warranted to obtain a competent medical opinion to determine whether the incomplete paralysis of any of the other five involved peripheral nerves of the right lower extremity (other than the sciatic nerve) manifests in impairment that is entirely distinct from (neither duplicative nor overlapping) the impairment attributed to the paralysis of the sciatic nerve as part of the disability resulting from the service-connected spinal pathology. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Accordingly, the case is REMANDED for the following action: 1. The AOJ should secure for the record copies of complete updated clinical records (any not already of record) of all VA and/or private treatment the Veteran has received for his right lower extremity neurological impairment on appeal. If the Veteran has received private treatment, the AOJ should ask the Veteran to provide the releases necessary for VA to secure the records of such treatment. 2. The AOJ should forward the Veteran's claims file to the author of the December 2014 VA peripheral nerves examination (or another appropriate specialist) for a medical opinion, with examination only if deemed necessary, addressing the nature and etiology of the Veteran's right lower extremity neurological deficits. The VA examiner is asked to review the claims file and address the following questions: The December 2014 VA peripheral nerves examination report identified moderate incomplete paralysis of six different right lower extremity nerves ("Sciatic Nerve," "External popliteal (common peroneal) nerve," "Musculocutaneous (superficial peroneal) nerve," "Anterior tibial (deep peroneal) nerve," "Internal popliteal (tibial) nerve)," and "Posterior tibial nerve"). The Veteran is currently in receipt of disability compensation for right lower extremity neurological impairment based upon moderate incomplete paralysis of the sciatic nerve, but additional compensation might be warranted if the noted impairment of one or more of the other identified nerves manifests in impairment that is entirely distinct from (neither duplicative nor overlapping) the impairment attributed to the paralysis of the right sciatic nerve. Please identify any impairment/symptomatology of any right lower extremity nerve found to be affected by incomplete paralysis (including those indicated in the December 2014 VA examination report) where such impairment/symptomatology is entirely distinct from (neither duplicative nor overlapping) the impairment from the paralysis of the right sciatic nerve. A complete rationale should be provided for each opinion expressed. 3. The AOJ should then review the record and readjudicate the claim remaining on appeal. If the appeal remains denied to any extent, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs