Citation Nr: 1800791 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 14-07 330A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating higher than 10 percent for degenerative arthritis of the lumbar spine (low back disability). 2. Entitlement to an initial rating higher than 10 percent prior to October 14, 2013, and 20 percent thereafter for degenerative arthritis of the cervical spine with status post C5-C7 fusion surgery (cervical spine disability). 3. Entitlement to an initial rating higher than 20 percent for right shoulder disability. 4. Entitlement to an initial rating higher than 20 percent for left shoulder disability. 5. Entitlement to an initial rating higher than 10 percent for status post repair of right dorsal ligament (right wrist disability). 6. Entitlement to an initial compensable rating prior to October 14, 2013, for scars of the abdomen. 7. Entitlement to an initial rating higher than 10 percent for scars of the abdomen. 8. Entitlement to service connection for a left leg disability. REPRESENTATION Veteran represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD Ashley Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1980 to September 2010, to include service in the Southwest Asia Theater of operations during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In the April 2011 rating decision, the RO granted service connection for low back disability and assigned a noncompensable rating; cervical spine disability and assigned a 10 percent rating; right shoulder disability and assigned a noncompensable rating; left shoulder disability and assigned a noncompensable rating; right wrist disability and assigned a 10 percent rating; scars of the abdomen and assigned a noncompensable rating, all with an effective date of October 1, 2010, the date the Veteran separated from service. Additionally, in the April 2011 rating decision, the RO denied entitlement to service connection for a left leg disability. The Veteran timely disagreed with the initial ratings and the service connection claim. In June 2013, the Veteran testified at a hearing before a Decision Review Officer (DRO). A transcript of the hearing has been associated with the claims file. In May 2016, the Board, in pertinent part, remanded the Veteran's claims for further evidentiary development. As will be discussed below, the record reflects substantial compliance with the Board's remand directives as to the initial rating claims. Stegall v. West, 11 Vet. App. 268 (1998). In a February 2017 rating decision, the RO increased the assigned rating for the cervical spine disability to a 20 percent, effective October 14, 2013. This created a staged rating, as indicated on the title page. Furthermore, in the February 2017 rating decision, the RO increased the assigned ratings for the left shoulder disability to a 20 percent, effective October 1, 2010. Additionally, the RO granted earlier effective dates of October 1, 2010, for the 20 percent rating for the right shoulder disability and the 10 percent rating for the low back disability. The Veteran has not expressed satisfaction with the increased ratings; thus, these issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). Also in the February 2017 rating decision, to RO granted service connection for bilateral feet, left elbow, right elbow, left ankle, right ankle, right knee, right foot, and right hip disabilities, which were previously on appeal after being denied by the RO's April 2011 rating decision. As the Veteran has not appealed either the evaluations or effective dates assigned to these disabilities, these matters are not before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In the February 2017 rating decision, the RO awarded service connection for left sided cervical radiculopathy associated with the cervical spine disability. The Veteran did not submit a NOD as to that issue and as such it is not before the Board at this time. The issue of entitlement to service connection for a left foot 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. The evidence is at least evenly balanced as to whether the symptoms of the Veteran's low back disability have more nearly approximated forward flexion of 30 degrees or less, and symptoms did not more nearly approximate ankylosis of the entire thoracolumbar spine or incapacitating episodes as defined in the applicable regulation. 2. The evidence is at least evenly balanced as to whether, throughout the pendency of the appeal period, symptoms of the Veteran's cervical spine disability have more nearly approximated forward flexion of 15 degrees or less, and symptoms did not more nearly approximate unfavorable ankylosis of the cervical spine. 3. The evidence is at least evenly balanced as to whether the symptoms of the Veteran's right (dominant) shoulder disability more nearly approximate limitation of motion of the arm to 25 degrees from the side, but did not more nearly approximate ankylosis, fibrous union of the humerus, nonunion of the humerus, flail shoulder, or the nonunion of the clavicle or scapula. 4. The evidence is at least evenly balanced as to whether symptoms of the Veteran's left (minor) shoulder disability, have more nearly approximate limitation of motion of the arm to 25 degrees from the side, but did not more nearly approximate ankylosis, fibrous union of the humerus, nonunion of the humerus, flail shoulder, or the nonunion of the clavicle or scapula. 5. The symptoms of the Veteran's right wrist disability manifested by pain and limitation of motion, complaints of stiffness, and with no evidence of ankylosis. 6. Throughout the appeal period, the Veteran has had two scars of the abdomen that have manifested in pain and have not caused disabling effects not considered in the applicable diagnostic code. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 40 percent, but no higher, for the low back disability are met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242 (2017). 2. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 30 percent, but no higher, for the cervical spine disability, throughout the appeal period, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 40 percent, but no higher, for the right shoulder disability are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5201 (2017). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 30 percent, but no higher, for the left shoulder disability are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5201. 5. The criteria for an initial rating higher than 10 percent for the right wrist disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.321, 4.3, 4.71a, DCs 5010, 5214, 5215 (2017). 6. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 10 percent, but no higher, prior to October 14, 2013, for scars of the abdomen are met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. § 4.118, DC 7804 (2017). 7. The criteria for an initial rating higher than 10 percent for scar s of the abdomen are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C. §§ 5103(a), 5103A; 38 C.F.R. § 3.129(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. The Veteran's claims for initial ratings are "downstream" issues in that they arose from initial grants of service connection. In July 2010, the Veteran submitted a signed Pre-Discharge/DES Notice Response. This notice advised the Veteran of the evidence necessary to substantiate his claim for service connection, the Veteran's and VA's respective obligations with regard to obtaining evidence, and the process by which disability ratings and effective dates are assigned. Importantly, where, as here, service connection has been granted and the initial ratings and effective dates have been assigned, the claim for service connection have been more than substantiated and proven, thereby rendering 38 U.S.C. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the duty to notify has been met in this case. VA fulfilled its duty to assist the Veteran in obtaining treatment records and any other identified and available evidence needed to substantiate his claims. The Veteran was afforded VA examinations in August 2010 and October 2013 to determine the severity of his service-connected disabilities. As indicated above, the appeal was remanded in May 2016 to, among other things, afford the Veteran VA examinations to determine the severity of his service-connected disabilities. In December 2016, the Veteran was afforded examinations as to the severity of his service-connected disabilities. The Board notes that in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 38 C.F.R. § 4.59 provides, "The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." With respect to the December 2016 VA examinations, the VA examiners did not provide findings consistent to Correia, 28 Vet. App. 158. However, the Board, herein, is granting the highest ratings possible under the applicable diagnostic codes based on limitation of motion, with higher ratings requiring ankylosis. Any error in not conducting Correia-complaint range of motion testing with regard to these joints is therefore harmless. Therefore, the Board finds that there was compliance with the Board's May 2016 remand directives. See Stegall, 11 Vet. App. at 271. Notably, during the June 2013 DRO hearing and in the Veteran's March 2014 VA Form 9, he asserted that the August 2010 VA examinations were not adequate because the examiner did not provide ranges of motion of his joints or noted whether there was tenderness upon palpation of the joints. As will be illustrated below, the August 2010 VA examiner provided ranges of motion of each service-connected disability on appeal. Nevertheless, as stated above, the Board, herein, is granting the highest ratings possible under the applicable diagnostic codes based on limitation of motion; thus, any contention regarding the inaccuracy of the ranges of motion testing is harmless in this case. Furthermore, the Board finds that the VA examinations of record are adequate because they are based on consideration of the Veteran's medical history and described the disabilities in sufficient detail to allow the Board to make fully informed evaluations. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board will therefore proceed to the merits of the claims being decided herein. II. Initial Higher Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims. Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia, 28 Vet. App. 158, the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 38 C.F.R. § 4.59 provides, "The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." A. Low Back and Cervical Spine The Veteran's low back and cervical spine disabilities are rated separately under 38 C.F.R. § 4.71a, DC 5242. Under the applicable criteria, disabilities rated under DC 5242 are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, DCs 5235, 5237. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees; or, combined range of motion of the entire thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees, but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. Id. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion, extension, and left and right lateral flexion of the cervical spine are all zero to 45 degrees and left and right lateral rotation of the cervical spine are both zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and the normal combine range of motion of the thoracolumbar spine is 240 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. Alternatively, degenerative disc disease may be rating under the Formula for Rating IVDS Based on Incapacitating Episodes. This formula provides for ratings based upon the frequency and duration of incapacitating episodes during a 12-month period. An "incapacitating episode" is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician. 38 C.F.R. § 4.71a, Note (1). Under this formula, ratings are assignable based on the frequency and duration of incapacitating episodes in a 12 month period: 10 percent for a total duration of at least one week but less than 2 weeks; 20 percent rating a total duration of at least 2 weeks but less than 4 weeks; 40 percent rating a total duration of at least 4 weeks but less than 6 weeks; and 60 percent for a total duration of at least 6 weeks. In August 2010, the Veteran was afforded an examination. As to the low back disability, he reported symptoms of stiffness, spasms, weakness, and moderate pain exacerbated by physical activity. He stated that his low back disability limits his walking. He stated that he is able to continue his daily activities and continues to work. Upon physical examination of the lumbosacral spine, ranges of motion were recorded as forward flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to30 degrees. There was no additional loss of motion following repetitive- use testing. The examiner indicated that there was no evidence of radiation pain on movement, weakness, muscle spasm, tenderness, guarding, or muscle atrophy. Motor and sensory functions were normal. Reflexes of the lower extremities were equal at 2+. With respect to the cervical spine disability, the Veteran reported that in 2003, he underwent a cervical spine operation. At the time of the examination, he reported symptoms of stiffness, decreased motion, paresthesias, numbness, and weakness. He stated that he has constant, moderate neck pain, exacerbated by physical activity. He denied functional impairment. Upon physical examination of the cervical spine, ranges of motion were recorded as forward flexion to 45 degrees, extension to 10 degrees, right lateral flexion to 30 degrees, left lateral flexion to 20 degrees, right lateral rotation to 40 degrees, and left lateral rotation to 30 degrees. There was no additional loss of motion following repetitive- use testing. The examiner diagnosed prior fusion C5 through C7, very mild posterolisthesis C4-5. In October 2013, the Veteran was afforded an examination. As to the low back disability, he reported flare-ups with increased pain and stiffness that occur once a month and will last three to four days. The Veteran indicated that during flare-ups, he is unable to sit, stand, and walk for prolong distances, squat or climb. Upon physical examination of the lumbosacral spine, ranges of motion were recorded as forward flexion to 75 degrees, extension to 15 degrees with pain at 10 degrees, right lateral flexion to 10 degrees with pain, left lateral flexion to 10 degrees with pain, right lateral rotation to 10 degrees with pain at 5 degrees, and left lateral rotation to15 degrees. The examiner indicated that there was no additional loss of motion following repetitive- use testing. There was functional loss and functional impairment in terms of less movement than normal and pain on movement. There was no localized tenderness or pain to palpation for the joints or soft tissue of the spine. There was no guarding or muscle spasm. Muscle strength, deep tendon reflexes, and sensory testing were normal. The examiner indicated that there was no radicular pain or any other signs due to radiculopathy. There was no IVDS of the thoracolumbar spine. The examiner diagnosed lumbar spine arthritis. The examiner opined that the Veteran's low back disability impacts his ability work, as he is unable to walk more than 20 to 30 minutes and sit or stand for prolonged periods of time. With respect to the cervical spine disability, he reported flare-ups with increased pain that occur twice a month and that last for 48 hours. The Veteran indicated that during neck flare-ups, he is limited due to severe pain. Upon physical examination of the cervical spine, ranges of motion were recorded as forward flexion to 40 degrees with pain at 35 degrees, extension to 5 degrees, right lateral flexion to 15 degrees with pain at 10 degrees, left lateral flexion to 15 degrees with pain at 10 degrees, right lateral rotation to 40 degrees with pain at 35 degrees, and left lateral rotation to 45 degrees with pain at 35 degrees. Upon repetitive- use testing, forward flexion was limited to 40 degrees. There was functional loss and functional impairment in terms of less movement than normal and pain on movement. There was localized tenderness or pain to palpation for the joints or soft tissue of the spine. There was guarding or muscle spasm but it did not result in abnormal gait or spinal contour. Muscle strength, deep tendon reflexes, and sensory testing were normal. The examiner opined that the Veteran's cervical spine disability impacts his ability work, as he is unable to walk more than 20 to 30 minutes and sit or stand for prolonged periods of time. Private treatment records dated in April 2016 and September 2016 documents the Veteran's complaints of neck pain with weakness. An April 2016 private treatment provider diagnosed prolapsed cervical intervertebral disc. In December 2016, the Veteran was afforded an examination. As to the low back disability, he reported flare-ups described as aches across his low back. He indicated that he is unable to sit for prolonged periods of time and bend at the waist. He stated that he is employed part time as a contractor and provides trainings. Upon physical examination of the thoracolumbar spine, ranges of motion were recorded as forward flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 20 degrees with pain on all ranges of motion. Upon repetitive- use testing, forward flexion was limited to75 degrees. There was pain, fatigue, lack of endurance that caused functional loss. The examiner indicated that the examination was not conducted during a flare-up. The examiner was unable to estimate ranges of motion during a flare-up. The Veteran had muscle spasm of the thoracolumbar spine that did not result in abnormal gait or abnormal spinal contour. There was no muscle atrophy, ankylosis, or IVDS of the thoracolumbar spine. Muscle strength, deep tendon reflexes, and sensory testing were normal. The examiner indicated that there was no radicular pain or any other signs due to radiculopathy. The examiner diagnosed ankylosing spondylitis and degenerative arthritis of the lumbar spine. The examiner opined that the Veteran's back disability impacts his ability to work, as his ability to walk or stand for prolonged periods of time or carry heavy objects is impaired. With respect to the cervical spine, during the December 2016 examination, the Veteran reported flare-ups with increased pain. He stated that he has difficulty with tasks that require him to bend his neck such as reading a computer screen and driving. He also stated that he has difficulty sleeping. Upon physical examination of the cervical spine, the ranges of motion were recorded as forward flexion to 45 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 40 degrees, right lateral rotation to 55 degrees, and left lateral rotation to 55 degrees with pain on all ranges of motion. There was additional loss of range of motion after three repetitions with respect to left lateral rotation. There was pain, fatigue, and lack of endurance that caused functional loss. The examiner was unable to estimate ranges of motion during a flare-up. There was localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. There was muscle spasm; however it did not resulting in abnormal gait or abnormal spinal contour. There was no muscle atrophy, ankylosis, or IVDS of the cervical spine. Muscle strength, deep tendon reflexes, and sensory testing were normal, except there was decreased sensation to light to touch in the right hand and finger. The examiner diagnosed degenerative arthritis of the cervical spine and residuals of cervical fusion and discectomy. The examiner indicated that there was a cervical spine scar that was not painful, unstable, was less than 39 square centimeters. The examiner opined that the Veteran's cervical spine disability impacts his ability to work. The VA examiner explained that the Veteran's cervical spine disability impairs his ability to perform occupational tasks that require frequent head and neck motions such as typing, working overhead, and driving. Analysis for Low Back The Board finds that the Veteran's low back disability more closely approximate the criteria for a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. The evidence reflects that, at worst, forward flexion was limited to 75 degrees with pain. However, throughout the appeal period the Veteran has consistently reported back pain, stiffness, weakness, muscle spasms, constant flare-ups, and limitation of motion. During the December 2016 examination, the examiner indicated that pain, fatigue, lack of endurance caused functional loss. The Veteran has credibly stated that during back flare-ups he is unable to sit for prolonged periods of time or bend as the waist. See VA examination report dated December 2016. He described flare-ups with increased pain and stiffness that occur once a month and will last three to four days. See VA examination report dated October 2013. Although the Veteran described flare-ups during VA examinations, no VA examiner was able to determine the additional loss of range of motion that would result during a flare-up. Therefore, in light of the Veteran's statements reports of back pain, stiffness, weakness, muscle spasms, severe flare-ups of lumbar spine symptoms, and that no VA examiner was able to determine the additional loss of range of motion that results during a flare-up the evidence is at least evenly balanced as to whether the symptoms of the low back disability more nearly approximate forward flexion less than 30 degrees required for a 40 percent rating under the General Rating Formula. As 40 percent is the highest schedular rating for limitation of motion, the Board does not have to consider whether he is entitled to a higher disability rating because of functional loss under §§ 4.40 and 4.45. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In Johnston, the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Id. at 84-85 (although the Secretary suggested remand because of the Board's failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). For the same reasons, as the Veteran is now in receipt of the highest schedular rating for limitation of motion, the Court's holding in Correia, 28 Vet. App. at 158 is not applicable here. See also Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (finding orthopedic examination inadequate with regard to flare-ups where the examination was the basis for a denial of a higher disability rating and the Veteran was not receiving the maximum schedular rating based on limitation of motion). An increased rating in excess of 40 percent is not warranted. Neither the reports of examination, treatment records, or the Veteran's statements indicate that there was unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. Further, there is no evidence showing that a physician required bed rest for a duration of six weeks during the past 12 months, as required under the Formula for Rating IVDS. Thus, an increased rating in excess of 40 percent is not warranted. For the foregoing reasons, the preponderance of the evidence reflects that an initial rating of 40 percent, but no higher, is warranted for the Veteran's low back disability. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Analysis for Cervical Spine The Board finds that the Veteran's cervical spine disability more closely approximate the criteria for a 30 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. During the appeal period, at worst, forward flexion was limited to 40 degrees with pain at 35 degrees. However, the Veteran has consistently reported neck pain, stiffness, weakness, muscle spasm, constant flare-ups, and limitation of motion. He also exhibited localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. The Veteran has credibly stated that during cervical spine flare-ups he has difficulty with tasks that require him to bend his neck such as reading a computer screen and driving. He described his neck flare-ups occurring twice a month and that they will last for 48 hours. See VA examination report dated October 2013. Although the Veteran described flare-ups during VA examinations, no VA examiner was able to determine the additional loss of range of motion that results during a flare-up. Therefore, given that the Veteran experienced stiffness, weakness, muscle spams, constant flare-ups, exhibited additional loss of function, and that no VA examiner was able to determine the additional loss of range of motion that results during a flare-up the evidence is at least evenly balanced as to whether the symptoms of the cervical spine disability more nearly approximate forward flexion less than 15 degrees required for a 30 percent rating under the General Rating Formula throughout the appeal period. As 30 percent is the highest schedular rating for limitation of motion, the Board does not have to consider whether he is entitled to a higher disability rating because of functional loss under §§ 4.40 and 4.45. See Johnston, 10 Vet. App. 80 at 85. The Veteran is now in receipt of the highest schedular rating for limitation of motion, the Court's holding in Correia, 28 Vet. App. at 158 is not applicable here. See also Sharp, 29 Vet. App. at 33 (finding orthopedic examination inadequate with regard to flare-ups where the examination was the basis for a denial of a higher disability rating and the Veteran was not receiving the maximum schedular rating based on limitation of motion). An increased rating in excess of 30 percent is not warranted. A schedular rating in excess of 30 percent requires ankylosis or incapacitating episodes, which have not been shown. There is no evidence of any ankylosis. The VA reports of examination or the Veteran's statements do not reveal that there was no unfavorable ankylosis of the entire cervical spine or the entire spine. Further, although the April 2016 private treatment provider diagnosed prolapsed cervical intervertebral disc, there is no evidence showing that a physician required bed rest for a duration of six weeks during the past 12 months, as required under the Formula for Rating IVDS. Thus, an increased rating in excess of 30 percent is not warranted. The Board has considered the Veteran's scars in the evaluation of the cervical spine disability. However, the evidence shows that the Veteran's scar was superficial and the total areas of those scars were not greater than 39 square centimeters (6 square inches) each. As such, a separate, compensable rating for a cervical scar is not appropriate. See 38 C.F.R. § 4.118, DCs 7801-7805. For the foregoing reasons, the preponderance of the evidence reflects that an initial rating of 30 percent, but no higher, is warranted for the Veteran's cervical spine disability. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. B. Right and Left Shoulders The Veteran's right shoulder disability is assigned a 20 percent disability rating under 38 C.F.R. § 4.71a, DC 5201. His left shoulder disability is assigned a 20 percent disability rating under 38 C.F.R. § 4.71a, DCs 5003-5201. Under Diagnostic Code 5003, degenerative arthritis 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. 38 C.F.R. § 4.71a, DC 5003. When, however, the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings will not be combined with ratings based on limitation of motion. Id. The rating criteria for the shoulder are found at 38 C.F.R. § 4.71a, DCs 5200 through 5203. DCs 5200-5203 distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. § 4.69 (2017). The evidence shows the Veteran to be right-hand dominant. DC 5201 provides that limitation of motion of the arm at shoulder level warrant a 20 percent rating. Limitation of motion of the arm from midway between the side and shoulder level warrants a 30 percent rating for a major extremity and 20 percent rating for the minor extremity. Limitation of motion to 25 degrees from the side warrants a 40 percent rating for a major extremity, and 30 percent rating for a minor extremity. See 38 C.F.R. § 4.71a, DC 5201. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. In August 2010, the Veteran was afforded an examination. As to the right and left shoulder, the Veteran reported a history of rotator cuff tears impingement. At the time of the examination, he reported symptoms of weakness, flare-ups, giving way, tenderness and pain, exacerbated by physical activity. He indicated that during flare-ups activities that involve his shoulders are limited. He stated that he has difficulty reaching overhead or sideways. Upon physical examination ranges of motion bilaterally were recorded as forward flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The examiner indicated that the Veteran denied pain upon ranges of motion and there was no additional degree of loss of motion after repetitive use. The examiner diagnosed left should degenerative arthritis, status post-surgery and right shoulder small bone island. Private treatment records dated in September 2013 reflect that the Veteran underwent left shoulder arthroscopic labral debridement and arthroscopic subacromial decompression. Additionally, September 2013 private treatment records show a diagnosis of degenerative osteoarthrosis of the left shoulder. In October 2013, the Veteran was afforded an examination. He reported right and left shoulder pain with flare-ups that occur three to four times a week that last for 24 hours. He stated that when he has shoulder flare-ups, he is unable to use his arms for any substantial use. As to the right shoulder, upon physical examination, ranges of motion were recorded as forward flexion to 140 degrees, abduction to 70 degrees with pain at 60 degrees, external rotation to 25 degrees with pain at 20 degrees, and internal rotation to 90 degrees. With respect to the left shoulder, upon physical examination, ranges of motion were recorded as forward flexion to 90 degrees, abduction to 130 degrees with pain at 120 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The Veteran had localized tenderness or pain to palpation of the joints/ soft tissue, biceps tendons of the left shoulder. He had guarding of the left shoulder. Furthermore, as to the right and left shoulder, the examiner indicated that the Veteran was unable to perform repetitive use testing due to pain. The Veteran had functional impairment of the right and left shoulders, in terms of less movement than normal and pain on movement. Muscle strength was normal bilaterally. There was no ankylosis, recurrent dislocation (subluxation) of the glenohumeral joints. The examiner diagnosed right shoulder bone island. The examiner diagnosed left shoulder arthritis and post status arthroscopic surgery. The examiner opined that the Veteran's right and left shoulder disabilities impacts his ability work, as he is unable to lift more than 20 pounds. Private treatment records dated in August 2016 documents the Veteran's complaints of bilateral shoulder pain. In December 2016, the Veteran was afforded an examination. As to the right shoulder, he reported flare-ups that occur a couple times a week and last for 24 hours. He stated that he has difficulty sleeping and lifting his arms overhead, or bending his arms behind his back. Upon physical examination of the right shoulder, ranges of motion were recorded as flexion to 150 degrees with pain, abduction to 155 degrees with pain, external rotation to 90 degrees, and internal rotation to 90 degrees. There was no additional functional loss or range of motion after three repetitions. The examiner was unable to estimate ranges of motion during flare-up. The examiner diagnosed right shoulder impingement syndrome. Muscle strength was normal. With respect to the left shoulder, he reported that he underwent a second left shoulder arthroscopic surgery in 2013 due to severe arthritis pain. He reported left shoulder pain and flare-ups that occur a couple times a week and last for 24 hours. Upon physical examination of the left shoulder, ranges of motion were recorded as flexion to 160 degrees with pain, abduction to 125 degrees with pain, external rotation to 75 degrees with pain, and internal rotation to 50 degrees with pain. The examiner was unable to estimate ranges of motion during flare-up. There was no additional functional loss or range of motion after three repetitions. There was evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and crepitus. There was left shoulder dislocation and clavicle or scapula condition affect range of motion of the shoulder (glenohumeral) joint. The examiner diagnosed left shoulder impingement syndrome, glenohumeral joint osteoarthritis, and acromioclavicular joint separation. As to the right and left shoulder, the examiner indicated that muscle strength was normal and there was no ankylosis. The examiner opined that the Veteran's right and left shoulder disabilities impacts his ability to perform occupational tasks. The examiner explained that the Veteran's shoulders impair his ability to perform overhead activities, carrying heavy objects, prolonged driving, or repetitive reaching posteriorly. Analysis for the Right Shoulder The Board finds that the Veteran's symptoms of his right shoulder disability more nearly approximates the criteria for the 40 percent rating. In this case, Veteran's limitation of motion for forward flexion was limited to, at worst, 140 degrees and abduction was limited to, at worst, 70 degrees. However, the Veteran consistently reported right shoulder pain, weakness, giving way, tenderness, limitation of motion, inability to perform overhead activities, and flare-ups, which demonstrates a significant limitation of range of motion of the right shoulder. He stated that his flares-ups that occur a couple times a week and last for 24 hours. Importantly, no VA examiner was able to determine the additional loss of functional or ranges of motion during flare-ups. Taking into consideration of the facts noted above and that the Veteran has consistently reported severe right shoulder symptoms, such as weakness, giving way, tenderness, flare-ups, the Board finds that the Veteran's right shoulder disability more nearly approximates limitation to 25 degrees from the side required for a 40 percent disability rating. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca, 8 Vet. App. at 206-207. The Board has assigned the highest rating possible for limitation of motion of the Veteran's right, dominant. The provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Thus, additional compensation for functional loss is not appropriate. For the foregoing reasons, an initial rating of 40 percent, but no higher, for the Veteran's right shoulder disability is warranted. The benefit of the doubt doctrine is not for application and the claim for an initial higher than that assigned herein must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Analysis for the Left Shoulder The Board finds that the Veteran's left shoulder disability more nearly approximates the criteria for an initial rating of 30 percent under DC 5201. The Veteran's left shoulder disability, which involves his non-dominant extremity, has exhibited different limitations of motion throughout the appeal. At its worst, the Veteran's shoulder flexion was limited to 90 degrees and abduction was limited to 125 degrees. During the appeal period, he stated that he has difficulty with overhead activities and is unable to bend his arms behind his back. Moreover, the Veteran has consistently reported left shoulder flare-ups, weakness, giving way, tenderness and pain, exacerbated by physical activity. Although the Veteran's shoulder motion has not been shown to be limited to 25 degrees, the Veteran's VA examinations were not conducted during flare-ups. Importantly, no VA examiner was able to determine the additional loss of functional or ranges of motion during flare-ups. In consideration of the evidence above, the Board finds that the Veteran's left shoulder disability more nearly approximates limitation to 25 degrees from the side required for a 30 percent disability rating. Although there is x-ray evidence of left shoulder degenerative arthritis, under DC 5003, degenerative arthritis will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. However, DC 5003 provides for a maximum of only a 10 percent rating. Thus, the 30 percent rating under DC 5201 is more favorable to the Veteran. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as reasons and bases as well as the evidence support it. Butts v. Brown, 5 Vet. App. 532, 538 (1993). By this decision, the Veteran is assigned the highest rating possible for limitation of motion of his left shoulder under DC 5201. The provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Thus, additional compensation for functional loss is not appropriate. The Board has also considered whether a separate rating is warranted under other codes. DC 5203 pertains to impairment of the clavicle or scapula, including dislocation, nonunion with or without loose movement, or malunion. In the alternative, the disability may be rated on impairment of function of a contiguous joint. 38 C.F.R. § 4.71a, DC 5203 (2017). To this end, the December 2016 VA examiner indicated that the Veteran has a left shoulder dislocation and clavicle or scapula condition affect range of motion of the shoulder (glenohumeral) joint. The examiner diagnosed left shoulder impingement syndrome, glenohumeral joint osteoarthritis, and acromioclavicular joint separation. Although there is evidence of shoulder dislocation and clavicle or scapula condition, DC 5203 directs the evaluation to be determined under impairment of function of a contiguous joint. Here, the Veteran is awarded the highest rating possible for limitation of motion for the left shoulder throughout the appeal period, under DC 5201. Thus a grant of a separate rating would result in awarding separate ratings for the same disability, or pyramiding, which is prohibited. 38 C.F.R. § 4.14. The record does not establish, and the Veteran has not alleged, ankylosis, a flail shoulder, a false flail joint, or fibrous union of the humerus. Therefore, consideration under DCs 5200 or 5202 is not warranted. For the foregoing reasons, an initial rating of 30 percent, under DC 5201, for the left shoulder disability is warranted. As the preponderance of the evidence is against any higher or separate rating, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. C. Right Wrist The Veteran's right wrist disability is assigned an initial rating of 10 percent under 38 C.F.R. § 4.71a, DC 5215. Under DC 5215, limitation of motion of wrist evidence by palmar flexion limited in line with forearm or dorsiflexion less than 15 degrees warrant a 10 percent disability rating. This is the maximum disability rating under DC 5215. In August 2010, the Veteran was afforded an examination. He reported that in 2001, he underwent a right wrist-dorsal ligament repair. At the time of the examination, he reported symptoms of stiffness, fatigability, pain, and tenderness, exacerbated by physical activity. He stated that because he is right handed, he has difficulty with activities that require the use of his right hand. Upon physical examination, ranges of motion of the right wrist were recorded as dorsiflexion to 70 degrees, palmar flexion to 50 degrees, radial deviation to 10 degrees, and ulnar deviation to 30 degrees, with pain upon all ranges of motion. There was no additional degree of limitation after repetitive use testing. The examiner diagnosed status post repair of right dorsal ligament. In October 2013, the Veteran was afforded an examination. He reported right wrist flare-ups occurring three to four times a week lasting for 24 hours. He indicated that during flare-ups, he is unable to use his right hand. Upon physical examination, ranges of motion of the right wrist were recorded as dorsiflexion to 40 degrees with pain at 0 degrees and palmar flexion to 40 degrees with pain at 0 degrees. Repetitive use testing revealed ranges of motion limiting dorsiflexion to 35 degrees and palmar flexion to 35 degrees. The examiner indicated that the Veteran has functional impairment of the wrist in terms of weakened movement and pain on movement. There was localized tenderness or pain on palpation of the joints and/or soft tissue. Muscle strength was normal. There was no ankylosis. The examiner indicated that the Veteran has pain in his right wrist with scaring due to his right dorsal ligament repair. The examiner indicated that x-ray reports showed degenerative or traumatic arthritis. The examiner opined that the Veteran's right wrist disability impacts his ability work, as he is unable to lift more than 20 pounds. In December 2016, the Veteran was afforded an examination. He reported chronic wrist pain. He stated that he has right wrist flare-ups. He indicated that he has severe flare-ups that disable him to do anything with his right wrist. He explained that he has difficulty with typing and grabbing objects in his right hand. Upon physical examination of the right wrist, the ranges of motions were recorded as palmar flexion to 50 degrees with pain and dorsiflexion was to 60 degrees with pain. Upon repetitive use testing, ranges of motion were limited for palmar flexion to 45 degrees and dorsiflexion was to 55 degrees. The examiner was unable estimate ranges of motion during flare-ups. There was mild tenderness to palpation of the mid dorsal wrist. There was evidence of crepitus. Muscle strength was normal. There was no evidence of muscle atrophy or ankylosis. The examiner diagnosed postsurgical changes within the scaphoid bone. The examiner opined that the Veteran's right wrist disability impacts his ability to perform occupational tasks, such as any task that require repetitive hand and wrist motion such as opening containers. The Board finds that an initial rating higher than 10 percent for the right wrist disability is not warranted. This is the maximum disability rating under DC 5215. See also Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2017) (a compensable rating is warranted for joint pain pursuant to 38 C.F.R. § 4.59 for orthopedic disabilities rated under diagnostic codes containing a compensable rating, and the criteria for such a rating can be satisfied with lay and other non-medical evidence). The Board has considered whether the Veteran is entitled to higher disability rating under other relevant diagnostic codes. In this regard, DC 5214 evaluates ankylosis of the wrist. In this case, the evidence does not show nor does the Veteran contend that he has ankylosis of the right wrist. Thus, the Veteran is not entitled to a disability rating in excess of 10 percent under Diagnostic Code 5214. Furthermore, as noted, the regulations relating to limitation of motion and DeLuca are not for application, as the Veteran is receiving the highest rating for limitation of motion of the wrist, a higher rating requires ankylosis. D. Scars The Veteran's scars of the abdomen are under DC 7804. Under DC 7804, a 10 percent evaluation is assigned for 1 or 2 unstable or painful scars; a 20 percent evaluation is assigned for 3 or 4 unstable or painful scars; and, a 30 percent evaluation is assigned for 5 or more unstable or painful scars. See 38 C.F.R. § 4.118, DC 7804 (2015). Note (1) indicates that an unstable scar is one where, for any reason, there is frequent loss of covering over the scar. Additionally, if one or more scars are both unstable and painful, an extra 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. Id., Note (2). In an August 2010 examination report, the Veteran reported that he had a revision of an abdominal scar in 1977 and 2003. He denied that his scar caused functional impairment. Upon physical examination, the examiner indicated that the Veteran had two well-healed scars, one located on the middle of the abdomen measuring at 16 centimeters (cm.) x .3 cm. and the second scar located on the right iliac fossa measuring at .2 cm x .2 cm. The examiner indicated that there was no tenderness, disfigurement, instability, or skin breakdown. The examiner opined that the Veteran's scars do not impact his functioning or usual occupation or his daily living activities. In October 2013, the Veteran was afforded an examination. He reported that he had one painful abdominal scar. The examiner indicated that the Veteran has one abdominal scar measuring at 14 cm x 2 cm. The examiner indicated that scar was not unstable with frequent loss of covering of skin over the scar. The examiner indicated that the scar does not result in limitation of function. In December 2016, the Veteran was afforded an examination. He gave a history that in 1977 he underwent a surgical repair on his abdomen, which left a scar. Thereafter, in 2003, he underwent a cosmetic scar revision, which left a painful scar that occasionally "cramps" upon activities. Upon physical examination of the abdominal scar, the examiner indicated that the scar was superficial and non-linear, measuring at 7.5 cm x .5 cm. There was no evidence that the scar was unstable with loss of covering of skin over the scar. The examiner opined that the Veteran's scar does not impact his ability to work. After review of the record and resolving reasonable doubt in favor of the Veteran, the Board finds that prior to October 14, 2013, an initial 10 percent rating is warranted for the Veteran's scars of the abdomen. While pain was not noted during the August 2010 VA examination, the Board notes that the Veteran is competent to report observable symptoms, such as pain and other discomfort, and any doubt as to whether the scars of the abdomen manifested by pain is resolved in the Veteran's favor. Therefore, given the competent evidence showing that at least one of the Veteran's scars of the abdomen was painful, the Board finds that his disability warrants an initial 10 percent rating, but no higher, since October 14, 2013, under DC 7804. Throughout the appeal period, the Board finds that an initial rating of 10 percent for scars of the abdomen is not warranted as there is no evidence that three or four scars are unstable or painful. The Board has considered the Veteran's scars of the abdomen under other diagnostic codes pertaining to scars. However, his scars are not located on his head, face, or neck to warrant consideration under DC 7800; nor are the scars shown to be deep (associated with underlying soft tissue damage) or cover sufficient area to warrant consideration under DC 7801 or DC 7802. The Board also notes that the Veteran's scars of the abdomen are not shown to have any disabling effects other than pain and tenderness, which is contemplated by the 10 percent rating assigned under DC 7804. Accordingly, DC 7805 is not for application in this case. Therefore, the other potentially applicable diagnostic codes do not assist the Veteran in obtaining an initial higher rating. For the foregoing reasons, prior to October 14, 2013, an initial rating of 10 percent, but no higher, is warranted for the Veteran's scars of the abdomen. And entitlement to an initial rating higher than 10 percent is not warranted. The benefit of the doubt doctrine is not for application and the claim for an initial rating higher than that assigned herein must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. The Board has considered the Veteran's increased rating claims and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his initial rating claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). Finally, a request for an entitlement to a total disability rating based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. Here, the Veteran did not assert that his service-connected disabilities rendered him unemployable, and the issue of entitlement to a TDIU has therefore not been raised by the evidence of record. Id. ORDER Entitlement to an initial rating of 40 percent, but no higher, for the low back disability is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating of 30 percent, but no higher, for the cervical spine disability, for the entire appeal period, is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating of 40 percent, but no higher, for the right shoulder disability is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating of 30 percent, but no higher, for the left shoulder disability is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating higher than 10 percent for the right wrist disability is denied. Entitlement to an initial compensable rating prior to October 14, 2013, for scars of the abdomen is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating higher than 10 percent for scars of the abdomen is denied. REMAND A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran claims that he developed a left leg disability during his active military service. Service records reflect that he served in Southwest Theater of Operations during the Persian Gulf War. 38 U.S.C. § 1117 (2012) and 38 C.F.R. § 3.317 (2017) are therefore potentially applicable. In May 2016, the Board remanded the Veteran's service connection claim for a left leg disability to afford him a VA examination with an opinion to determine the nature and etiology of the claimed left leg disability, to include consideration whether the left leg symptoms are due to an undiagnosed illness. In December 2016, the Veteran was afforded an examination; however the examiner did not address whether the Veteran had a left leg disability or the symptoms thereof. To this end, although the December 2016 examiner gave an opinion addressing the left knee, it is unclear whether this opinion encompasses the left leg disability or the symptoms thereof. Therefore, the Board finds that a remand is necessary to obtain an opinion to address the nature and etiology of the Veteran's claimed left leg disability. Accordingly, the remaining claim is REMANDED for the following action: 1. Obtain any outstanding records of treatment that the Veteran may have received at any VA health care facility. All such available documents should be associated with the claims file. 2. Then, the claims folder should be referred to an appropriate VA physician for an opinion as to the etiology of the Veteran's left leg disability. A copy of this remand must be made available to the physician for review in connection with the requested opinion. The physician should identify any left leg disability and then provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that it had its onset during military service or is otherwise related to service. Because the Veteran served in the Persian Gulf, the matter of undiagnosed illnesses is for consideration. Therefore, if any of the Veteran's left leg symptoms cannot be attributed to a known clinical diagnosis, the examiner must indicate whether the Veteran has signs and symptoms such as muscle and joint pain due to an undiagnosed illness or a medically unexplained chronic multisymptom illness. 3. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017). Department of Veterans Affairs