Citation Nr: 18142356 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 17-12 728 DATE: October 15, 2018 ORDER Entitlement to service connection for a throat or lymph nodes disability, to include as due to chemical or radiation exposure, is denied. Entitlement to service connection for an eye disability, to include as due to chemical or radiation exposure, is denied. Entitlement to service connection for hair loss, to include as due to chemical or radiation exposure, is denied. Entitlement to service connection for a skin rash on the chest and back, to include as due to chemical or radiation exposure, is denied. Entitlement to service connection for a right knee disability, to include as secondary to the service-connected low back disability, is denied. Entitlement to service for coronary artery disease, to include as secondary to service-connected disability, is denied. Entitlement to an increased rating in excess of 40 percent for low back disability, status post lumbar strain with degenerative disc disease, is denied. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy associated with low back disability is denied. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy associated with low back disability is denied. REMANDED Entitlement to service connection for a cervical spine (neck) disability, claimed as secondary to the service-connected low back disability, is remanded. Entitlement to service connection for a left shoulder disability, claimed as secondary to the service-connected low back disability, is remanded. Entitlement to service connection for a right shoulder disability, claimed as secondary to the service-connected low back disability, is remanded. Entitlement to service connection for a left hip disability, claimed as secondary to the service-connected low back disability, is remanded. Entitlement to service connection for a right hip disability, claimed as secondary to the service-connected low back disability, is remanded. Entitlement to total disability on the basis of individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran has not had a diagnosed radiogenic disease or disease that may be induced by ionizing radiation affecting the eyes at any time during the appeal period; and any current eye disability is not due to a disease, injury, or any exposure to ionizing radiation in service. 2. The Veteran has not had a diagnosed radiogenic disease or disease that may be induced by ionizing radiation affecting the throat or lymph nodes at any time during the appeal period; and any current throat or lymph nodes disability is not due to a disease, injury, or any exposure to ionizing radiation in service. 3. The Veteran has not had a diagnosed radiogenic disease or disease that may be induced by ionizing radiation manifested by hair loss at any time during the appeal period; and any disability manifested by hair loss is not due to a disease, injury, or any exposure to ionizing radiation in service. 4. The Veteran has not had a diagnosed radiogenic disease or disease that may be induced by ionizing radiation manifested by skin rash at any time during the appeal period; and any disability manifested by skin rash is not due to a disease, injury, or any exposure to ionizing radiation in service. 5. The Veteran’s coronary artery disease is neither proximately due to or aggravated beyond its natural progression by service-connected disability; it is not a radiogenic disease or disease that may be induced by ionizing radiation; it did not first manifest within one year after service discharge; and it is not otherwise related to an in-service injury, event, or disease. 6. The Veteran’s right knee chronic strain with Baker’s cyst is not proximately due to or aggravated beyond its natural progression by his service-connected back disability, and it is not otherwise related to an in-service injury, event, or disease. 7. The Veteran’s low back disability does not manifest by ankylosis, objective neurologic abnormality other than radiculopathy of the lower extremities, or incapacitating episodes totalling at least 6 weeks during any 12-month period. 8. Throughout the appeal period, the Veteran has had no more than mild sciatic radiculopathy of the left lower extremity. 9. Throughout the appeal period, the Veteran has had no more than mild sciatic radiculopathy of the right lower extremity. CONCLUSIONS OF LAW 1. The criteria for service connection for an eye disability are not met. 38 U.S.C. §§ 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.311 (2018). 2. The criteria for service connection for a throat or lymph nodes disability are not met. 38 U.S.C. §§ 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(d), 3.311. 3. The criteria for service connection for hair loss are not met. 38 U.S.C. §§ 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(d), 3.311 (2018). 4. The criteria for service connection for a skin rash on the chest and back are not met. 38 U.S.C. §§ 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(d), 3.311 (2018). 5. The criteria for service connection for coronary artery disease are not met. 38 U.S.C. §§ 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.311 (2018). 6. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2018). 7. The criteria for an increased rating in excess of 40 percent for low back disability are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237 & 5243 (2018). 8. The criteria for an initial rating in excess of 10 percent for left lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2018). 9. The criteria for an initial rating in excess of 10 percent for right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service in the U.S. Army from June 1978 through January 1984, during peacetime. The current appeal proceeds from a September 2014 rating decision. The Board previously denied entitlement to an increased rating for the low back and a TDIU in February 2010; the Veteran did not appeal from that denial, and he submitted a claim for increase in April 2013. This led to the award of separate ratings, or service connection, for radiculopathy of the lower extremities, effective since the April 15, 2013, date of claim. Additionally, the agency of original jurisdiction (AOJ) previously denied service connection for throat, eye, and hair loss disabilities in a September 2004 rating decision. In general, decisions of the AOJ that are not timely appealed are final, and new and material evidence is required as a threshold jurisdictional matter to reopen the prior claim. See 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156(a), 20.1100, 20.1103. However, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file at the time of the prior decision, VA will reconsider the claim without the need for new and material evidence. 38 C.F.R. § 3.156(c)(1). In this case, additional relevant service records related to the claimed in-service event were received in September 2014, and there is no indication that those records did not previously exist or that the Veteran had not provided sufficient information to obtain them. See 38 C.F.R. § 3.156(c)(1)-(2). Thus, these issues will be reviewed de novo, without the need to reopen. Id. Service Connection The Veteran has asserted several theories of service connection, which will be discussed as relevant below. In general, direct service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. § 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. In addition, certain specific diseases may be presumed to have been incurred in service if specific criteria are met, to include based on chronic disease or radiation exposure. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a)&(d), 3.311. Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or aggravated beyond its natural progression, by service-connected disability. 38 U.S.C. § 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. Reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. , 2., 3., & 4. Service connection for eye, throat (to include the lymph nodes), hair loss, and skin rash disabilities, to include as due to radiation exposure The Veteran has consistently reported that he was exposed to ionizing radiation, also referred to as nuclear radiation or chemicals weapons, while performing duties as a military police (MP) or site security officer with top secret security clearance at a NATO nuclear weapons site in Germany between 1982 and 1984. The Veteran further reports having problems with a rash or bumps in his throat and on his chest while at that site. He states that he sought private treatment after service from 1984 to 1986 for a rash on the chest from “being exposed to radiation in a chemical environment,” but that those records are no longer available. The Veteran believes that radiation exposure during service resulted in current eyesight, throat or lymph nodes, hair loss, and skin rash disabilities. See, e.g., statements in April 2004, December 2010, May 2014, September 2014 (notice of disagreement on VA Form 9); Radiation Risk Activity Information Sheets in June 2004 and May 2014. To warrant presumptive service connection based on radiation exposure during service, the Veteran must have a currently diagnosed disease that is listed in either 38 C.F.R. § 3.309(d) or 38 C.F.R. § 3.311(b)(2)(i), for radiation based claims. These listed diseases are essentially various forms of cancer. The Veteran does not claim to have a diagnosis of cancer, to include of the eyes, throat or lymph nodes, or manifested by hair loss or skin rash, and the medical evidence does not suggest any such diagnosis. Thus, presumptive service connection cannot be granted. Under § 3.311, for a claimed condition based on radiation exposure that is not a listed radiogenic disease, there must be “competent scientific or medical evidence that the claimed condition is a radiogenic disease,” which is defined as a disease that may be induced by ionizing radiation. 38 C.F.R. § 3.311(b)(2), (4). The Veteran has not submitted any scientific or medical evidence to that effect, and there is no suggestion in the medical records that any current condition affecting the eyes, throat or lymph nodes, hair loss, or skin may be induced by ionizing radiation. Therefore, service connection also cannot be granted on this basis. Where there is no entitlement under presumptive provisions for service connection, direct service connection still may be shown through direct proof of in-service causation. Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). However, any service connection claim generally requires a currently diagnosed disability, which will be satisfied if the disability was present at any time during the appeal period, even if it subsequently resolved. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this case, it is unclear whether the Veteran has a current diagnosis or disability for any of his claimed conditions. Although he has reported problems with eyesight, throat rash or lymph nodes, hair loss, and skin rash, statements for his appeal are unclear whether he means recent complaints, except as to the throat. Complaints regarding eyesight near the appeal period appear to be only temporary. The Veteran’s only reported treatment relating to these claims is private treatment for a skin rash on the chest and back from 1984 to 1986, which are not available and would not establish a current disability, and a January 2014 report of treatment with a private gastroenterologist for a throat condition or lymph nodes. Records from the gastroenterology provider reflect a February 2013 complaint of recent onset of odynophagia, for which he underwent a duodenoscopy, and a March 2013 notation of a history of esophageal stenosis and gastroesophageal reflux disease (GERD) with dysphagia, difficulty swallowing, and heartburn. Medical records spanning from 1998 through 2017 do not mention hair loss or a skin rash. VA treatment records include a systems review in September 2003 that examined the eyes, skin, and mouth or throat and found no eye abnormalities, no rash or other skin abnormalities, and no oral lesions affecting the mouth or throat. A November 2005 VA treatment record for other conditions again examined the skin and found no abnormalities. An October 2013 VA treatment record reflects complaints of temporary loss of vision associated with severe neck pain one year earlier, noted as vision changes with headaches. The provider noted the Veteran’s report of being told during an eye evaluation that “a piece of calcium went in blood vessel behind eyes and caused the symptoms?” No eye diagnosis was noted at that time. A July 2016 VA treatment record recorded no lymphadenopathy and no GERD. The Veteran is competent to report observable symptoms, such as a rash on his skin, hair loss, or an abnormal feeling in his eyes or throat or involving his vision. It is possible that he has such symptoms with no specified diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Veteran is not competent to diagnose a specific condition for those complaints or to give an opinion as to what caused them, to include whether they were due to any radiation exposure during service. These questions are medically complex, as they require specialized medical knowledge of the interaction between multiple organ systems in the body, as well as knowledge of potential effects of radiation exposure, and consideration of the Veteran’s other medical history. Id. at 1377, 1377 n.4. As explained above, it is unclear whether there has been a current disability for the eyes, hair loss, or skin rash, and the only diagnosis relating to the throat or lymph nodes area was GERD and esophageal stenosis in early 2013. However, it is unnecessary to seek clarification in this regard because there is no reasonable possibility that this would help establish entitlement to service connection. The Board acknowledges the Veteran’s assertions that VA denied his claims previously due to no records to confirm him serving at a NATO site in Germany involving radiation or nuclear weapons or that relevant records were lost. See, e.g., December 2010 statement, September 2014 notice of disagreement (on VA Form 9). The Board first emphasizes that it is unnecessary to clarify the nature or extent of any exposure to ionizing radiation during the Veteran’s service because it would not have a reasonable possibility of helping to substantiate any of his claims on appeal, in that there is no diagnosed radiogenic disease or competent evidence that a current disability may have been induced by ionizing radiation. Additionally, the Veteran is not competent to identify whether he was exposed to ionizing radiation or nuclear chemicals as part of his duties, and he made conflicting reports in June 2004 and May 2014 Radiation Risk Activity Information Sheets as to whether he was present when explosions or atmospheric nuclear tests occurred, so as to establish a radiation-risk activity under § 3.309(d). Moreover, there is no competent evidence to suggest that ionizing radiation or proximity to nuclear chemical weapons during the Veteran’s service resulted in a current disability. Additionally, the available evidence does confirm that the Veteran served where he has reported, via official service records received in 2003 and 2014. To the extent that there may be additional records concerning nuclear weapon or radiation exposure, they would not help substantiate his claims for the reasons explained above. The claims file includes the Veteran’s service treatment records covering his full period of service, as well as service personnel records that confirm his reports of serving in Germany from 1982 to 1984 with the 61st Military Police (MP) Company, with duties as an MP as of 1981 and as an assistant squad leader as of December 1982, as well as that he functioned in a “nuclear duty position” without specifying his duties in that regard. See DA Form 2-1, DA Form 4515. A search was conducted in 2004 for any additional information concerning radiation exposure, to include a DD Form 1141, but none was found. Additional personnel records received in 2014 identified the Veteran’s duties as a custodial agent and squad leader in Germany from 1982 to 1984, that this was at a NATO site, and that he was granted top secret clearance as of November 1982 (via DA Form 873). Finally, the Board has considered the Veteran’s assertions of having complaints in service as a potential avenue for direct service connection. Service treatment records do not reflect any complaints, treatment, or diagnosis of a skin, hair loss, or eye condition. There was treatment while in Germany in 1980 and 1983 for throat complaints diagnosed as tonsillitis and strep throat; however, there is no indication that these were chronic conditions or continued after treatment. A February 1983 periodic examination, while the Veteran was stationed in Germany, did not reflect any relevant abnormalities, his vision was 20/20, and he declined a separation examination in January 1984. The Veteran is not competent to link any current disability to any complaints in service, and there is no medical evidence to suggest such a connection. See Jandreau, 492 F.3d at 1376-77. As noted above, private treatment records in 2013 noted recent onset of throat complaints involving difficulty swallowing, and records in 2014 noted that vision complaints were recent and related to headaches. Thus, the preponderance of the evidence is against finding that a current disability was incurred as a result of an in-service injury, disease, or event, and the claims must be denied. See 38 C.F.R. §§ 3.102, 3.303. 5. Service connection for coronary artery disease, to include as secondary to service-connected disability The Veteran contends that his current coronary artery disease is secondary to his currently service-connected back disability and his other claimed conditions because of pain, suffering, nerves, and stress over the years since service. He has also asserted that his coronary artery disease may be due to “possible chemical agents,” or chemical duties working around nuclear weapons at a NATO site. See December 2013 Congressional inquiry with Veteran report, January 2014 Veteran statement, September 2014 notice of disagreement. The lay and medical evidence consistently show that the Veteran’s coronary artery disease was first diagnosed after a heart attack in 1998, and he subsequently had two more heart attacks. However, the preponderance of the evidence is against finding that this disability is proximately due to or the result of, or was aggravated beyond its natural progression, by service-connected disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.310. As discussed under the increased rating issues below, the Veteran has a severe back disability with associated pain and neurologic symptoms in his lower extremities, including pain in the hips and to below the knees. Nevertheless, medical providers have not suggested that either these service-connected disabilities or his other claimed conditions proximately resulted in his heart disability or aggravated it beyond its natural progression. The claims file includes medical-treatise type information noting risk factors and common causes of coronary artery disease. Although this information must be considered as related to the Veteran’s particular history and does not determine the etiology of the Veteran’s disability, it has some weight and is probative in this case. Risk factors include: hypertension; elevated blood lipids, particularly cholesterol and triglycerides, elevated levels of low-density lipoprotein and reduced levels of high-density lipoprotein; cigarette smoking; high-fat, high-carbohydrate diets; diabetes mellitus; obesity; male gender; and a family history of heart disease. Presumed risk factors also include physical inactivity and increasing age. The most common cause of coronary artery disease is atherosclerosis. Other causes of coronary artery disease include: arteritis, coronary artery spasms, certain infectious diseases, and congenital defects in the coronary vascular system. Although the Veteran believes his coronary artery disease was caused or aggravated by his service-connected disabilities or other claimed conditions, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems of the body, to include the musculoskeletal, neurological system, and cardiac systems, and interpretation of the evidence together with the Veteran’s history. Jandreau, 492 F.3d at 1377 n.4. Consequently, his opinion has no weight. For the same reasons, the Veteran is not competent to provide an opinion that his coronary artery disease is due to chemical exposure from nuclear weapons in service. Moreover, as discussed above under issues 1 through 4, the Veteran is not competent to identify the nature or extent of any chemical or radiation exposure during service. His coronary artery disease is not a listed radiogenic disease, and there is no medical evidence suggesting that it may be induced by ionizing radiation or otherwise due to any potential chemical exposure during such service. The Veteran has not claimed that his coronary artery disease began during service, or within one year after service to allow for presumptive service connection as a chronic disease, and there is no evidence to suggest such a link. As noted above, his first noted cardiac symptoms and diagnosis were many years after service. In sum, the preponderance of the evidence is against finding that the Veteran’s coronary artery disease is proximately due to or aggravated beyond its natural progression by service-connected disability, and it is not otherwise related to in-service injury, event, or disease, to include based on radiation exposure or on a presumptive basis as a chronic disease. Service connection must be denied. See 38 C.F.R. §§ 3.102, 3.303, 3.307(a)(3), 3.309(a), 3.310, 3.311. 6. Service connection for a right knee disability, to include as secondary to the service-connected low back disability. The Veteran contends that his current right knee disability is secondary to his service-connected back disability because his severe back problems “have spread throughout the body.” See September 2014 notice of disagreement. The Veteran has a current diagnosis of mild right knee chronic strain with Baker’s cyst, as shown by a November 2013 MRI and noted in VA treatment records and a September 2014 VA examination. However, the preponderance of the evidence is against finding that this disability is proximately due to or the result of, or was aggravated beyond its natural progression, by service-connected disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.310. The September 2014 VA examiner noted the Veteran’s onset of right knee pain and swelling in late 2013, which is consistent with VA treatment records from October 2013 to April 2014. The examiner further noted that the Veteran’s pain while driving a bus due to the way his knee hits the seat while driving is related to the now known Baker’s cyst. The VA examiner opined that there is no connection between his knee and back pathologies, and that his right knee disability is instead more likely related to employment and normal aging. This opinion is probative because it considers the Veteran’s full and accurate history and provides a medical rationale. Although the Veteran believes his right knee disability was caused or aggravated by his service-connected back disability, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of the interaction between different parts of the musculoskeletal system and interpretation of the evidence together with the Veteran’s history. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the September 2014 VA examiner’s medical opinion. There is no contrary medical evidence or opinion to suggest either causation or aggravation of the Veteran’s right knee disability by his service-connected back disability. A July 2015 VA treatment record reflects a history that the Veteran was appealing the denial of his claim and needed documentation concerning several conditions, including that his knee condition is secondary to his back disability. The Veteran’s report or request does not constitute medical evidence just because it is recorded in a medical record. Significantly, the provider did not document an opinion concerning the knee, although the “plan” section of that record did document medical notations that other claimed disabilities were affected by the Veteran’s low back pain. The Veteran has not claimed that his right knee disability began during service or is otherwise directly related to service, and there is no evidence to suggest such a link. As noted above, his right knee symptoms began many years after service. In sum, the preponderance of the evidence is against finding that the Veteran’s right knee chronic strain with Baker’s cyst was caused or aggravated by service-connected disability, and it is not otherwise related to in-service injury, event, or disease. Service connection must be denied. 38 C.F.R. §§ 3.102, 3.303, 3.310. Increased Rating 7. Increased rating in excess of 40 percent for low back disability, status post lumbar strain with degenerative disc disease The Veteran’s status post lumbar strain with degenerative disc disease has been assigned a 40 percent rating based on his limitation of motion of the spine throughout the appeal period. As noted above, the Board previously denied a higher rating in February 2010. He again claimed an increased rating on April 10, 2013. The Veteran has now been assigned separate ratings of 10 percent for neurological manifestations in each lower extremity (leg), effective April 10, 2013. Spinal disabilities involving intervertebral disc syndrome (IVDS) will be rated either under the General Rating Formula for Diseases and Injuries of the Spine, which provides for assignment of a separate rating for any associated objective neurological abnormalities, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The method that results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25 should be used. See 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5237 & 5243, General Rating Formula & Note (1), IVDS Formula & Notes (1) & (2). In this case, the Veteran has limited movement of the thoracolumbar spine with pain during movement and that radiates up his back and down through his legs, muscle tightness, and fatigue, as well as increased pain and weakness at times after repetitive use or with flare-ups. During those periods, he has additional impairment or functional loss such as an extreme difficulty or inability to walk, rise from a sitting or reclined position, and bend or turn until the pain subsides. The Veteran’s descriptions of his back disability, as well as descriptions from his friends and family members in 2014, are consistent with the medical evidence in this regard. The Veteran indicated in his September 2014 notice of disagreement that his problems had worsened over the past five years. The last VA examination was in 2014, but treatment records through 2017 reflect similar chronic complaints. Under the General Rating Formula, spinal disability will be assigned a 40 percent rating where there is forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Thus, the Veteran’s limited motion, including additional functional loss due to increased pain and other factors at times, is contemplated by the 40 percent rating. See 38 C.F.R. § 4.71a, DCs 5237 & 5243, General Rating Formula; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). A higher rating of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine, and 100 percent requires ankylosis of the entire spine. Unfavorable ankylosis means the indicated portion of the spine is fixed in flexion or extension and the ankylosis results in certain specified impairments. See 38 C.F.R. § 4.71a, DCs 5237 & 5243, General Rating Formula & Note (5). The 2014 VA examiners found no ankylosis, and the Veteran retained range of motion, albeit with pain. In fact, the Veteran had forward flexion to 70 and 90 degrees, with pain at those points, during examinations in August and September 2014. His 40 percent rating is consistent with additional loss of range of motion during flare-ups or after repetitive use. However, the Veteran’s spine is not fixed in flexion or extension to establish ankylosis, unfavorable or otherwise. Therefore, a rating in excess of 40 percent is not warranted on this basis. Id. The Veteran has already been assigned ratings for neurologic abnormality in both legs, which are discussed in the next section. There is no suggestion of any other neurologic abnormalities, including but not limited to bowel or bladder impairments, related to his service-connected back disability. The Veteran and other lay witnesses have not described any such impairment, and he consistently denied bowel or bladder complaints at the VA examination and in treatment records. Thus, a separate rating is not warranted on this basis. Id. at Note (2). Applying 38 C.F.R. § 4.25 to the Veteran’s ratings of 40 percent for the low back and 10 percent each for the lower extremities, along with the bilateral factor under § 4.26, these ratings combine to 52 percent, which rounds down to 50 percent. To warrant the next higher, and maximum, rating of 60 percent for spinal disability under the alternative IVDS Formula, there must be incapacitating episodes having a total duration of at least 6 weeks during a 12-month period. 38 C.F.R. § 4.71a, DC 5243, IVDS Formula. For this purpose, an incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). Although the Veteran has times when he is unable to walk or rise from a sitting or reclined position due symptoms in his back and/or lower extremities, there is no indication of prescribed bed rest, or that any such episodes totaled at least 6 weeks during any 12-month period on appeal. Thus, a higher rating is not warranted under the IVDS Formula. In sum, the Veteran’s manifestations of his service-connected low back disability have been relatively consistent, and any increases in severity were not sufficient to more nearly approximate the criteria for the next higher rating, even when resolving reasonable doubt in his favor. See 38 C.F.R. §§ 4.3 & 4.7. Therefore, staged ratings are not appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 8. & 9. Initial rating in excess of 10 percent each for left and right lower extremity radiculopathy associated with low back disability The Veteran has been assigned separate ratings of 10 percent radiculopathy affecting the sciatic nerve in each lower extremity (leg), effective April 10, 2013. In his 2014 notice of disagreement, he requested a 20 percent or higher rating. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve. To warrant the next higher rating of 20 percent, there must be moderate incomplete paralysis of the sciatic nerve. Higher ratings of 40, 60, and 80 percent are warranted for moderately severe and severe incomplete paralysis and for complete paralysis. Neuritis of this nerve is rated based on the same criteria under DC 8620, and neuralgia is rated under DC 8720. 38 C.F.R. § 4.124a. Although “mild,” “moderate,” etc. are not defined for these purposes, the regulations provide guidance that is binding on the Board. Peripheral neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, will be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. With sciatic nerve involvement, the maximum rating allowed for neuritis not characterized by these types of organic changes is moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Peripheral neuralgia characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, will be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Under DC 8520, symptoms of incomplete “severe” paralysis include marked muscular atrophy; and symptoms of complete paralysis include where the foot dangles and drops, no active movement is possible of the muscles below the knee, and flexion of the knee is weakened or lost. 38 C.F.R. § 4.124a. As noted above, the Veteran and his family members and friend submitted statements in 2014 describing severe pain in the back and legs, indicating that some days he is unable to walk or has difficulties getting up or moving around. An October 2013 VA physical therapy record noted the Veteran’s complaints of weakness and pain in the back and recently in his right thigh and inner knee, stating that the leg complaints had been present for the past few months. During August and September 2014 VA examinations, testing showed objectively normal muscle strength, reflexes, and sensory responses. He also had a positive straight leg raising test in the September 2014 test. The August 2014 examiner found no symptoms of radiculopathy, but the September 2014 examiner noted that the Veteran had mild intermittent pain that was usually dull and mild paresthesias and/or dysesthesias. (The Board notes that medical definitions of paresthesia and dysesthesia reflect an abnormal touch sensation, either with or without an external stimulus. See Dorland’s Illustrated Medical Dictionary 1404 & 584 (31st ed. 2007).) There was no constant pain that is excruciating at times and no numbness. The examiner summarized that overall there was mild involvement of the sciatic nerve bilaterally. In September 2014 VA examination reports concerning the back, hips, and knees, the examiner opined that the Veteran’s daily pain in the bilateral hips to below the knees is likely related to radiculopathy from his back. A July 2015 VA treatment record also noted that the Veteran had hip pain related to his low back. VA treatment records through 2017 reflect similar continued complaints. In light of the above, the evidence does not demonstrate organic changes of loss of reflexes, muscle atrophy, sensory disturbances, or constant pain along the sciatic nerve distribution that is excruciating at times. Instead, there is generally dull and intermittent pain in the lower extremities associated with the low back disability. See 38 C.F.R. §§ 4.123 & 4.124. The complaints described by the Veteran and other lay witnesses pertain primarily to his low back area, which is separately rated at 40 percent. His complaints related to his lower extremities, including pain going from his back into the hips and to below the knees, amount to intermittent pain that is more severe at times but is generally dull in nature and intermittent subjectively abnormal touch sensation. There has been no decrease, let alone loss, in reflexes or muscle strength for the lower extremities. The Board agrees with the VA examiner that these symptoms reflect overall mild incomplete paralysis of the sciatic nerve; they do not rise to the level of moderate incomplete paralysis or higher. Thus, a rating in excess of 10 percent is not warranted for either lower extremity. Id. In sum, the Veteran’s neurologic manifestations in the lower extremities have been relatively consistent, and any increases in severity were not sufficient to more nearly approximate the criteria for the next higher rating, even when resolving reasonable doubt in his favor. See 38 C.F.R. §§ 4.3 & 4.7. Therefore, staged ratings are not appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). REASONS FOR REMAND 1. , 2., 3., 4. & 5. Service connection for a neck (cervical spine) disability, left and right shoulder disabilities, and left and right hip disabilities, all claimed as secondary to the service-connected low back disability, are remanded. The Board cannot make a fully-informed decision on the issues of service connection for disabilities of the neck, left and right shoulder, and left and right hips on a secondary basis because the September 2014 VA examiner’s opinion did not consider an accurate history or subsequently received relevant evidence. Concerning the neck or cervical spine, the 2014 VA examiner noted an onset of neck pain in 2013, diagnosed mild degenerative joint disease of the cervical spine, and stated there was “no medical evidence of a connection between the low back and the neck.” However, the Veteran’s sister and mother reported in January 2014 that they observed him with neck pain for years. VA treatment records further reflect “neck pain” added to the problem list in December 2009, and an October 2013 physical therapy record notes neck pain with an onset of 5-6 years, including a second episode of severe neck pain that had occurred one year earlier. Additionally, in a July 2015 record, a VA treating physician documented an opinion that the Veteran’s neck pain was “related to abnormal gait and tension/stress caused by low back pain.” No rationale was provided for this opinion, but it has some probative value and contradicts the 2014 examiner’s statement that there was “no medical evidence” of a connection between the neck and back. Therefore, an addendum opinion is required to consider an accurate medical history and the additional medical evidence concerning a secondary nexus. Concerning the shoulders, the 2014 VA examiner noted the Veteran’s complaints of chronic strain/arthralgia of the shoulders, stated that there was no complaint of shoulder pain in the medical records, and stated that there was “no evidence of any lower back condition that would cause or even aggravate his shoulders.” The examiner stated that it is as likely as not that the Veteran’s shoulder pain may be related to his neck condition and is radicular pain. Subsequent evidence includes VA treatment records in July 2015 with reports of shoulder pain, and the treating physician documented an opinion that the Veteran’s neck and shoulder pain were “related to abnormal gait and tension/stress caused by low back pain.” No rationale was provided for this opinion, but it has some probative value and contradicts the 2014 examiner’s statement that there was “no evidence” that the back condition could affect the shoulders. Therefore, an addendum opinion is required to consider the additional medical evidence concerning a secondary nexus. Concerning the hips, the 2014 VA examiner noted the Veteran’s complaints of daily hip pain with back pain, and x-rays conducted for the examination showed minimal degenerative changes to both hips. The examiner opined that complaints of hip pain at the L5-S1 distribution were likely radiculopathy from his back disability, and that the degenerative joint disease was less likely than not related to the low back. The examiner stated that there was “no evidence” to connect these two diagnoses and no evidence of any complaint of bilateral hip joint pain to treating providers. Subsequent evidence includes VA treatment records in July 2015 with reports of hip pain, and the treating physician documented an opinion that the Veteran’s hip pain was “related to abnormal gait caused by low back pain.” The provider subsequently noted that there may be radiculopathy. No rationale was provided for this opinion, but it has some probative value and contradicts the 2014 examiner’s statement that there was “no evidence” of a connection between the hip and back conditions. Therefore, an addendum opinion is required to consider the additional medical evidence concerning a secondary nexus. 6. Entitlement to a TDIU is remanded. Because a decision on the remanded service conenction issues could significantly impact a decision on the issue of entitlement to TDIU, the issues are inextricably intertwined. Therefore, a remand of the claim for TDIU is also required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s neck (cervical spine) disability, bilateral shoulder disabilities, and bilateral hip disabilities are at least as likely as not proximately due to or aggravated beyond their natural progression by the service-connected back disability. The examiner should consider the evidence of onset of neck pain prior to the 2013 diagnosis of arthritis, to include as of 2009; and the medical opinions as to effects from the low back disability in the July 2015 VA treatment record. If the examiner reviews subsequent VA treatment records, they should be associated with the claims file. The examiner should explain the reasons behind any opinions and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 2. After completion of the above, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Wheatley