Citation Nr: 18142803 Decision Date: 10/16/18 Archive Date: 10/16/18 DOCKET NO. 15-35 295A DATE: October 16, 2018 ORDER Entitlement to a compensable initial rating prior to April 5, 2017, and a rating in excess of 50 percent as of April 5, 2017, for tension headaches is denied. Entitlement to a disability rating in excess of 20 percent for a right shoulder strain (hereinafter referred to as a “right shoulder disability”) on a schedular basis is denied. Entitlement to an initial rating in excess of 20 percent for a left shoulder strain with degenerative joint disease (DJD) (hereinafter referred to as a “left shoulder disability”) on a schedular basis is denied. REMANDED Entitlement to disability rating in excess of 10 percent prior to April 16, 2012; in excess of 20 percent from April 16, 2012, to July 13, 2017; and in excess of 40 percent thereafter for degenerative disc disease (DDD) and DJD of the lumbosacral spine (hereinafter referred to as a “lumbosacral spine disability”) is remanded. Entitlement to a disability rating in excess of 20 percent for a right shoulder disability on an extraschedular basis is remanded. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability on an extraschedular basis is remanded. FINDINGS OF FACT 1. Prior to April 5, 2017, the Veteran did not experience characteristic prostrating headache attacks. 2. Beginning April 5, 2017, the Veteran experienced severe migraines with very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. 3. The Veteran’s right shoulder disability has been manifested by forward flexion and abduction ranging from 90 to 180 degrees, even after considering pain. 4. The Veteran’s left shoulder disability has been manifested by forward flexion and abduction ranging from 90 to 180 degrees, even after considering pain. CONCLUSIONS OF LAW 1. Prior to April 5, 2017, the criteria for an initial compensable rating for tension headaches were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8100. 2. Beginning April 5, 2017, the criteria for a disability rating in excess of 50 percent for tension headaches are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 3. For the entire appeal period, the criteria for a disability rating in excess of 20 percent for a right shoulder disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5201. 4. For the entire appeal period, the criteria for an initial rating in excess of 20 percent for a left shoulder disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1972 to October 1975, from November 1975 to November 1979, and from November 1981 to November 1994. Increased Ratings Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a compensable initial rating prior to April 5, 2017, and a rating in excess of 50 percent as of April 5, 2017, for tension headaches The Veteran contends that higher ratings for his tension headaches, as well as extraschedular consideration, are warranted. In September 2017, he complained of migraines once or twice a month that lasted anywhere from one to three months. In his June 2018 appellate brief, he asserted that the evidence reflected additional symptomatology not reflected in the rating criteria, which warranted higher ratings pursuant to 38 C.F.R. §§ 4 and 3.321(b)(1). The Board notes that, in a November 2017 letter, the Regional Office informed the Veteran that his tension headache claim was considered to be resolved as the January 2017 rating decision increased the rating to 50 percent, the maximum rating available under DC 8100, which was considered an award of full benefits sought on appeal. However, the Board is adjudicating the claim herein as the 50 percent rating was only assigned as of April 5, 2017, and not for the entire period on appeal. Additionally, the Veteran contends that extraschedular consideration is warranted. Based on all of the evidence of record, the Board finds that the level of disability of the Veteran’s tension headaches most closely approximates the currently assigned noncompensable evaluation under DC 8100 prior to April 5, 2017, as the evidence of record does not demonstrate that the Veteran suffers from prostrating headaches, which is necessary for a compensable rating. Additionally, the level of disability of his tension headaches most closely approximates a 50 percent rating under DC 8100 as of April 5, 2017. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The Veteran’s tension headaches are currently rated as noncompensable from March 8, 2013, to April 5, 2017, under 38 C.F.R. § 4.124a, DC 8199-8100. A diagnostic code ending in “99” and followed by a hyphen connotes a disability which does not exist in the rating schedule and instead has been rated as analogous to a different disability which does exist in the rating schedule. 38 C.F.R. § 4.20. The RO determined that tension headaches are most closely analogous to DC 8100 for migraines. Under DC 8100, a 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating requires characteristic prostrating attacks occurring on an average once a month over the last several months. A 10 percent rating requires characteristic prostrating attacks averaging one in two months over the last several months. A noncompensable rating is applied for less frequent attacks. In this case, an August 2013 VA examination report reflects a diagnosis of tension headaches, which did not require medication. The Veteran reported pulsating or throbbing pain on both sides of the head, which worsened with physical activity, as well as nausea. He did not have characteristic prostrating attacks. In October 2013, the Veteran stated that his daily headaches were minimized by over-the-counter medication. Social Security Administration (SSA) records include a May 2015 treatment record reflecting daily headaches. VA treatment records from February 2016 reflect the Veteran’s report of migraines described as light-headed and throbbing pain in the forehead with no radiation, light or sound sensitivity, nausea, or vomiting. They occurred daily and lasted one hour after taking motrin or Tylenol. On April 5, 2017, he complained of severe migraines, which occurred twice a week and were frontal in nature. He felt pressure and heaviness in his head, had no vision changes, and had light sensitivity. An October 2017 VA examination report reflects review of the Veteran’s claims file and diagnoses of chronic tension headaches and cervicogenic headaches. The Veteran reported that his headaches had worsened about eight months prior with daily headaches, pressure, throbbing with associated eye strain, dizziness, photophobia, phonophobia, and neck pain. He had pulsating or throbbing pain on both sides of the head along with nausea, and sensory changes (such as feeling of pins and needles in the extremities). He had daily debilitating headaches that lasted for hours, characteristic prostrating attacks once every month, and very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. The Veteran worked as a substitute teacher, but was unable to work in over six months as his headaches were debilitating and relieved by Fioricet and sleep. Prior to April 5, 2017, the relevant evidence reflects that the Veteran did not experience prostrating attacks at all. In fact, the August 2013 VA examination report reflects that he did not even require medication and specifically stated that he did not have characteristic prostrating attacks. Subsequently, it was noted that the Veteran had daily headaches, but they were minimized and only lasted an hour after taking over-the-counter medication. There is no indication of characteristic prostrating attacks during this period of time, which are required in order to warrant a compensable rating. However, on April 5, 2017, the Veteran sought treatment for severe migraines that occurred twice a week and manifested with pressure, heaviness in his head, and light sensitivity. Additionally, at the October 2017 VA examination, the Veteran reported daily headaches, pressure, throbbing with associated eye strain, dizziness, photophobia, phonophobia, and neck pain. The examiner determined that the Veteran had very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability as his headaches were debilitating and affected his ability to work as a substitute teacher. As such, as of April 5, 2017, a 50 percent rating, which is the maximum schedular rating available under DC 8100, is warranted. The Board considered whether the Veteran’s service-connected tension headaches presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). The Board compared carefully the level of severity and symptomatology of the Veteran’s service-connected tension headaches with the established criteria found in the rating schedule. The Board finds that the symptoms associated with the service-connected tension headaches addressed in this decision are fully addressed by the rating criteria under which such disability is rated. Indeed, the ratings currently assigned for the disability contemplate the overall functional loss from the symptomatology attributable to the Veteran’s headaches, characterized by whether they cause prostrating attacks and the severity of such, as detailed above. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. 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). Issues 2-3: Entitlement to a disability rating in excess of 20 percent for a right shoulder disability and to an initial rating in excess of 20 percent for a left shoulder disability The Veteran contends that ratings in excess of 20 percent, as well as extraschedular consideration, are warranted for his right and left shoulder disabilities. Specifically, in his May 2004 Notice of Disagreement (NOD), he complained of spasms in both shoulders, tight constrictions of his connective tissues that were at times very painful across his shoulder blades, radiating across his back and upper shoulders. Despite substantial effort to control both shoulders, he was able to suppress them for only minutes or hours at times before the “tension buil[t] and the spasms [came] back in a flood.” He stated that the spasms could “last for variable lengths of time, and [were] sometimes uncontrollable.” He reported that his “shoulder shrugging” made social adjustment “terribly problematic,” and interfered with his daily activities. In November 2011, the Veteran reported that his ongoing shoulder pain and discomfort gave him significant problems during prolonged standing, walking, and even sitting at times. In his September 2013 NOD, the Veteran contended that a higher rating was warranted for his left shoulder disability as it had “a lot of painful motion with daily activities” and he did not have full use of his left shoulder because of the discomfort. Additionally, he stated that range of motion (ROM) of the right shoulder varied, and that sometimes he experienced pain if he lifted his arm chest-high. He had limitation of motion of the arm at shoulder level and frequently experienced a lot of aching pain, along with muscle spasm and twitching. In his June 2018 appellate brief, the Veteran contended that increased ratings should be granted. He reported additional symptomatology not reflected in the rating criteria. As such, he asserted that higher evaluations are warranted under 38 C.F.R. §§ 4 and 3.321(b)(1). Based on a careful review of all of the evidence, the Board finds that ratings in excess of 20 percent are not warranted for his right and left shoulder disabilities. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The Veteran was initially assigned a 10 percent rating for his right shoulder disability, effective November 26, 1979. An April 2004 rating decision increased the rating to 20 percent, effective December 22, 2003, under 38 C.F.R. § 4.71a, DC 5003-5201. Additionally, the Veteran was assigned a 10 percent rating for his left shoulder disability, effective November 28, 2011. A September 2017 rating decision increased the rating to 20 percent, effective November 28, 2011, under 38 C.F.R. § 4.71a, DC 5201. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. As such, the Veteran’s right shoulder disability, specifically osteoarthritis of the right shoulder under DC 5003, is rated under DC 5201 based on limitation of motion of the arm. The Board notes that the left shoulder also has been diagnosed with osteoarthritis and thus could be rated under DC 5003-5201 rather than DC 5201. However, this does not change the rating criteria under which the disability is evaluated. As a foundational matter, ratings based on function impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major. 38 C.F.R. § 4.69. The medical evidence in this case reflects that the Veteran is right-hand dominant. See February 2016 VA examination report. Therefore, his right upper extremity will be considered as the major extremity, and the left upper extremity will be considered as the minor extremity. DC 5201 provides for a 20 percent rating for limitation of minor arm motion at the shoulder level, a 20 percent rating for limitation of the minor arm to midway between the side and shoulder level, and a maximum 30 percent rating for limitation of the minor arm to 25 degrees from the side. 38 C.F.R. § 4.71a. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Turning to the evidence, a February 2004 VA examination report reflects the Veteran’s report of chronic muscle spasms, and his ability to function at 100 percent of his usual capacity during flare-ups. However, he stated that his shoulder would twitch and jump, which interfered with his driving and exercising. He had flexion and abduction to 180 degrees without pain; no additional limitation; no fatigue, weakness, lack of endurance, or incoordination; and no ankylosis. X-rays revealed a normal right shoulder. In May 2004, the Veteran’s wife stated that the Veteran had always had uncontrollable twitching, but that it had increased with more pain associated with his right shoulder disability. He experienced an increase in twitching and pain after driving even short distances, discomfort with wearing a seat belt, and pain all the time. An October 2004 VA examination report reflects the Veteran’s report of constant pain in his right shoulder with a tic, as well as weakness, pain, and the inability to control his shoulder well. He denied that he was considered to be incapacitated due to the right shoulder tic, did not claim that he was recommended for bedrest, and did not claim any specific functional impairment resulting from the tic. On examination, the appearance was abnormal on the right due to an obvious constant twitching of the muscles throughout the right shoulder, although the appearance of the left shoulder was within normal limits. His right shoulder had flexion to 140 degrees, at which point pain began; and abduction to 170 degrees, at which point pain began. There was no ankylosis, and ROM was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. X-rays revealed evidence of degenerative, arthritic changes with mild to moderate severity at the acromioclavicular (AC) joint. The diagnosis of chronic muscle spasm with tic of unknown etiology in the right shoulder was changed to chronic muscle spasm with tic of unknown etiology of the right shoulder, and DJD of the right shoulder with probable impingement syndrome (right rotator cuff). A July 2013 VA examination report reflects diagnoses of bilateral shoulder strain, right shoulder DJD, and right AC joint DJD. The Veteran reported constant tics of the right shoulder with flare-ups described as rapid twitching that occurred with prolonged sitting, standing, or walking. ROM testing demonstrated flexion and abduction to 180 degrees with pain beginning at 175 degrees bilaterally, with no additional limitation in ROM following repetitive-use testing. The Veteran did not have ankylosis, an AC joint condition, or any other impairment of the clavicle or scapula. X-rays revealed degenerative changes in the right shoulder and a small osteophyte of the medial humeral head. An August 2013 VA examination report reflects diagnoses of bilateral shoulder strain, left DJD of the AC joint, and left subacromial spur. The Veteran reported flare-ups consisting of twitching that promoted pain and discomfort. His right shoulder had flexion to 180 degrees with no objective evidence of painful motion, and abduction to 180 degrees with pain beginning at 175 degrees. His left shoulder had flexion and abduction to 180 degrees with pain beginning at 175 degrees. He did not have additional limitation in ROM following repetitive-use testing. He did not have ankylosis, any AC joint condition, other impairment of the clavicle or scapula. X-rays of the left shoulder reflect moderate degenerative narrowing of the AC joint and subacromial spur. SSA records reflect that, in May 2015, the Veteran reported that he could lift his right arm out front without any problems, but that it hurt to raise his arm completely overhead. VA treatment records reflect that in October 2015, ROM was significantly limited as the Veteran could not flex or abduct past 90 degrees. He also complained of pain in the shoulders with movement and an involuntary twitch in the bilateral shoulders described as feeling “heavy on [his] shoulders” and as a “shrug of the shoulders,” which occurred either unilaterally or simultaneously and “all the time.” In November 2015, both shoulders had forward flexion to 130 degrees on active motion and to 135 degrees on passive motion, and abduction to 100 degrees on active motion and 120 degrees on passive motion. A February 2016 VA examination report reflects review of the Veteran’s claims file and diagnoses of bilateral shoulder impingement syndrome, bilateral glenohumeral joint osteoarthritis, and bilateral acromioclavicular joint osteoarthritis. The Veteran denied any flare-ups. Both shoulders had flexion and abduction to 90 degrees; pain was noted on examination, but did not result in or cause functional loss. Repetitive use testing did not result in additional functional loss or ROM. Neither shoulder had ankylosis. There is no clavicle, scapular, AC, or sternoclavicular joint condition suspected. There is also no condition or impairment of the humerus. The Board finds the weight of the competent evidence demonstrates the Veteran does not meet the criteria for ratings in excess of 20 percent for his right and left shoulder disabilities. DC 5201 reflects that a rating in excess of 20 percent requires that motion be limited to 25 degrees from the side. However, although the Veteran has experienced limitation in motion of his arms, there is no indication that it was ever limited to the point that a 30 percent rating is warranted, specifically limited to 25 degrees from his side. Rather, forward flexion and abduction, even after pain is considered, has been limited, at the most severe, to 90 degrees bilaterally. Although the Veteran had pain on examination, the February 2016 VA examiner stated that there was no additional functional loss or ROM. Moreover, the Veteran stated that he experienced pain when he lifted his right arm chest-high in his September 2013 NOD, and that he could lift his right arm out front without any problems but experienced pain when he raised it completely overhead in May 2015. The Board acknowledges that the Veteran reported flare-ups at the February 2004, July 2013, and August 2013 VA examinations although he denied flare-ups at his February 2016 VA examination. Regardless, additional limitation in ROM is not indicated during flare-ups. At his February 2004 VA examination, the Veteran stated that he was able to function at 100 percent of his usual capacity during flare-ups. At his July 2013 and August 2013 VA examinations, he reported flare-ups consisting of rapid twitching that resulted in pain and discomfort. As such, ratings in excess of 20 percent based on limitation of motion even considering flare-ups are not warranted. The Board also considered the remaining DCs relating to the shoulder; however, the Board finds that they are not applicable to the Veteran’s case. Upon review of the claims file, the record does not demonstrate evidence of ankylosis of the scapulohumeral articulation (DC 5200), other impairment of the humerus (DC 5202), or impairment of the clavicle or scapula (DC 5203). As such, the Board finds that higher or separate ratings for the right and left shoulder disabilities are not warranted under any of these DCs. Additionally, the Board has considered the Veteran’s contention that extraschedular consideration is warranted for the issue on appeal. As discussed above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran’s service-connected disabilities, which are recited in detail above, are not specifically contemplated by the schedular rating criteria. Therefore, the claims for higher ratings for right and left shoulder disabilities is remanded below for extraschedular consideration. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. REASONS FOR REMAND 1. Entitlement to an increased rating for a lumbosacral spine disability is remanded. The claim for increased ratings for the Veteran’s lumbosacral spine disability is remanded for a new VA examination. The October 2017 VA examination did not completely evaluate the Veteran’s flare-ups by ascertaining adequate information, such as frequency, duration, characteristics, severity, or functional loss. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). He noted the Veteran’s reports that his flare-ups consisted of worsening pain, difficulty walking and completing activities of daily living, the inability to do anything, and resting in bed. However, it is not clear how often and for how long these flare-ups occur. As such, a remand is necessary in order to more fully address the Veteran’s flare-ups and any additional limitations that may result. Issues 2-3: Entitlement to a disability rating in excess of 20 percent for a right shoulder disability and an initial rating in excess of 20 percent for a left shoulder disability on an extraschedular basis is remanded. Pursuant to 38 C.F.R. § 4.71a, shoulder disabilities are rated based on ankylosis, limitation of motion of the arm, impairment of the humerus, or impairment of the clavicle or scapula. No additional criteria are listed in that rating code. The provisions of 38 C.F.R. § 3.321(b) provide that where the disability picture is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the Veteran for the service-connected disability, an extraschedular evaluation will be assigned. Consideration of whether a claimant is entitled to an extraschedular rating is a three-step inquiry. Thun, supra. Based on the evidence discussed above, the Veteran’s main symptom regarding his bilateral shoulder disabilities is the constant muscle spasms in his shoulders that are sometimes uncontrollable and interfere with his daily activities. He also describes flare-ups as involving twitching that resulted in pain and discomfort. Because such twitching, tics, and muscle spasms are not specifically addressed in 38 C.F.R. § 4.71a, DC 5201 or any other DCs for shoulder disabilities, the Board finds it prudent to refer the Veteran’s claim for extraschedular ratings for right and left shoulder disabilities to the Under Secretary for Benefits or the Director of the Compensation and Pension for consideration. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to evaluate his service-connected lumbosacral spine disability. All indicated tests and studies should be accomplished and the findings reported in detail. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. The examiner is asked to examine the Veteran, review his claims file, and then respond to the following: (a) Indicate all current symptoms associated with the Veteran’s service-connected lumbosacral spine disability and address their severity. In doing so, also ascertain adequate information regarding the Veteran’s flare-ups, such as the frequency, duration, characteristics, severity, and functional loss. (b) Test and report the ROM in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, s/he should clearly explain why that is so. If an opinion cannot be given without resorting to mere speculation, the VA examiner should state so and further provide a reason for such conclusion. (c) In reporting the ROM findings, comment on the extent of any painful motion, at which measurement the pain begins, functional loss due to pain, weakness, excess fatigability, and additional disability during flare-ups or upon repetitive use testing. (d) Provide information concerning any functional impairment resulting from the service-connected lumbosacral spine disability that may impact the Veteran’s ability to function and perform tasks in a work or work-like setting. The examiner should provide an explanation for any conclusions reached. (Continued on the next page)   2. Refer the Veteran’s right and left shoulder disabilities to the Under Secretary for Benefits or the Director of Compensation and Pension Services for extraschedular consideration. See 38 C.F.R. § 4.16(b). The Director is asked to consider the Veteran’s report of twitching, involuntary tics, and muscle spasms associated with his right and left shoulder disabilities. 3. Thereafter, readjudicate the remanded claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jane R. Lee