Citation Nr: 18144120 Decision Date: 10/24/18 Archive Date: 10/23/18 DOCKET NO. 14-24 972A DATE: October 24, 2018 REMANDED Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy is remanded. Entitlement to a rating in excess of 10 percent on an extraschedular basis for residuals of a back injury with degenerative disc disease at L5-S1 is remanded. REASONS FOR REMAND The appellant served in the United States Navy from March 1974 to May 1974. This matter originally came to the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied a rating in excess of 40 percent rating for residuals of a back injury with degenerative disc disease at L5-S1, and a rating in excess of 10 percent for left sciatic radiculopathy. The appellant appealed the March 2013 rating decision and in an August 2016 decision, the Board denied a schedular rating in excess of 40 percent for the low back disability and a schedular rating in excess of 10 percent for left lower extremity radiculopathy. The Board also concluded that the appellant’s low back disability did not warrant referral for extraschedular consideration because his symptoms were contemplated by the rating criteria for low back disabilities. The appellant appealed the Board’s August 2016 decision to the U.S. Court of Appeals for Veterans Claims (Court). In a November 2017 memorandum decision, the Court vacated the Board’s decision denying entitlement to a rating greater than 10 percent for left lower extremity radiculopathy and entitlement to a rating in excess of 40 percent on an extraschedular basis for the appellant’s low back disability. The Court dismissed the appeal with respect to the issue of entitlement to a schedular rating in excess of 40 percent for the appellant’s low back disability. Entitlement to a rating greater than 10 percent for left lower extremity radiculopathy is remanded. The appellant contends his left lower extremity radiculopathy is more disabling than currently rated. In relation to this claim, the appellant underwent a VA examination in February 2013 which found his disability was only mildly disabling in the examiner’s opinion; however, no rationale was provided explaining why the examiner classified the appellant’s symptoms as only mildly disabling. That examination included nonsensory findings such as absent deep tendon reflexes, although these findings were bilateral and not clearly attributed to the service-connected radiculopathy. In view of the record, the Board finds that remand is necessary to obtain a medical examination and opinion. 1. Entitlement to a rating in excess of 40 percent on an extraschedular basis for residuals of a back injury with degenerative disc disease at L5-S1 is remanded. The appellant contends that his lower back disability should be considered on an extraschedular basis because he has difficulty ambulating and uses a walker to get around and that these symptoms are not compensated by the currently-assigned 40 percent rating. The appellant asserts that the limitations which require him to used a walker are symptoms of his service-connected low back disability; however, a review of the appellant’s private treatment records indicates that his mobility issues and use of a walker may be related to either a nonservice-connected right foot disability and/or his non service-connected obesity. See e.g. Private Medical Treatment Notes, dated August 12, 2011 and April 26, 2012. As such, the Board finds that remand is necessary to ascertain whether the appellant’s difficulties ambulating and his use of a walker are related to his service connected low back disability or other nonservice-connected disabilities. If the medical opinion determines the appellant’s mobility issues and use of a walker are proximately due to his service connected low back disability, the RO should refer the appellant’s claim for extraschedular consideration. The matter is REMANDED for the following action: 1. Schedule the appellant for an examination to determine the severity of his left lower extremity radiculopathy. After examining the appellant and reviewing the record, the examiner should delineate all symptoms associated with the service-connected left lower extremity radiculopathy, to include any impaired sensation, reflex abnormality, weakness, or muscle atrophy. The examiner should also characterize the current and past severity of the appellant’s left lower extremity severity as mild, moderate, moderately severe, or severe with marked muscular atrophy. The examiner should provide an adequate rationale for this classification. In providing the requested opinion, the examiner should review the relevant evidence of record, to include the February 2013 examination in which the examiner classified the appellant’s radiculopathy as mild but did not provide an explanation for that characterization. 2. Obtain an addendum opinion addressing the nature, severity, and cause of the appellant’s reported difficulties ambulating and the cause of his use of a walker. The examiner should provide an opinion on whether the appellant’s difficulty ambulating, and his use of a walker is due in whole or in part to his service-connected low back disability or some other nonservice-connected disability, such as his noted right foot deformity and his obesity. 3. If it is determined that the appellant’s difficulty ambulating and use of a walker are related to his service-connected disabilities, refer the appellant’s claim for an increased rating for his low back disability to VA’s Director of Compensation Service for extraschedular consideration. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kleponis, Associate Counsel