Citation Nr: 18149549 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 11-12 707 DATE: November 9, 2018 ORDER Entitlement to service connection for costochondritis, to include as secondary to service-connected disability, is denied. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected disability. Entitlement to a rating higher than 10 percent for left ankle strain is denied. Entitlement to a rating higher than 10 percent for degenerative joint disease of the thoracic spine is denied. Entitlement to a rating higher than 10 percent for stress fracture of the left inferior pubic ramus is denied. Entitlement to a rating higher than 10 percent for stress fracture of the right inferior pubic ramus is denied. Entitlement to a rating higher than 10 percent for right foot strain is denied. REMANDED Entitlement to service connection for radiculopathy, to include as secondary to the service-connected thoracic spine disability, is remanded. Entitlement to service connection for bilateral foot cramps, to include as secondary to service-connected disability, is remanded. Entitlement to a total rating based on unemployability due to service-connected disability (TDIU), is remanded. FINDINGS OF FACT 1. The most probative evidence of record is against a finding of a current diagnosis of costochondritis. 2. The most probative evidence of record is against a finding of a current diagnosis of a sleep disorder. 3. The Veteran’s left ankle disability is manifested by complaints of pain with full range of motion, it is not shown to have been productive of marked limitation of motion. 4. The evidence shows that the Veteran’s thoracic spine disability does not result in limitation of forward flexion of the thoracolumbar spine to 60 degrees or less, a combined range of motion of 120 degrees or less, severe guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis, ankylosis, or incapacitating episodes requiring bedrest and treatment by a physician. 5. The Veteran’s stress fracture, right inferior and superior pubic ramus, has not been manifested by limitation of flexion to 30 degrees or abduction of the thigh beyond 10 degrees. 6. The Veteran’s stress fracture, left inferior pubic ramus, has not been manifested by limitation of flexion to 30 degrees or abduction of the thigh beyond 10 degrees. 7. The Veteran’s right foot strain residuals have been manifested by symptoms, primarily pain, stiffness, swelling, fatigue, and weakness while standing or walking, that are no more than moderate in severity. CONCLUSIONS OF LAW 1. The criteria for service connection for costochondritis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 3. The criteria for a rating higher than 10 percent for the left ankle strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5099-5024, 5271. 4. The criteria for a rating higher than 10 percent for a thoracic spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code Codes 5237-5242. 5. The criteria for a rating higher than 10 percent for stress fracture, right inferior and superior pubic ramus, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252, 5253. 6. The criteria for an initial evaluation in excess of 10 percent for a stress fracture, left inferior pubic ramus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252, 5253. 7. The criteria for a rating higher than 10 percent for right foot strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 2001 to May 2002. These matters come before the Board of Veterans’ Appeals (Board) from June 2010 and April 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The June 2010 rating decision denied a July 2009 claim which included service connection for leg and foot cramps, IBS, costochondritis, a bilateral wrist disability, and a bilateral elbow disability; a September 2009 claim for a TDIU, which was also construed as a claim of entitlement to increased ratings for right foot strain, left ankle strain, stress fractures of the left and right inferior pubic ramus, and degenerative joint disease of the thoracic spine; and a January 2010 claim of entitlement to service connection for a sleep disorder. The April 2014 rating decision denied a November 2012 claim of entitlement to service connection for lumbar radiculopathy. In October 2017 the Board remanded the claims for additional development. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be “competent”. However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Under section 3.310(a), service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 1. Entitlement to service connection for costochondritis, to include as secondary to service-connected disability The Veteran contends that she currently suffers from costochondritis due to the service-connected thoracic spine disability. The service treatment records are negative for any complaints, findings or diagnosis consistent with chest trauma or costochondritis. On VA examination in March 2002 the Veteran reported recurrent chest pain. Imaging studies revealed no chest abnormalities. A May 2003 report noted an obvious deformity of the anterior chest wall with prominent right thoracic cage. Imaging studies of the chest were normal. In August 2004 report she complained of chest pain was assessed costochondritis. In March 2005, a clinician noted kyphoscoliosis along with pectus ex clavatum and a large right thoracic rib causing some rotation. A VA examiner in August 2018, following a review of the claims file and an examination of the Veteran, concluded that there was no competent medical evidence to support a diagnosis of costochondritis, citing a normal lab data, imaging studies, DEXA and bone scans. Accordingly, the examiner opined that there was no link between the service-connected thoracic spine condition and the Veteran’s complaints of chest pain. In summary, the preponderance of the evidence weighs against a finding of a diagnosis of costochondritis during the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007). The only evidence of record in support of the Veteran’s claim is the 2004 clinical assessment of costochondritis, which, as noted above, is outweighed by the other evidence of record, which includes objective testing to rule out such a diagnosis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110; 1131. In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C. § 1131 requires existence of present disability for VA compensation purposes). To the extent the Veteran complains of chest pain, the Board has considered whether the Veteran’s claimed symptoms are of such severity that these would be considered a “disability” as used in 38 U.S.C. 1110. While functional loss caused by pain is akin to functional loss caused by physical disability, in this case, the August 2018 VA examiner attributed the Veteran’s complaints of chest pain to a diagnosis of congenital pectus excavatum. The Board notes that the issue of entitlement to service connection for pectus excavatum is not currently before the Board as that claim was previously denied in unappealed prior final rating decision in May 2008. The Board finds credible the Veteran’s reports of chest pain; however, she does not possess the requisite medical expertise to diagnose costochondritis, and the weight of the competent evidence does not associate the Veteran’s reported chest pain with any diagnosed costochondritis. Rather, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Jones v. Brown, 7 Vet. App. 134, 137 (1994). The Board finds the opinion and findings of the VA examiner to be significantly more probative than the Veteran’s lay assertions. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule does not apply. Service connection is not warranted for costochondritis. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, supra. 2. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected disability. The Veteran contends that she currently suffers from a sleep disorder as secondary to service-connected disability. Specifically, she describes being woken up during sleep secondary to pain from service-connected disabilities. In this regard, it is important for the Veteran to understand that any problem the Veteran is having with her service-connected problems (such as being woken up) would be addressed with those problems. The symptom of a service-connected problem is not a separate disability. The service treatment records are negative for any complaints, findings or diagnosis consistent with a chronic sleep disorder. After service treatment records show difficulty getting comfortable during sleep. She repeatedly denied insomnia. On VA examination in August 2018 the examiner noted the Veteran’s complaints of cramps at night and problems getting comfortable. She denied insomnia or impairment in daytime functioning related to sleep issues The examiner concluded, following a review of the claims file and an examination of the Veteran, that a diagnosis of sleep disorder was not appropriate because there was no evidence, lay or otherwise, to support any such diagnosis. Further, as there was no evidence of sleep apnea, a sleep study was not indicated for evaluation of this Veteran’s claim. In sum, as there is no evidence of record suggesting a diagnosed sleep disorder, nor is there any evidence that the Veteran’s sleep complaints cause any impairment of earning capacity. Brammer, supra. Finally, the Board again notes that the Veteran does not possess the training or credentials to diagnose a chronic sleep disability. See Jandreau, supra. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. See 38 U.S.C. § 5107 (b); Ortiz, supra; Gilbert, supra. Increased Rating Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will also consider entitlement to staged ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). The assignment of a particular diagnostic code to evaluate a disability is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the diagnosis, and demonstrated symptomatology. Traumatic arthritis shown by x-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent disability rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5003 states that 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, Diagnostic Code 5003. When, however, the limitation of motion is noncompensable 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. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. 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 are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton, 25 Vet. App. at 5. Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while “pain may cause a functional loss, pain itself does not constitute a functional loss,” and, is therefore, not grounds for entitlement to a higher disability rating). 3. Entitlement to a rating higher than 10 percent for left ankle strain The Veteran claims that she is entitled to a higher disability rating for her left ankle disability. The Veteran’s left ankle strain is currently rated pursuant to Diagnostic Codes 5099-5024, as tenosynovitis. This disability is rated on limitation of range of motion of affected parts as degenerative arthritis. Under Diagnostic Code 5271, a 10 percent rating is warranted for a moderate limitation of ankle motion. A 20 percent rating is warranted for a marked limitation of ankle motion. Words such as “moderate” and “marked” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. However, the Rating Schedule provides some guidance by defining full range of motion of the ankle as from zero to 20 degrees of dorsiflexion and from zero to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II. During an August 2009 VA examination, the Veteran reported weakness, stiffness, swelling, heat, locking, tenderness and pain. She had flare-ups of severe pain precipitated by physical activity, stress and sitting or prolonged standing. She was unable to sleep during flare-ups as a result of her increased pain. She described impaired abilities to engage in housework, sit, stand, bend or walk for an extended period of time, which, according to the Veteran, made it difficult to keep a job. Range of motion testing showed no limitation of motion. Dorsiflexion was to 20 degrees and plantar flexion was to 45 degrees. There was no additional limitation of motion upon repetition; however, the examiner did note evidence of increased pain upon repetition. The left ankle x-ray showed no indication of arthritis or malunion. On VA examination in August 2018 the Veteran denied ankle pain, flare-ups or treatment for her ankle since 2010. There was no localized tenderness or pain on palpation. There was no crepitus. The Veteran had full range of motion of the ankle as from zero to 20 degrees of dorsiflexion and from zero to 45 degrees of plantar flexion. There was no additional limitation of motion or functional loss with repetitive movements. Left ankle strength was 5/5. There was no ankle instability or dislocation. There was no evidence of pain on weight bearing or passive range of motion. Imaging studies did not reveal arthritis of the ankle. The examiner determined that the Veteran’s left ankle strain resolved. The examiner further noted that the Veteran’s complaints of foot cramps were not associated with the left ankle strain because the Veteran no longer had a condition of the left ankle. In sum, although the Veteran has reported pain associated with the left ankle, the evidence does not demonstrate loss of range of motion of the ankle or reduced strength, even with repetitive movement. As noted above, in order to warrant an increased 20 percent disability rating for the Veteran’s left ankle for the entire appeal period, her ankle disability must result in marked limited motion of the ankle. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Notably, the objective VA examinations discussed herein do not document objective findings which warrant an increased 20 percent disability rating for the Veteran’s left ankle. Concerning the Veteran’s complaints of pain, the Board finds that such complaints are adequately contemplated by the currently assigned 10 percent disability rating. See 38 C.F.R. § 4.59; Mitchell, 25 Vet. App. 32. The Board has also considered all potentially applicable provisions of the rating schedule, whether or not they have been raised by the Veteran or the record, as required by Schafrath, 1 Vet. App. 589. However, the Board has found no section that provides a basis upon which to assign increased disability ratings for any period on appeal. There has been no objective finding of ankylosis of the Veteran’s left ankle, subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy; therefore, Diagnostic Codes 5270, 5272, 5273, and 5274 are not for application. Similarly, the Board does not find any additional foot or ankle symptoms consistent with a finding of severe residuals of a foot injury or loss of use of the foot as required for higher ratings under Diagnostic Code 5284. See 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272-5274, 5284. As the preponderance of the evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 4. Entitlement to a rating higher than 10 percent for degenerative joint disease of the thoracic spine The Veteran claims that she is entitled to a higher disability rating for her thoracic spine disability (the back). The regulations provide for evaluation of the spine under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Intervertebral disc syndrome (IVDS) may alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, The Spine, Note (6). The Veteran’s service-connected thoracic spine disability is rated under Diagnostic Codes 5237-5242. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted where there is forward flexion of the thoracolumbar spine of 30 degrees or less. A higher 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities are evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note 1. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are 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 thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula, Note (2); see also Plate V. Alternatively, intervertebral disc disease can be evaluated under the Formula for Rating IVDS Based on Incapacitating Episodes. Under that Formula, a 10 percent rating is assigned where intervertebral disc syndrome is manifested by incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted where incapacitating episodes have a total duration of at least two weeks but less than 4 weeks during the past 12 months. A rating of 40 percent is warranted where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted where the evidence reveals incapacitating episodes having a total duration of at least six weeks during the past 12 months. Incapacitating episodes are defined as requiring bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, IVDS Formula. On VA examination in August 2009 the Veteran reported symptoms of stiffness, fatigue, spasms, decreased motion, paresthesia, numbness, pain, and weakness of the spine, leg and foot. Physical examination noted that her posture was within normal limits. She exhibited a slight limp. Examination of the thoracolumbar spine revealed no evidence of radiating pain on movement or muscle spasm. There was tenderness noted on exam described as T10-L1. The examiner noted that spinal contour was preserved, though there was tenderness. There was no guarding of movement. The examination did not reveal any weakness. There was no ankylosis of the thoracolumbar spine shown. Range of motion of the thoracolumbar spine was within normal limits, with forward flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right rotation to 30 degrees, and left rotation to 30 degrees. There was pain noted at the end of each range of motion movement. The examiner reported that joint function of the thoracolumbar spine is additionally limited by pain after repetitive use, but not by fatigue, weakness, lack of endurance, or incoordination. However, range of motion remained within normal limits after repetition. The inspection of the spine revealed normal head position with symmetry in appearance. There was symmetry of spinal motion with normal curves of the spine. There were no signs of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement. Muscle tone and musculature were normal. Straight leg raising test was negative bilaterally. Lasegue’s sign was negative. There was no atrophy in the limbs. On VA examination in August 2018 the Veteran complained of back and shoulder pain with prolonged sitting or standing. She used yoga to loosen up her muscles. She denied flare-up in symptoms. Range of motion of the thoracolumbar spine was normal with 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 to 30 degrees. The examiner noted no pain on examination, no pain on weight bearing or with passive range of motion. There was no objective evidence of localized tenderness or pain on palpation of the joints. There was no additional loss of function or range of motion after three repetitions, or guarding or muscle spasm. Muscle strength, deep tendon reflexes and sensory were normal. There was no evidence of IVDS. Imaging studies of the thoracolumbar spine failed to arthritis of the spine. There was no objective evidence of degenerative changes of the spine. The examiner determined that the Veteran’s thoracic spine disability had resolved and was not productive of any occupational or functional limitations on occupational environment or functional limitations. Initially, the Board notes that throughout the period on appeal the Veteran has not reported physician-prescribed bed rest. Additionally, none of the treatment records treatment records show incapacitating episodes as defined by VA regulation. Moreover, the VA examiner in 2018 specifically found no evidence of IVDS. As such, the Veteran does not satisfy the criteria for an increased rating under Diagnostic Code 5243 for IVDS because the record does not show documented periods of acute signs and symptoms of IVDS that required bed rest prescribed by a physician and treatment by a physician. Accordingly, the Board finds that she is not entitled to higher disability ratings based upon incapacitating episodes at any time throughout the period on appeal. As the Veteran is not entitled to increased ratings based upon incapacitating episodes, it is necessary to determine whether she is entitled to higher ratings under the General Rating Formula. The Board finds that the Veteran is not entitled to a rating in excess of 10 percent. To warrant a 20 percent rating, there must be evidence of limitation of flexion to 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a. During this period, the only recorded range of motion findings show Veteran’s flexion was noted to be 90 degrees with no pain, and the combined range of motion of the thoracolumbar spine was greater than 120 degrees. There was no evidence that the Veteran experiences additional limitation due to pain on repetition. 38 C.F.R. § 4.40, 4.45. Further, there was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. With regard to repeated use over time and flare-ups, the examiner stated that she could not comment about additional loss of range of motion, fatigue, pain, weakness or incoordination during flare ups without resorting to mere speculation, as the Veteran denied flare-up while being examined. Therefore, the Board finds that a rating in excess of 10 percent is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Consideration has been given to assigning a separate rating for neurological abnormalities related to the lumbar spine disability. A claim for service connection has been raised for radiculopathy of the lower extremities and is addressed in the Remand portion of this decision. There is otherwise no reliable objective evidence of any neurological abnormalities, including bladder or bowel dysfunction, of the thoracic spine that would provide adequate information to assign any separate compensable rating. For this reason, separate ratings for objective neurological abnormalities are not warranted. In conclusion, the Board has carefully considered the lay and medical evidence of record, and finds that the preponderance of the evidence weighs against the Veteran’s claim of entitlement to a disability rating higher than 10 percent for the lumbar spine disability. As such, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 5. Entitlement to a rating higher than 10 percent for stress fracture of the left inferior pubic ramus 6. Entitlement to a rating higher than 10 percent for stress fracture of the right inferior pubic ramus The Veteran contends that her stress fracture of the right inferior and superior pubic ramus, and stress fracture of the left inferior pubic ramus are more disabling than contemplated by the current 10 percent disability evaluation. The Veteran’s disabilities have been evaluated under the Diagnostic Code for limitation of extension of the thigh, which warrants a 10 percent evaluation for extension limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. This is the maximum available rating for limitation of extension. Related Diagnostic Codes include limitation of flexion of the thigh which contemplates a 10 percent evaluation for flexion limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. A 20 percent rating requires that flexion be limited to 30 degrees. Id. Limitation of rotation of the thigh warrants a 10 percent rating when toe-out of the affected leg cannot be performed to more than 15 degrees or limitation of adduction when the legs cannot be crossed. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Limitation of abduction of the thigh warrants a 20 percent rating when motion is lost beyond 10 degrees. Id. The standard range of motion of the hip is from zero degrees of extension to 125 degrees of flexion; normal abduction of the hip is from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. On VA examination in August 2018, the Veteran complained of pain. She denied flare-ups. It was noted that in 2009 she was seen by an orthopedic specialist, and it was confirmed that stress fractures healed without residuals. She was diagnosed with trochanteric bursitis. She was offered injections and declined. The examiner noted that all of the inflammatory lab markers were negative and imaging studies of the pelvis, including DEXA scan and bone scans, were all negative in 2009. She exhibited full range of motion in both hips, with flexion to 125 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees, bilaterally. Repetitive use testing with at least three repetitions was not productive of functional loss or additional loss of motion. There was no evidence of pain on examination or on weight bearing. There was no crepitus, or localized tenderness or pain on palpation. Muscle strength was normal, bilaterally, with no muscle atrophy. There was no ankylosis. Imaging studies did not reveal arthritis of the hips. The examiner diagnosed Right inferior and superior pubic ramus stress fracture, resolved with no residuals, and left inferior pubic ramus stress fracture, also resolved with no residuals. The examiner also noted that bilateral trochanteric bursitis noted in 2009 was not caused by or aggravated by the service-connected bilateral hip disorders. Based on the evidence of record, the Board finds that Veteran’s right and left hip disabilities do not meet the criteria for a rating in excess of the current 10 percent ratings. She is in receipt of the maximum disability available for limitation of extension evaluation so a higher rating under Diagnostic Code 5251 is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Additionally, she has not demonstrated flexion limited to 30 degrees so a higher rating under Diagnostic Code 5252 is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5252. There is also no indication of limitation of abduction of the thigh with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Therefore, a rating in excess of the current 10 percent rating for either hip is not warranted. Regarding the possibility of increased ratings in excess of the separate 10 percent ratings assigned, the Board finds also that the evidence, both lay and medical does not indicate functional loss of the either hip, to include flare-ups due to pain, fatigability, incoordination, and weakness, so as to approximate abduction of either hip functionally limited to 10 degrees or less; flexion of either hip functionally limited to 30 degrees or less; or abduction of either hip functionally limited to 10 degrees or less. 38 C.F.R. §4.71a, Diagnostic Codes 5252, 5253, DeLuca, supra. Moreover, the record contains no evidence of a hip flail joint or any impairments of the Veteran’s femur; therefore, the criteria under Diagnostic Codes 5254 and 5255 are inapplicable in this matter. 38 C.F.R. § 4.71a. Additionally, the Veteran has not been shown to have evidence of arthritis of either hip. Accordingly, consideration for arthritis is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Moreover, the record contains no indication that either hip disability during the applicable rating periods more nearly approximated hip ankylosis, flail joint, or impairment of the femur, the Board finds that Diagnostic Codes 5250, 5254, and 5255 are not applicable. 38 C.F.R. § 4.71a. As the preponderance of the evidence weighs against the Veteran’s claims, there is no reasonable doubt to be resolved, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 7. Entitlement to a rating higher than 10 percent for right foot strain The Veteran claims that she is entitled to a rating higher than 10 percent for residuals of a right foot strain. The Veteran’s right foot strain is rated under Diagnostic Code 5284, which references other foot injuries. Under Diagnostic Code 5284, foot injuries are rated as 10 percent disabling when moderate, as 20 percent disabling when moderately severe, and as 30 percent disabling when severe. 38 C.F.R. § 4.71a. With actual loss of use of the foot, a 40 percent rating is assigned. Id. On VA examination in August 2009 the Veteran complained of pain in the entire right foot, toes, heel, and top and bottom of the ankle. She reported pain at rest, stiffness, swelling, fatigue, and weakness while standing or walking. Physical examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. Examination of the right foot revealed tenderness, but did not show painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, erythema, or instability. Achilles tendon alignment was noted to be normal on weight bearing and non-weight bearing. The examiner noted no limitations with standing or walking. She did not require any type of support with shoes. Right foot x-ray findings were within normal limits. On VA examination in August 2018 the Veteran complained of intermitted foot cramp and numbness on prolonged sitting, standing, or at rest. It resolved with repositioning. She associated these symptoms with radiculopathy. The Veteran reported she had not sought medical treatment for her right foot since at approximately 2010. She stated that she broke a bone in her right foot the previous summer but it healed without pain, and there was no laterality to her numbness or cramping. She denied flare-ups or functional loss. The examiner noted no objective evidence of pain on examination. The examiner opined that there was no additional loss of motion or functional loss due to pain, weakness, fatigability, or incoordination that limited functional ability during flare-ups or with repetitive use. The examiner concluded that the foot sprain in service resolved. Based on consideration of the evidence of record, the Board finds that a rating in excess of 10 percent for service-connected chronic right foot strain is not warranted. Here the evidence shows that the Veteran’s primary problem with her right foot was pain and some reports of stiffness, swelling, fatigue, and weakness while standing or walking. While she complained of intermittent numbness and cramps, these symptoms have been associated with possible radiculopathy, as opposed to residuals of right foot strain. There was no objective evidence of painful motion. There was no additional loss of motion or functional loss due to pain, weakness, fatigability, or incoordination that limited functional ability during flare-ups or with repetitive use. Further, the VA examiner found that the Veteran had normal shoe wear pattern without breakdown and no callosities to indicate abnormal weight bearing. Most recently, the condition was noted to have resolved. Collectively, this evidence indicates that the Veteran’s symptoms more closely approximated no more than moderate severity, pursuant to Diagnostic Code 5284. The Board further notes that of the Veteran’s right foot disability is not shown to have involved any other factor(s) warranting evaluation under any potentially applicable diagnostic code. The evidence of record is devoid of any findings of flatfoot, weak foot, claw foot, hallux valgus, hallux rigidus, hammer toe, malunion or nonunion of the metatarsal bones, Morton’s neuroma, or other right foot deformity. Thus, a higher or separate rating under Diagnostic Codes 5276, 5277, 5278, 5279, 5280, 5281, 5282, and/ or 5283, respectively, is not warranted. As the preponderance of the evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 1. Entitlement to service connection for radiculopathy, to include as secondary to the service-connected thoracic spine disability, is remanded. 2. Entitlement to service connection for bilateral foot cramps, to include as secondary to service-connected disability, is remanded. The Veteran contends that she currently suffers from radiculopathy, manifested by intermittent numbness and cramping, affecting the lower extremities as secondary to the service-connected thoracic spine disability. The Veteran underwent a private nerve conduction study in June 2009 for complaints of bilateral lower extremity pain and paresthesias. Diagnostic testing confirmed electrophysiologic evidence of bilateral lumbosacral radiculopathy. On VA examination in August 2018 the Veteran complained of intermit numbness and cramping of the feet that she attributed to radiculopathy. Examination showed muscle strength and reflexes in the lower extremities were normal. Her sensory examination was also normal. Straight leg raise was negative, bilaterally. The examiner found no evidence of radicular symptoms or radiculopathy secondary to thoracic spine. The Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to VA’s adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 321 (2013). Accordingly, an addendum opinion is required to reconcile the determination that the Veteran does not have a diagnosis of lower extremity radiculopathy with the remainder of the evidence of record and, to provide an opinion as to whether any lower extremity radiculopathy is related to the Veteran’s thoracic spine disability. The development requested in connection with claim for service connection for radiculopathy could have bearing on the claim for service connection for bilateral foot cramps, as the evidence of record indicate potential overlap of symptoms. Hence, this issue is not yet ripe for appellate review and must be deferred pending readjudication of the other remanded claims. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two or more issues are inextricably intertwined if the disposition of one claim could have a significant impact on the outcome of another). 3. TDIU The Board finds that the Veteran’s claim of entitlement to a TDIU is inextricably intertwined with the pending claims for service connection for bilateral foot cramps and radiculopathy, which if granted, could affect whether the Veteran meets the schedular criteria for a TDIU. As such, the Board defers consideration of the claim pending adjudication of the inextricably intertwined claims for service connection for bilateral foot cramps and radiculopathy. See Harris, supra. The matter is REMANDED for the following action: Forward the record and a copy of this remand to the examiner who conducted the August 2018 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. The examiner must reconcile the June 2009 nerve conduction study findings with his or her own opinion. The examiner should provide the following: (a) Whether the Veteran has a current diagnosis of any lower extremity radiculopathy, or, if not, whether any diagnosed lower extremity radiculopathy has since resolved or was misdiagnosed. (b) For any lower extremity radiculopathy found offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the disability is caused or aggravated (made permanently worse beyond the natural progression of the disease) by the service-connected thoracic spine disability. If a lower extremity radiculopathy disability has been aggravated by the service connected thoracic spine disability, the examiner should attempt to quantify the degree of aggravation beyond the baseline level of disability. The examiner is advised that the Veteran is competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. All opinions expressed must be accompanied by a complete rationale. In providing the above opinion, the examiner should be mindful that even if the Veteran’s previously diagnosed acquired psychiatric disability has resolved, an opinion is still required regarding the etiology of the diagnosed disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007). John Crowley Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Azizi-Barcelo, Tatiana