Citation Nr: 18151700 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 07-21 612 DATE: November 20, 2018 ORDER An effective date of February 27, 2006, but no earlier, for the award of service connection for radiculopathy of the left lower extremity associated with scoliosis and degenerative disc disease of the thoracolumbar spine with disc bulges, bone spurs, facet joint disease and arthritis (left lower extremity disability) is granted. An effective date of April 1, 2012, but no earlier, for the award of service connection for radiculopathy of the left upper extremity associated with degenerative disc disease of the cervical spine (left upper extremity disability) is granted. An initial disability rating in excess of 10 percent prior to September 8, 2016 for the left lower extremity disability is denied. An increased disability rating of 20 percent, but no higher, from September 8, 2016 for the left lower extremity disability is granted, subject to the governing criteria applicable for the payment of monetary benefits. REMANDED The issue of entitlement to service connection for a bilateral hip disability, to include as secondary to scoliosis and degenerative disc disease of the thoracolumbar spine with disc bulges, bone spurs, facet joint disease and arthritis (thoracolumbar spine disability) is remanded. The issue of entitlement to an initial disability rating in excess of 10 percent prior to March 6, 2015 for the thoracolumbar spine disability is remanded. The issue of entitlement to an increased disability rating in excess of 10 percent for degenerative disc disease of the cervical spine (cervical spine disability) is remanded. The issue of entitlement to an initial disability rating in excess of 10 percent for the left upper extremity disability is remanded. The issue of entitlement to an effective date prior to March 6, 2015 for the award of a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran was first diagnosed with radiculopathy of the left lower extremity in August 2006 following a nerve conduction study, but immediately prior to the nerve conduction study she complained of intermittent tingling and numbness in the toes of her left foot for six months prior. 2. The Veteran was first diagnosed with radiculopathy of the left upper extremity in December 2007. 3. Prior to September 8, 2016, the Veteran’s left lower extremity disability was only manifested by intermittent tingling and numbness as well as decreased, but not absent, sensation to light touch in the left thigh/knee. 4. From September 8, 2016, the Veteran’s left lower extremity disability was manifested by mild paresthesias and/or dysesthesias, moderate numbness and decreased, but not absent, sensation to light touch in the left thigh/knee. CONCLUSIONS OF LAW 1. The criteria for an effective date of February 27, 2006, but no earlier, for the left lower extremity disability have been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 2. The criteria for an effective date of April 1, 2012, but no earlier, for the left upper extremity have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 3. The criteria for an initial disability rating in excess of 10 percent prior to September 8, 2016 for the left lower extremity disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.124a, Diagnostic Code (DC) 8520 (2017). 4. The criteria for an increased disability rating of 20 percent, but no higher, from September 8, 2016 for the left lower extremity disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1985 to March 1989. In July 2016, the Board issued a decision denying, in pertinent part, the Veteran’s claim for an initial disability rating in excess of 20 percent prior to March 6, 2015 for the thoracolumbar spine disability, to include on an extraschedular basis. She appealed that decision to the United States Court of Appeals for Veterans’ Claims (Court). By a March 2018 Memorandum Decision, the Court set aside the Board’s July 2016 decision in relevant part and remanded the matter for further action consistent with its decision. Effective Date 1. The issue of entitlement to an effective date prior to March 6, 2015 for the award of service connection for the left lower extremity disability. The Veteran contends that she is entitled to an effective date prior to March 6, 2015, for the grant of service connection for the left lower extremity disability. See March 2016 Notice of Disagreement. Generally, the effective date of a grant of service connection is based on either the date the original claim was received; the date the petition to reopen the claim was received after a final disallowance; or the date the entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The Veteran was granted service connection for the left lower extremity disability, effective March 6, 2015, in a March 2015 rating decision during the pendency of the appeal of her claim for an initial disability rating in excess of 20 percent for the thoracolumbar spine disability. May 2010 Notice of Disagreement. As such, it became a part and parcel of the claim for an initial disability rating in excess of 20 for the thoracolumbar spine disability. The claim for an initial disability rating in excess of 20 percent for the thoracolumbar spine disability was received by the VA on February 27, 2006. February 2006 Veteran’s Application for Compensation and/or Pension. As such, the earliest possible effective date for the award of service connection for the left lower extremity disability is February 27, 2006. Here, a review of the claims file reveals that in August 2006 the Veteran complained of intermittent tingling and numbness in the toes of her left foot over the past six months, suggesting these symptoms have been present at least since February. August 9, 2006 O.I.O. Encounter Note. Two weeks later, she underwent a nerve conduction study. August 23, 2006 O.I.O Nerve Conduction Study. Despite indicating that the study with respect to the left lower extremity was incomplete because of her poor tolerance to the testing, the private treatment provider nevertheless found the electrophysiologic evidence they were able to obtain was consistent with mild left lumbar radiculopathy. Considering the above, the Board finds the preponderance of the evidence supports an earlier effective date of February 27, 2006 for radiculopathy of the left lower extremity associated with the thoracolumbar spine disability. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 2. The issue of entitlement to an effective date prior to October 25, 2013 for the award of service connection for the left upper extremity disability. The Veteran contends that she is entitled to an effective date prior to October 25, 2013, for the grant of service connection for radiculopathy of the left upper extremity associated with the cervical spine disability. See March 2016 Notice of Disagreement. The Veteran was granted service connection for the cervical spine disability in a February 2013 rating decision. She did not initiate an appeal of this decision and it became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2017). Thereafter, in April 2013, the Veteran submitted a claim for TDIU. December 2012 Veteran’s Application for Increased Compensation Based on Unemployability (received by the VA on April 1, 2013). Although she did not expressly initiate an increased disability rating claim for the cervical spine disability along with the claim for TDIU, given her TDIU claim was based on her service-connected thoracolumbar and cervical spine disabilities, it appears the Regional Office (RO) interpreted the claim to include an increased disability rating claim for the cervical spine disability. In a March 2014 rating decision, the RO denied an increased disability rating in excess of 10 for the cervical spine disability. She appealed this decision. See March 2015 Notice of Disagreement. During the pendency of the appeal of the Veteran’s claim for an increased disability rating in excess of 10 for the cervical spine disability, she was granted service connection for the left upper extremity disability, effective October 25, 2013, in an April 2015 rating decision. Although prior to the appeal, the Veteran expressly filed a separate service connection claim for radiculopathy of the left upper extremity, since the claim for an increased disability rating in excess of 10 for the cervical spine disability was pending at the time she filed the service connection claim, the Board finds it became part and parcel of the claim for an increased disability rating in excess of 10 for the cervical spine disability. October 2014 Application for Disability Compensation and Related Compensation Benefits. Where an increase in the rating assigned is at issue, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(o)(2). Thus, in this instance, the earliest possible effective date is April 1, 2012, one year prior to the date the Veteran’s Application for Increased Compensation Based on Unemployability. The Board acknowledges the Veteran’s representative’s disagreement in the March 2015 Notice of Disagreement that her claim for an increased disability rating for the cervical spine disability was a new claim. The Veteran’s representative explained that it was not a new claim because new and material evidence was submitted within one year of the February 2013 rating decision granting service connection for the cervical spine disability in accordance with 38 C.F.R. § 3.156(b) (2017). As such, according to the Veteran’s representative, the earliest possible effective date was February 27, 2006, the date the original service connection claim for the cervical spine disability was received. See February 2006 Veteran’s Application for Compensation and/or Pension. The Veteran’s representative’s reliance on 38 C.F.R. § 3.156(b) is misplaced. 38 C.F.R. § 3.156 applies to the reopening of finally adjudicated claims. If new and material evidence is received, which relates to an unestablished fact necessary to substantiate the claim, and it is received prior to the expiration of the appeal period it is to be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. Here, the underlying service connection claim may not be reopened because it was finally adjudicated in her favor in the February 2013 rating decision. Therefore, there was no unestablished fact remaining to be substantiated by new and material evidence. The issue of entitlement to a higher initial disability rating is a downstream issue, requiring a separate notice of disagreement to initiate an appeal. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (1997). A review of the claims file discloses a private treatment provider first noted an impression of left sided cervical radiculopathy following a complaint of left sided neck pain radiating into the left shoulder region in December 2007. December 2007 N.C.O.P.S. Neurosurgical Consultation. The Veteran underwent a VA examination in April 2012, following which the VA examiner concluded there was no evidence of radiculopathy of the bilateral upper extremities. April 2012 Neck Conditions VA Examination Report. Unfortunately, the VA examiner did not reconcile this conclusion with their finding that there was moderate left upper extremity paresthesias and/or dysesthesias, which was a symptom of radiculopathy. As such, the VA examiner did not expressly exclude the presence of radiculopathy of the left upper extremity. In view of the above, the Board accords the Veteran the benefit of the doubt, and finds the preponderance of the evidence warrants an earlier effective date of April 1, 2012 for the left upper extremity disability. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Increased Rating 3. The issue of entitlement to an initial disability rating in excess of 10 percent for the left lower extremity disability. The Veteran contends that she is entitled to an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity associated with the thoracolumbar spine disability. See March 2016 Notice of Disagreement. Preliminarily, the Board notes the applicable DC is DC 8599-8520. The use of a hyphenated DC indicates the rating is based on a residual condition. 38 C.F.R. § 4.24. The first DC denotes the underlying condition, while the second DC identifies the residual condition stemming from it. In such cases, the applicable diagnostic criteria are the ones associated with the residual condition. In this instance, DC 8599 signifies the underlying condition is an unlisted condition related to the peripheral nerves, while DC 8520 indicates the residual condition is for paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Thus, the applicable diagnostic criteria are the one prescribed under DC 8520. Under DC 8520, a 10 percent disability rating is warranted if there is mild, incomplete paralysis; a 20 percent disability rating is warranted for moderate, incomplete paralysis; and a 40 percent disability rating is warranted for moderately severe incomplete paralysis; and a 60 percent disability rating is warranted for severe, incomplete paralysis, with marked muscular atrophy. The words “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the VA’s Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. Part 4, § 4.124a, DC 8520. As such, rather than applying a mechanical formula, the Board must evaluate all the evidence for an “equitable and just decision.” 38 C.F.R. § 4.6. Generally, in assessing the evidence of record, the Board acknowledges the Veteran was competent to provide evidence regarding the lay observable symptoms of his left lower extremity disability. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007), abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013). However, he was not competent to render a medical diagnosis or opinion on such a complex medical question as to the clinical factors contributing to an assessment of mild, moderate, moderately severe, or severe disability. See Barr, supra; Jones v. West, 12 Vet. App. 460, 465 (1999). In that respect, the Board relies primarily on the medical evidence of record. As in this instance, when an initial disability rating is at issue, the evidence to be considered includes the entire appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). A review of the claims file shows the treatment evidence of record pertaining to this claim is limited. The first complaint associated with radiculopathy of the left lower extremity of record comes in December 2003. December 2003 S.R.M.C. MRI Lumbar Spine. At that time, the Veteran reported suffering from paresthesia of the left lower extremity. No further information is provided to assess the severity thereof. Subsequently, in August 2006 the Veteran complained of intermittent tingling and numbness in the toes of her left foot over the past six months. August 9, 2006 O.I.O. Encounter Note. Two weeks later, she underwent a nerve conduction study. August 23, 2006 O.I.O Nerve Conduction Study. Despite indicating that the study with respect to the left lower extremity was incomplete because of her poor tolerance to the testing, the private treatment provider nevertheless found the electrophysiologic evidence they were able to obtain was consistent with mild left lumbar radiculopathy. The only other relevant treatment evidence of record is a June 2012 Encounter Summary from another private treatment provider. At that time, the Veteran complained of low back pain, which radiated into her left lower extremity. Generally, she described the pain she experienced as constant, aching, dull and deep. She rated the pain at a seven out of 10, with 10 being the most severe. However, at times she stated the pain rose to a 10 out of 10. Unfortunately, she did not distinguish between the pain attributable to her left lower extremity as opposed to her low back. For this reason, the probative value of her lay statements describing pain associated with her left lower extremity is limited to confirmation of the presence of pain. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Upon examination, the private provider noted there was decreased, but not absent, sensation to light touch at the sole of her left foot as well as the posterior and medial aspects of the left leg and left knee. Even so, the private treatment provider found the Veteran’s muscle strength and reflexes were normal in all respects. Further, straight leg testing was negative for any evidence of radiculopathy. Specifically, in this regard, the Veteran has been examined by the VA twice; first in March 2015, then in September 2016. March 2015 Peripheral Nerves VA Examination Report; September 8, 2016 Peripheral Nerves VA Examination Report. Prior to the March 2015 examination, the Veteran underwent a spine VA examination in July 2006. July 2006 Spine VA Examination Report. At that time, she reported experiencing some numbness in the third and fourth toes of her left foot. Upon examination, the VA examiner found her muscle strength and reflexes were normal in all respects. The VA examiner neither diagnosed nor assessed the overall severity of the radiculopathy of her left lower extremity. As such, the probative value of the July 2006 Spine VA Examination Report is limited to acknowledging her complaint of experiencing some numbness in her toes and the VA examiner’s finding that her muscle strength and reflexes were normal in all respects. See Madden, supra. During the March 2015 examination, the Veteran averred she suffered from occasional numbness in the left leg. March 2015 Peripheral Nerves VA Examination Report. Following examination, the VA examiner found there was evidence of mild numbness, left lower extremity. However, her muscle strength was normal in all respects without any evidence of muscle atrophy. Her reflexes remained normal in all respects. There was decreased, but not absent, sensation to light touch in the left thigh/knee. There was normal sensation to light touch in the left lower leg/ankle and foot/toes. No tophic changes were observed. While she demonstrated an antalgic gait, the VA examiner attributed it to her cervical spine and thoracolumbar spine disabilities. In the end, the VA examiner assessed there was mild, incomplete paralysis of the left lower extremity affecting the sciatic nerve. In March 2015, the Veteran also underwent a back conditions VA examination, which was conducted by the same VA examiner. March 2015 Back Conditions VA Examination Report. The VA examiner reiterated there was evidence of mild numbness of the left lower extremity; muscle strength was normal in all respects without any evidence of muscle atrophy; and reflexes were normal in all respects. However, the VA examiner indicated there was normal sensation to light touch in all respects, including the left thigh/knee. Further, the VA examiner provided no response regarding the nerve root affected. Of note, the VA examiner indicated the left lower extremity was not affected by the radiculopathy despite indicating that she exhibited signs or symptoms due to radiculopathy. In light of the discrepancies noted in the March 2015 Back Conditions VA Examination Report, the Board accords the March 2015 Peripheral Nerves VA Examination Report more probative weight as it contains a more thorough and complete assessment of the left lower extremity disability. See Madden, supra; see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996). At the time of the September 2016 examination, the Veteran relayed experiencing pain and tingling in her left leg. September 8, 2016 Peripheral Nerves VA Examination Report. After examination, the VA examiner found there was evidence of mild paresthesias and/or dysesthesias as well as moderate numbness in the left lower extremity. Her muscle strength remained normal in all respects, without any evidence of muscle atrophy. Her reflexes also remained normal in all respects. Again, there was decreased, but not absent, sensation to light touch at the left thigh/knee. Id.; October 2017 VA Addendum Medical Opinion. There was normal sensation to light touch in the left lower leg/ankle and foot/toes. September 8, 2016 Peripheral Nerves VA Examination Report. No tophic changes were observed. While she demonstrated an antalgic gait, this VA examiner also attributed it to the pain from her cervical spine and thoracolumbar spine disabilities. Overall, the VA examiner assessed there was moderate, incomplete paralysis of the left lower extremity affecting the sciatic nerve. In contemplating the above, the Board finds the preponderance of the evidence does not substantiate an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity prior to September 8, 2016. Cf. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.124a, DC 8520 (2017); cf. also Fagan v. Shinseki, 573 F.3d 1282, 1287 (2009). Prior to September 8, 2016, the evidence of record establishes the Veteran’s experienced at worst intermittent tingling and numbness in her left lower extremity as well as decreased, but not absent, sensation to light touch in the left thigh/knee. Her sensation to light touch remained intact at the left lower leg/ankle and foot/toes. No other symptoms were reported or found upon examination. Notwithstanding these symptoms, her muscle strength and reflexes remained normal at all times. Each time the overall severity was assessed by a competent medical professional, it was found to be mild in nature. From September 8, 2016, the date of the September 2016 peripheral nerves VA examination, the Board finds the preponderance of the evidence supports an increased disability rating of 20 percent, but no higher, for radiculopathy of the left lower extremity. 38 C.F.R. § 4.124a, DC 8520. Beginning in September 8, 2016, the VA examiner assessed there was moderate, incomplete paralysis of the left lower extremity affecting the sciatic nerve upon finding evidence of mild paresthesias and/or dysesthesias, moderate numbness and decreased, but not absent, sensation to light touch in the left thigh/knee. A higher disability rating in excess of 20 percent is not warranted because there is no evidence of record whatsoever demonstrating moderately-severe, incomplete paralysis. In fact, her muscle strength remained normal in all respects, without any evidence of muscle atrophy. Her reflexes also remained normal in all respects. Her sensation to light touch in the left lower leg/ankle and foot/toes remained intact. No tophic changes were observed. Ordinarily, the Board’s inquiry would not end here as the Board must also consider increased evaluations under other potentially applicable DCs. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, there are no other symptoms raised by the record, which are not contemplated under the diagnostic criteria for DC 8520. Therefore, further consideration is unnecessary. REASONS FOR REMAND 1. The issue of entitlement to service connection for a bilateral hip disability, to include as secondary to the thoracolumbar spine disability is remanded. In this regard, the Veteran was afforded a VA examination in March 2015. March 2015 Hip and Thigh Conditions VA Examination Report. Following examination, the VA examiner diagnosed her with osteoarthritis of the left hip. Nevertheless, the VA examiner rendered a negative nexus opinion, finding the diagnosis was not proximately due to the thoracolumbar spine disability. In doing so, the VA examiner failed to address the issue of whether the osteoarthritis of the left hip was aggravated beyond its natural progression by the thoracolumbar spine disability. Cf. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). For this reason, a remand is necessary for another VA examination. 2. The issue of entitlement to an initial disability rating in excess of 10 percent prior to March 6, 2015 for the thoracolumbar spine disability is remanded. In furtherance of this claim, the Veteran was examined by the VA in July 2006 and April 2012. July 2006 Spine VA Examination Report; April 2012 VA Examination Report. Despite her complaints of flare-ups during each of these examinations, neither VA examiner offered an opinion as to the limitation of motion or function during a flare-up episode. Cf. Correia v. McDonald, 28 Vet. App. 158, 170 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). As such, a remand is necessary for an addendum VA medical opinion. 3. The issues of entitlement to an increased disability rating in excess of 10 percent prior to March 6, 2015 for the cervical spine disability; and an increased disability rating in excess of 20 percent from March 6, 2015 for the cervical spine disability are remanded. In this regard, the Veteran has been examined by the VA on three occasions; first in April 2012, then in February 2014 and March 2015. April 2012 Neck Conditions VA Examination Report; February 2014 Neck Conditions VA Examination Report; March 2015 Neck Conditions VA Examination Report. Each of these examinations were conducted prior to the decision in Correia v. McDonald. Correia, supra. For this reason, a remand is appropriate for another VA examination to ensure compliance with the Correia v. McDonald mandates. 4. The issue of entitlement to an initial disability rating in excess of 10 percent for the left upper extremity disability is remanded. With regard to this issue, the Board finds it is inextricably intertwined with the above claims for an increased disability rating in excess of 10 percent prior to March 6, 2015 and in excess of 20 percent from March 6, 2015 for the cervical spine disability given an examination of the cervical spine disability may include findings pertinent to the left upper extremity disability. See Harris v. Derwinski, 1 Vet. App. 180 (1991), overruled on other grounds by Tyrues v. Shinseki, 23 Vet. App. 166 (2009); Anglin v. West, 11 Vet. App. 361, 367 (1998). As such, the issue of an increased disability rating in excess of 10 percent for the left upper extremity disability is also remanded for further development, if necessary. 5. The issue of entitlement to an effective date prior to March 6, 2015 for the grant of TDIU is deferred. With regard to this issue, the Board finds it is also inextricably intertwined with each of the above claims as the resolution of these claims could impact the Board’s assessment of the Veteran’s occupational impairment arising from the combination of her service-connected disabilities prior to March 6, 2015. See Harris, supra; Anglin, supra. As such, the issue of TDIU is deferred until these claims are resolved. The matters are REMANDED for the following action: 1. Contact the Veteran to determine if there are any relevant, outstanding private treatment records. If so, undertake all appropriate development necessary to obtain a copy of these records from each treatment provider and/or facility identified by her. 2. Obtain all relevant, outstanding VA treatment records. 3. Once the first two requests have been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of her claimed bilateral hip disability. After reviewing the claims file, the examiner should: (a.) Identify all current and prior diagnoses of a hip condition, bilateral or otherwise, to include osteoarthritis of the left hip. (b.) Reconcile all prior diagnoses of a hip condition with the current findings. If a prior diagnosis cannot be reconciled with the current findings, explain why. (c.) As to each current diagnosis and prior diagnosis that cannot be reconciled with the current findings, opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s claimed bilateral hip disability was caused by or is otherwise related to her active duty service and explain why. (d.) As to any diagnosis that was not caused by or is not otherwise related to the Veteran’s active duty service, opine as to whether it is at least as likely as not (50 percent probability or greater) it is proximately due to or aggravated beyond its natural progression by her thoracolumbar spine disability and explain why. (e.) In doing so, the examiner should consider and weigh the Veteran’s relevant lay statements of record, to include her testimony during an October 2008 travel Board hearing, her February 2006 and August 2006 letters describing her left hip going out in service and her statements during the March 2015 VA examination that she injured her hips in service in 1985. 4. Once the first two requests have been completed, to the extent possible, obtain an addendum medical opinion from an appropriate medical professional regarding the nature and severity of the Veteran’s thoracolumbar spine disability prior to March 6, 2015. After reviewing the claims file prior to March 6, 2015, the examiner should: Describe the Veteran’s reports of flare-up episodes prior to March 6, 2015, to include his report of flare-ups during the July 2006 and April 2012 VA examinations. If there is any additional limitation of motion during a flare-up, provide an estimate, in degrees if possible, of the limitation of motion. If unable to provide an estimate, explain why. If there is any additional limitation of function during a flare-up, discuss its impact in terms of its severity, frequency and duration. Specifically, if factors such as pain, weakness, fatigability, or incoordination limit range of motion or functional ability during a flare-up, discuss its impact in terms of its severity, frequency and duration. If such factors do not limit range of motion or functional ability during a flare-up, explain why. If an opinion cannot be rendered without resorting to mere speculation, the examiner should state the same and explain why. 5. Once the first two requests have been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the current nature and severity of her cervical spine disability. After reviewing the claims file, the examiner should: (a.) Conduct all tests and examinations deemed necessary, to include range of motion testing with active and passive motions as well as with weight-bearing and in non-weight bearing. If any motion cannot be tested, explain why. If factors, such as pain, weakness, fatigability or incoordination limit range of motion or functional ability, discuss its impact in terms of the severity thereof. (b.) Determine whether the Veteran experiences any flare-up episodes or has any complaints with repeated use over time. If there is any additional limitation of motion during a flare-up or with repeated use over time, provide an estimate, in degrees if possible, of the limitation of motion. If unable to provide an estimate, explain why. If there is any additional limitation of function during a flare-up or with repeated use over time, discuss its impact in terms of its severity, frequency and duration. Specifically, if factors such as pain, weakness, fatigability or incoordination limit range of motion or functional ability during a flare-up or with repeated use over time, discuss its impact in terms of its severity, frequency and duration. If such factors do not limit range of motion or functional ability during a flare-up or with repeated use over time, explain why. If an opinion cannot be rendered without resorting to mere speculation, the examiner should state the same and explain why. 6. Once the above requests have been completed, to the extent possible, readjudicate the appeal. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Suh, Associate Counsel