Citation Nr: 18159311 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 13-04 460 DATE: December 19, 2018 ORDER Entitlement to an initial compensable rating for bilateral sensorineural hearing loss is denied. Entitlement to an initial rating in excess of 50 percent for an acquired psychiatric disorder is denied. Entitlement to an initial rating of 20 percent for sciatica of the left lower extremity prior to February 7, 2017, is granted. Entitlement to an initial rating in excess of 20 percent for sciatica of the left lower extremity since February 7, 2017, is denied. Entitlement to an initial rating of 20 percent for sciatica of the right lower extremity prior to February 7, 2017, is granted. Entitlement to an initial rating in excess of 20 percent for sciatica of the left lower extremity since February 7, 2017, is denied. REMANDED Entitlement to service connection for bilateral tinea pedis is remanded. Entitlement to an initial rating in excess of 10 percent for a right ankle disorder is remanded. Entitlement to a rating in excess of 10 percent for a left knee disorder is remanded. Entitlement to a rating in excess of 10 percent for a right knee disorder is remanded. Entitlement to a rating in excess of 20 percent for a thoracolumbar spine disorder. FINDINGS OF FACT 1. The Veteran demonstrates at worst Level I hearing acuity bilaterally. 2. The Veteran’s acquired psychiatric disorder has not been manifested by symptomology which results, or more nearly approximates, occupational and social impairment with deficiencies in most areas. 3. For the course of the entire appeal, the symptoms of sciatica of the left lower extremity most closely reflected moderate incomplete nerve paralysis. 4. For the course of the entire appeal, the symptoms of sciatica of the right lower extremity most closely reflected moderate incomplete nerve paralysis. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.85, 4.86, Diagnostic Code (DC) 6100 (2018). 2. The criteria for entitlement to an initial rating in excess of 50 percent for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.10, 4.130, DC 9434. 3. The criteria for entitlement to an initial rating of 20 percent for sciatica of the left lower extremity prior to February 7, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.124a, DCs 8620, 8720. 4. The criteria for entitlement to an initial rating in excess of 20 percent for sciatica of the left lower extremity since to February 7, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.124a, DCs 8620, 8720. 5. The criteria for entitlement to an initial rating of 20 percent for sciatica of the right lower extremity prior to February 7, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.124a, DCs 8620, 8720. 6. The criteria for entitlement to an initial rating in excess of 20 percent for sciatica of the right lower extremity since to February 7, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.124a, DCs 8620, 8720. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1996 to August 2000. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Schedule). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Relevant regulations do not require that all cases show all findings specified by the Schedule; however, findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7, 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In establishing an appropriate initial assignment of a disability rating, the proper scope of evidence includes all medical evidence submitted in support of the veteran’s claim. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an assigned disability rating has been challenged or appealed, it is possible for a veteran to receive a staged rating. A staged rating is an award of separate percentage evaluations for separate periods, based on the facts found during the appeal period. Id. at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. 1. Entitlement to an initial compensable rating for bilateral sensorineural hearing loss The Veteran is currently service-connected for bilateral hearing loss rated as noncompensable. Disability evaluations for hearing loss are derived from a mechanical application of the Rating Schedule to the numeric designations resulting from audiometric testing. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Under 38 C.F.R. § 4.85, an examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations are conducted without the use of hearing aids. Table VI, “Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone threshold average intersect. 38 C.F.R. § 4.85. Table VIA, “Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on the puretone threshold average. Table VIA will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. “Puretone threshold average,” as used in Tables VI and VIA, is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. This average is used in all cases (including those in 38 C.F.R. § 4.86) to determine the Roman numeral designation for hearing impairment from Table VI or VIA. Table VII, “Percentage Evaluations for Hearing Impairment,” is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is located at the point where the row and column intersect. During the relevant time period, the Veteran underwent VA audiological examinations in August 2010 and April 2018. At the August 2010 VA audiological examination, puretone thresholds, in decibels, were as follows: HERTZ A 1000 B 2000 C 3000 D 4000 A+B+C+D AVG. RIGHT 30 25 35 20 27.5 LEFT 30 40 31 25 31.5 The puretone threshold average was 27.5 decibels in the right ear and 31.5 in the left ear. The Maryland CNC controlled speech discrimination test scores were 92 percent bilaterally. According to Table VI, both ears are rated at level I. Applying these results to Table VII, the Veteran’s disability is rated as noncompensable. These test results do not show that the Veteran had an exceptional pattern of hearing impairment under 38 C.F.R. § 4.86(a). At the April 2018 VA audiological examination, puretone thresholds, in decibels, were as follows: HERTZ A 1000 B 2000 C 3000 D 4000 A+B+C+D AVG. RIGHT 20 20 25 20 21.25 LEFT 20 25 20 20 21.25 The puretone threshold average was 21.25 decibels bilaterally. The Maryland CNC controlled speech discrimination test scores were 94 percent bilaterally. According to Table VI, both ears are rated at level I. Applying these results to Table VII, the Veteran’s disability is rated as noncompensable. These test results do not show that the Veteran had an exceptional pattern of hearing impairment under 38 C.F.R. § 4.86(a). After reviewing the evidence in the record, the Board finds that the criteria for a compensable rating have not been met. The evidence from the August 2010 and April 2018 VA audiological examinations show that the Veteran is not entitled to a compensable rating. As noted above, disability evaluations for hearing loss are derived from a mechanical application of the Rating Schedule to the numeric designations resulting from audiometric testing. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). During his February 2017 Board hearing, the Veteran testified that he has ringing in his ears at night, and has a difficult time talking on the phone during work. He has otherwise described difficulty distinguishing speech, particularly in the presence of background noise. However, in regards to assigning the proper disability rating, the Board is bound by the explicit criteria stated in the Rating Code. His description of an inability to hear and discriminate speech has been measured according to puretone averages and speech discrimination, and is contemplated by the schedular criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). He has also been assigned a separate 10 percent rating for tinnitus. As to the actual severity of hearing loss, the Board holds that the objective findings of a medical professional relying on audiometric and word list testing are of greater probative value than the lay statements reflected in the record. As the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not applicable. 38 U.S.C. § 5107. 2. Entitlement to an initial rating in excess of 50 percent for an acquired psychiatric disorder For the relevant time period, the Veteran’s acquired psychiatric disorder, to include depression, is rated as 50 percent disabling under DC 9434. Under the General Rating Formula for Mental Disorders, a 50 percent rating is assigned where there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is assigned where there is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsession rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Global assessments of functioning scores are a scale reflecting the “psychological, social and occupational functioning on a hypothetical continuum of mental health-illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), page 32). A global assessment of functioning score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A global assessment of functioning score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A global assessment of functioning score of 61 to 70 indicates the examiner's assessment of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. The global assessment of functioning score assigned in a case, like an examiner’s assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the global assessment of functioning score must be considered in light of the actual symptoms of the veteran’s disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Board also notes that the global assessment of functioning scale was removed from the more recent DSM-5 for several reasons, including its conceptual lack of clarity and questionable psychometrics in routine practice. See DSM-5, Introduction, The Multiaxial System (2013). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to “DSM-IV,” Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fourth Edition (1994). The amendments replace those references with references to the recently updated “DSM-5.” In this case, however, the appeal was certified to the Board prior to August 4, 2014, and DSM-IV applies in this case. See January 2013 Substantive Appeals December 2013 Certification of Appeal. During a September 2010 VA examination, the examiner reviewed the claims file, examined the Veteran, and diagnosed him with a mood disorder secondary to his general medical condition, and anxiety disorder. The examiner noted “moderate” occupational and social impairment, and determined the Veteran had occasional decrease in work efficiency. During the examination, the Veteran was appropriately dressed; had clear speech; constricted affect; anxious mood; intact attention and orientation; unremarkable thought process and thought content; no delusions or hallucinations; unremarkable judgment and insight; no inappropriate or ritualistic behavior; no suicidal or homicidal ideation; fair impulse control; and the ability to maintain personal hygiene. The Veteran did have sleep disturbances and nightmares; daily panic attacks; and some moderate problems associated with daily living. His remote, recent, and immediate memory was normal. The Veteran had sustained employment for “5 to 10 years,” marriage for 13 years, and had a 12-year-old daughter with whom he enjoyed spending time. He reported a good relationship with his father and sisters, but no relationship with his biological mother. During an April 2018 VA examination, the examiner reviewed the claims file, examined the Veteran, and diagnosed him with major depressive disorder and generalized anxiety disorder. The examiner determined that the Veteran exhibited occupational and social impairment with reduced reliability and productivity. The Veteran reported that he had been married for over 20 years; had a very close relationship with his family; had a few friends; and avoided social gatherings. He also reported that he currently worked full-time as a logger. His symptoms included depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; flattened affect; disturbance of mood and motivation; difficulty in establishing and maintaining effective relationships; and difficulty in adapting to stressful circumstances. During the course of the appeal, the Veteran received VA psychiatric treatment. During treatment, he reported symptoms such as difficulty sleeping, irritability, frequent nightmares, anhedonia, lack of recreational activity, avoiding the crowds and family reunions, fluctuating appetite, low energy, difficulty focusing and concentrating, occasional crying spells, and occasional loss of control of his temper with tearing up of items. He described almost constant anxiety with irritability, pacing, restlessness, diaphoresis and rapid heartbeat which occurred 10 times a day. In September 2010 and October 2010, a GAF score of 54 was assigned. In December 2010 and January 2011, a GAF score of 55 was assigned. In April, July and October 2011 as well as February and August 2012, the VA examiner diagnosed PTSD and mild depressive disorder and assigned a GAF score of 60. His mental status examinations were significant for mild depression and blunted or constricted affect. During his February 2017 Board hearing, the Veteran testified that he did not like to leave his basement; did not have any friends; and had a good relationship with his wife. He testified to trout fishing; but also to avoidance of traffic, large crowds, and reunions. At a hearing in 2013, the Veteran testified to sleep impairment with nightsweats, terrible anxiety, and panic attacks. He avoided large crowds, and spent most of his time sitting in a room by himself. The Veteran is competent to report experiencing these symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds the testimony to be credible and probative of the issue on appeal. The Board finds that the Veteran’s symptoms described in the VA examinations, clinic records and the Veteran’s testimony do not rise to the level of symptoms for a 70 percent rating. The record reflects that the Veteran maintains a good relationship with his wife; maintains employment as a logger, and has some recreational activities. He describes recurrent anxiety with panic attacks during the day, and difficulty adapting to stressful circumstances. He had some past issues with anger control and possible excessive use of force as a correctional officer, but none described during the appeal period. He has sleep impairment with nightsweats. Beyond his family relations, he is socially withdrawn and spends most of his time by himself. However, the Veteran’s mental status examinations show no significant impairment of speech, orientation, impulse control, or personal appearance and hygiene. The Veteran is able to establish and maintain effective relationships in the workplace and at home. When considering the frequency, duration and severity of symptoms, the VA examiners opined that the Veteran’s depression was productive of no more than “moderate” occupational and social impairment, and determined the Veteran had occasional decrease in work efficiency. Additionally, the assessments in the VA clinic provided GAF scores ranging from 54 to 60 which are reflective of an overall impairment of psychological, social and occupational functioning that is no more than moderate in degree. Overall, the Board finds by a preponderance of the evidence that the frequency, duration and severity of the Veteran’s symptoms have not met, or more nearly approximated, the criteria for a 70 percent rating for any time during the appeal period. In so deciding, the Veteran’s description of symptoms are deemed credible but as it pertains to the overall effect his symptoms have on his occupational and social impairment, the Board places greater probative weight to the opinions of the VA examiners and clinicians who have greater training to determine how the severity, duration and frequency of symptoms affect employability and social relations. Therefore, a 70 percent rating is not warranted. 3. Entitlement to an initial rating in excess of 10 percent for sciatica of the left lower extremity prior to February 7, 2017 4. Entitlement to an initial rating in excess of 20 percent for sciatica of the left lower extremity since to February 7, 2017 5. Entitlement to an initial rating in excess of 10 percent for sciatica of the right lower extremity prior to February 7, 2017 6. Entitlement to an initial rating in excess of 20 percent for sciatica of the right lower extremity since to February 7, 2017 The Veteran’s left lower extremity sciatica is rated as ten percent disabling from April 15, 2010, to February 6, 2017, under the provisions of 38 C.F.R. § 4.124a, DC 8720; and as 20 percent disabling since February 7, 2017, under DC 8620. His right lower extremity sciatica is identically rated. A neurological disability is evaluated on the basis of nerve paralysis, partial paralysis, neuritis, or neuralgia in proportion to the impairment of motor or sensory function. 38 C.F.R. §§ 4.120-4.124a. Under DCs 8520, 8620, and 8720, mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating; moderate incomplete paralysis warrants a 20 percent rating; moderately severe incomplete paralysis warrants a 40 percent rating; and severe, with marked muscular atrophy warrants a 60 percent rating. 38 C.F.R. § 4.124a. In rating nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, a disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Descriptive words, such as “slight,” “moderate” and “severe,” 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. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The claims file reflects that the Veteran has received private medical treatment from a chiropractor for his spine disorder, including seeking treatment for symptoms such as numbness in his feet and calves. See, e.g., March 2015 and August 2012 Private Medical Records. As early as May 2010, the Veteran sought chiropractic treatment for symptoms that included pain, numbness, cramps, and pins and needles in both legs, and swelling in his feet. His physical findings reflected normal reflexes and strength bilaterally. During a September 2010 VA examination, the Veteran noted symptoms of bilateral sciatica which had become progressively worse over time. He reported numbness, paresthesias, and tingling bilaterally. During the examination, he manifested 1.5 centimeters of muscle atrophy in his left calf compared to his right calf. His right and left extremity strength was normal except for 4/5 strength in right great toe extension as well as left plantar flexion and great toe extension. Reflexes were hypoactive bilaterally. Sensory examination was normal except for decreased pain or pinprick in the left great toe. According to the examiner, the Veteran had decreased mobility and problems with prolonged walking or sitting. At a hearing in September 2013, the Veteran described his bilateral lower extremity symptoms as becoming progressively worse with his legs feeling constantly asleep. He could not sit for prolonged periods of time. During an October 2013 VA examination for the Veteran’s thoracolumbar disorder, the Veteran reported mild paresthesias and/or dysesthesias, and mild numbness in the lower extremities bilaterally. The Veteran also reported intermittent tingling sensations in both legs. Physical examination demonstrated normal muscle strength in all planes of motion, no atrophy, normal reflexes and normal sensory examination bilaterally. The examiner opined that the Veteran manifested mild radiculopathy bilaterally. During an April 2018 VA examination, the Veteran reported mild constant pain bilaterally; moderate intermittent pain bilaterally; moderate paresthesias and/or dysesthesias bilaterally; and moderate numbness bilaterally. He had normal tendon reflexes in the knees and ankles bilaterally. He had decreased, but not absent, sensation in the lower legs, feet, and toes bilaterally. His muscle strength testing of the right lower extremity was significant for 3/5 strength in ankle dorsiflexion, and 4/5 strength in ankle flexion and great toe extension. His left lower extremity was significant for 4/5 strength in knee extension. The Veteran had no muscle atrophy. His sensory examination was significant for decreased sensation in the lower leg/ankle (L4/L5/S1) and foot/toes (L5) bilaterally. His gait was normal. The examiner found that the Veteran’s sciatic nerve demonstrated moderate incomplete paralysis bilaterally. Nerve testing reflected other nerves of the lower extremities were normal. The examiner noted that the Veteran’s nerve conditions, including unrelated upper extremity nerve conditions, had resulted in the Veteran missing 0-to-1 week of work in that past year. In a June 2018 addendum opinion, a different examiner reviewed the evidence and opined that the sciatic is moderate, and there “is objective evidence contained within the C-file (including 2013 Peripheral Nerve DBQ) which demonstrates numbness and tingling which are worse with prolonged standing, sitting, and walking.” During his February 2017 Board hearing, the Veteran testified that his legs go numb when he sleeps at night, and that he experiences constant tingling in the bottom of his feet. Additionally, during a September 2013 regional office hearing, the Veteran testified that the numbness in his feet and legs was progressively getting worse. The Veteran is competent to report experiencing symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds the Veteran’s testimony to be credible and probative of the issues. The Board also notes that the Veteran currently works as a logger and participates in fly fishing. See April 2018 VA Examination; February 2017 Hearing Testimony. During the entire time period on appeal, the evidence reflects that the Veteran has experienced symptoms such as numbness, pain, and tingling in both lower extremities. The evidence also indicates that the Veteran’s condition has worsened at least from a subjective standpoint. During the entire course of the appeal, evidence of record reflects that the Veteran’s symptoms most closely resembled symptoms of moderate incomplete paralysis of the sciatic nerve bilaterally. Evidence contains chiropractic treatment for symptoms such as tingling, numbness, and pain in May 2010. September 2010, October 2013, and April 2018 VA examinations reflect similar symptoms of pain, numbness, and paresthesias bilaterally. The June 2018 addendum opinion, evaluating the bilateral sciatica as moderate, notes evidence as early as 2013 for symptoms of numbness and tingling worsening with prolonged standing, sitting, and walking. The Board can find no substantial difference in the medical evidence of symptoms described in the September 2010 and October 2013 VA examinations. In this respect, these examinations showed similar findings of 4/5 strength in great toe extension bilaterally. Therefore, a rating of 20 percent disabling for sciatica of both the right and left lower extremities is warranted for the entire appeal period. The evidence of record does indicate that the condition is worsening, but at no point in the appeal has either lower extremity manifested “severe” incomplete paralysis. The Veteran’s motor examination for the right lower extremity has generally shown mild (4/5) loss of strength in some planes of motion with 3/5 strength in ankle dorsiflexion in the last VA examination. The Veteran’s motor examination for the left lower extremity has generally shown mild loss of strength in some planes of motion. The Veteran has shown some reflex abnormalities which are not constant. He has decreased sensation in the legs and feet which is not total, and the Veteran has self-described his sensory abnormalities as no more than moderate in degree. There was initial muscle atrophy which has resolved. There are no tropic changes. Functionally, the record reflects that the Veteran is employed as a logger chopping lumber, and enjoys fly fishing for trout. When considering the character of moderate pain, mild to moderate motor strength loss in the right lower extremity, mild loss of strength in the left lower extremity, decreased but not total loss of sensation and slightly abnormal reflexes, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s right and left lower extremity radiculopathy has met or more nearly approximated “severe” incomplete paralysis of the sciatic nerve for any time during the appeal period. REASONS FOR REMAND 1. Entitlement to service connection for bilateral tinea pedis is remanded. The claims file contains two conflicting opinions with the same date and from the same physician regarding the nature and etiology of the Veteran’s tinea pedis. On remand, obtain clarification from that physician or an addendum opinion from an appropriate examiner. 2. Entitlement to a rating in excess of 10 percent for a right ankle disorder is remanded 3. Entitlement to a rating in excess of 10 percent for a left knee disorder is remanded. 4. Entitlement to a rating in excess of 10 percent for a right knee disorder is remanded. 5. Entitlement to a rating in excess of 20 percent for a thoracolumbar spine disorder is remanded. While the record contains contemporaneous VA examinations regarding the Veteran’s left knee, right knee, right ankle and thoracolumbar spine disorders, the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups, and the examiner did not indicate that the speculation was due to lack of knowledge within the medical community. On remand, an additional VA examination is needed. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records since October 2013, and associate them with the claims file. 2. Thereafter, obtain an addendum opinion from the physician who offered the conflicting June 2018 opinions, or from another appropriate examiner, regarding the nature and etiology of the Veteran’s tinea pedis. The addendum opinion should address whether it is at least as likely as not (i.e., 50 percent or greater possibility) that the tinea pedis is etiologically related to service. 3. Schedule the Veteran for an examination of the current severity of his left knee, right knee, right ankle and thoracolumbar spine disorders. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner should request the Veteran to demonstrate the degree of limitation of loss during a flare or repetitive use, and express the Veteran’s limitations in degrees of motion loss if possible. To the extent possible, the examiner should identify any symptoms and functional impairments due to the right ankle disorder alone and discuss the effect of the Veteran’s right ankle disorder on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Howell, Associate Counsel