Citation Nr: 1808911 Decision Date: 02/12/18 Archive Date: 02/23/18 DOCKET NO. 04-44 284 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea. 2. Entitlement to service connection for a left foot disability. 3. Entitlement to an initial rating in excess of 10 percent for thoracic spine compression fracture T6 with spondylosis T6-12, degenerative arthritis, and intervertebral disc syndrome, prior to April 3, 2015; and 40 percent thereafter. 4. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). 6. Entitlement to service connection for a cervical spine disorder. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney-at-Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Martha R. Luboch, Associate Counsel INTRODUCTION The Veteran had active duty service from August 1984 to August 1987. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2003, October 2014, and August 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles and San Diego, California. Jurisdiction of the claims file is with the San Diego RO. The Veteran testified at a travel Board hearing in July 2006 before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The issues discussed included entitlement to an increased rating for a left knee disorder. At his hearing, the Veteran stated that his knee disability made it hard for him to work. In a July 2011 decision, the Board found that the issue of entitlement to a total disability rating based on individual unemployability (TDIU) had been raised by the record. The Board remanded the Veteran's claim so that he could be provided VCAA notice and afforded a VA examination to determine the severity of his service-connected disabilities, which at the time were degenerative joint disease of the right and left knee and tinnitus. The examiner was also directed to describe what type of employment activities would be limited due to the Veteran's service-connected disabilities. A review of the record reveals that the Veteran was given notice in July 2011. In a November 2012 decision, the Board found that the issue of TDIU was under development with the AMC/RO and was not yet ripe for appellate review. The required VA examination was accomplished in March 2014. The issue was adjudicated by the RO in an August 2014 supplemental statement of the case (SSOC). As the issue has been fully developed and adjudicated, it is now properly before the Board. With regard to the issues adjudicated in the October 2014 and August 2015 rating decisions, the Veteran indicated on his April 8, 2016 and April 11, 2016 substantive appeals that he did not want a Board hearing. Therefore, the Board will consider all of the issues properly before it, as indicated on the title page. The Board acknowledges that in July 2017, another Veterans Law Judge granted the Veteran's request for an extension and that 38 U.S.C. § 7102(a) (2012) mandates that the assigned Veteran Law Judge make a determination on the proceeding, including any motion filed in connection therewith. However, because the extension was granted and the undersigned Veterans Law Judge concurs, the Board finds that there is no prejudice to the Veteran. The issues of entitlement to service connection for a cervical spine disorder and entitlement to a total disability rating based on individual unemployability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran's obstructive sleep apnea had its onset in service. 2. Plantar fasciitis of the let foot was caused by his service-connected right knee disability. 3. Prior to January 11, 2011, the Veteran's thoracic spine disability manifested by forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. He did not experience incapacitating episodes having a total duration of at least two weeks but less than four weeks during the prior 12 months. 4. Resolving all reasonable doubt in his favor, since January 11, 2011, the Veteran's thoracic spine disability manifested by muscle spasms severe enough to result in an abnormal spinal contour. 5. From January 11, 2011 to April 2, 2015, the Veteran's thoracic spine disability was not manifested by forward flexion of 30 degrees or less, or favorable anklyosis of the entire thoracolumbar spine. He did not experience incapacitating episodes having a total duration of at least four weeks but less than six weeks during the prior 12 months. 6. From April 5, 2013 to April 2, 2015, the evidence objectively shows that the Veteran experienced left lower extremity radiculopathy that resulted in moderate incomplete paralysis of the sciatic nerve. 7. Prior to April 3, 2015, the Veteran's right lower extremity radiculopathy resulted in no more than moderate incomplete paralysis of the L4-S1 nerve roots. 8. Since April 3, 2015, the Veteran's thoracic spine disability has manifested by forward flexion of 30 degrees or less. His disability has not manifested by ankylosis or incapacitating episodes having a total duration of at least six weeks during the prior 12 months. 9. Since April 3, 2015, the Veteran's left lower extremity radiculopathy has resulted in no more than moderately severe incomplete paralysis of the sciatic nerve. 10. Since April 3, 2015, the Veteran's right lower extremity radiculopathy has resulted in no more than moderate incomplete paralysis of the L4-S1 nerve roots. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1101, 1110, 1154, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). 2. The criteria for entitlement to service connection for plantar fasciitis of the left foot has been met. 38 U.S.C. §§ 1101, 1110, 1154, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. Prior to January 11, 2011, the criteria for a rating in excess of 10 percent for service-connected thoracic spine compression fracture T6 with spondylosis T6-12 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243 (2017). 4. From January 11, 2011 to April 2, 2015, the criteria for a rating of 20 percent for service-connected thoracic spine compression fracture T6 with spondylosis T6-12 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243. 5. Since April 3, 2015, the criteria for a rating in excess 40 percent for service-connected thoracic spine compression fracture T6 with spondylosis T6-12 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243. 6. From April 3, 2013 to April 2, 2015, the criteria for a rating of 20 percent for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 8520; 8720 (2017). 7. Prior to April 3, 2015, the criteria for a rating of 20 percent for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 8520; 8720. 8. Since April 3, 2015, the criteria for a rating in excess of 40 percent for service-connected left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 8520; 8720. 9. Since April 3, 2015, the criteria for a rating in excess of 20 percent for service-connected right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 8520; 8720. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110, 1131 (2012); 38 C.F.R. 3.303(a) (2017). Service connection may be established for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). Establishing service connection on a secondary basis for a disability requires evidence sufficient to show that a current disability was either proximately caused by or was proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a)-(b). (A) Sleep Apnea The Veteran contends that he has sleep apnea as a result of his active duty service. He reported being told he would snore and stop breathing in his sleep during service. The Veteran's service treatment records do not document any complaints, treatment, or diagnosis related to sleep apnea. VA treatment records from February 2011 indicate that the examiner suspected sleep apnea symptomatology. Private treatment records from August 2014 indicate that the Veteran complained of insomnia, snoring, gasping/choking, witnessed pauses in his breathing, morning headaches, teeth grinding, and daytime sleepiness. The examiner noted that the Veteran was diagnosed with moderate Obstructive Sleep Apnea in 2012 and was treated with continuous positive airway pressure (CPAP) at 8-10 cm H2o for optimal treatment. The examiner noted a history of obesity and stated that the findings of sleepiness, snoring, apneas, hypopneas, and desaturations with associated sleep fragmentation, along with the Veteran's clinical history, support a diagnosis of severe Obstructive Sleep Apnea. December 2014 and January 2015 statements submitted by the Veteran's former roommates indicate that while in service, the Veteran would wake up as if scared or gasping for air and would oftentimes snore and seem "to quiet down and even stop breathing." A VA medical opinion was obtained for the Veteran's obstructive sleep apnea in August 2015. After reviewing the Veteran's entire claims file, the examiner opined that the Veteran's obstructive sleep apnea was less likely than not incurred during military service. As rationale, the examiner stated that the Veteran was 22 at separation in August 1987. The examiner noted that there was no separation weight found, but the Veteran weighed 168 pounds in July 1987. The examiner concluded that this likely meant that the Veteran gained at least 32 pounds, and possibly more, since separation to the time of his sleep study. Using a weight of 168 pounds, the examiner stated that the Veteran was normal weight, or just barely overweight at separation, which would make obstructive sleep apnea less likely. The examiner stated that "as weight gain is the strongest risk factor for [obstructive sleep apnea], and aging is the second strongest risk factor (he aged 27 years after separation), he likely developed [obstructive sleep apnea] after separation due to aging and gaining 32 lbs. His weight gain was about 20 percent; this would have increased his risk of [obstructive sleep apnea] at least 6-fold." The Veteran submitted a private medical opinion dated in August 2017. After reviewing the Veteran's entire claims file, the examiner opined that it was more likely than not that the Veteran developed sleep apnea during service. The examiner noted the buddy statements which indicate that the Veteran had possible sleep apnea symptomatology during service. The examiner stated: "as the 2015 Compensation and Pension examiner notes, the Veteran gained over 30 pounds since service and this increase in weight placed him at an increased risk for development of sleep apnea. What she fails to note is that the Veteran gained 11 pounds in service and had already exhibited symptoms of sleep apnea during service." The evidence is clear that the Veteran has a current diagnosis of obstructive sleep apnea. Additionally, the Veteran has asserted that he experienced snoring and trouble sleeping in service. Therefore, the first and second elements of service connection are met and the remaining question therefore becomes whether there is a so-called "nexus" between the Veteran's claimed in-service snoring and sleep trouble and his current sleep apnea. As noted, there are two medical opinions of record. In August 2015, the VA examiner opined that the Veteran's obstructive sleep apnea was less likely than not incurred during military service. Essentially, the examiner found that because the Veteran left service at a "normal weight" and gained 32 pounds post-service, it was more likely that his sleep apnea developed post-service as this increase in weight "increased the Veteran's chances of developing sleep apnea at least six-fold." The August 2017 private examiner agreed that weight gain is the strongest risk factor for the development of obstructive sleep apnea. The examiner then noted that the Veteran additionally gained weight in-service and thus, given that, coupled with the statements submitted by the Veteran and his "buddies" which indicate that he had obstructive sleep apnea symptomatology in service, it was at least as likely as not that the Veteran's obstructive sleep apnea developed during service. The Board affords more probative weight to the August 2017 private medical opinion as the examiner considered the statements put forth by the Veteran and his former roommates. Both examiners agreed that weight gain is the strongest risk factor but the August 2015 VA examiner did not consider the Veteran's in-service weight gain and his reports of in-service symptomatology. In addition, the August 2017 opinion provides a clear conclusion and rationale and is supported by medical literature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for obstructive sleep apnea is warranted. (B) A left foot disability The Veteran contends that his bilateral plantar fasciitis is related to service. In the alternative, the Veteran contends that it is secondary to his service-connected disabilities. The Veteran's service treatment records document that he complained of left foot pain in December 1985. On separation, there were no complaints related to the feet. VA treatment records from August 2014 show that the Veteran had bilateral plantar fasciitis, more severe on the left. The Veteran was afforded a VA examination for his feet in April 2015. The examiner stated that there were no medical records to show that due to the Veteran's original injury, he developed flat feet or chronic foot pain with ensuing degenerative changes and therefore it was less likely than not that the Veteran's plantar fasciitis was related to service. In support of his conclusion, the examiner noted several instances of the Veteran having knee and ankle issues. The Veteran submitted a private medical opinion in August 2017. The examiner noted the Veteran's diagnosis of bilateral plantar fasciitis. After reviewing the entire record, the examiner stated: It is my medical opinion that it is more likely than not that the Veteran's bilateral plantar fasciitis is caused by his abnormal gait pattern and continued instability of his service-connected right knee, as well as weight gain from his service-connected bilateral knee disability. As noted in the literature below, obesity, as well as abnormal gait pattern, are risk factors for development of plantar fasciitis. Here, the evidence is clear that the Veteran has a diagnosis of bilateral plantar fasciitis. See August 2014 VA Podiatry Report. Additionally, he has stated that he believes his plantar fasciitis is due to his service-connected disabilities. Therefore, the remaining question is whether there is a so-called nexus between the Veteran's service-connected disabilities and his plantar fasciitis. As noted above, there is one medical opinion of record that addresses secondary service-connection. The Board finds the August 2017 medical opinion highly probative as it was based on a review of the evidence, the examiner considered the Veteran's lay contentions, and he provided a clear conclusion with a supporting rationale. The opinion is supported by medical literature. In addition, it could be argued that the April 2015 VA examiner also felt that there was a connection between the Veteran's plantar fasciitis and his service-connected knee disability as he seemed to suggest as much in his rationale for why the Veteran's plantar fasciitis was not directly caused by service. As such, the Board finds that the Veteran's plantar fasciitis was caused by his service-connected right knee disability and therefore service connection is warranted on a secondary basis. II. Increased Disability Ratings Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal exertion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca, 8 Vet. App. 202; 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Disabilities of the spine are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. IVDS is rated under Diagnostic Code 5243 and is to be evaluated under the General Rating Formula unless it is more favorable to rate under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides for a 10 percent 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. A 20 percent disability rating when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or when the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The General Rating Formula provides further guidance in rating diseases or injuries of the spine. In pertinent part, Note (1) provides that any associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion, extension, and bilateral flexion of the cervical spine is zero to 45 degrees, and bilateral rotation is zero to 80 degrees. Note (2) further provides that, for VA compensation purposes, 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 is 340 degrees for the cervical spine and 240 degrees for the thoracolumbar spine. 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. Alternatively, the IVDS Formula provides for a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. In addition, Diagnostic Code 8520 provides the rating criteria for evaluation of paralysis of the sciatic nerve. Under this provision, moderate incomplete paralysis warrants a 20 percent disability evaluation; moderately severe incomplete paralysis warrants a 40 percent evaluation; and, severe, with marked muscular atrophy, incomplete paralysis warrants a 60 percent disability evaluation. An 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, with no active movement possible of muscles below the knee, with flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520; 8720. The term "incomplete paralysis," with these and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. Facts Private treatment records from March 2010 show that the Veteran was given a lumbar MRI. The MRI showed a 2mm disc bulge without neural foraminal narrowing at L1-2; a 3mm disc bulge without central or lateral spinal stenosis at L2-3; a 4mm disc bulge with mild bilateral facet hypertrophy as well as mild to moderate central canal narrowing and mild right neural foraminal narrowing at L3-4; a 3 to 4 mm disc bulge and severe bilateral facet hypertrophy as well as severe central canal narrowing with mild bilateral neural foraminal narrowing at L4-5; and a 3mm disc buldge and moderate bilateral facet hypertrophy with mild central canal narrowing at L5-S1. Private treatment records from January 11, 2011 indicate that the Veteran had "paravertebral muscle spasm bilaterally, as well as flattening of the lumbar spine." An August 2011 X-ray of the spine showed that the Veteran had mild lumbar spine curvature/scoliosis with minimal spondylosis. There was no significant degenerative disease. The Veteran had flexion to 90 degrees and lateral flexion to 35 degrees. Pin prick was intact in the lower extremities. VA treatment records from November 2011 show that the Veteran complained of numbness in the scrotal, buttock, posterior thighs and calf down to the feet for several years. He denied any bowel/bladder incontinence. His back pain improved by flexion but worsened by extension. He reported his pain slightly improved by Tylenol and over-the-counter anti-inflammatories. A December 16, 2011 VA MRI report indicates "there is normal anatomic alignment of the lumbar spine. The vertebral bodies heights are maintained. There is mild disc space narrowing at L3-4 and mild disc desiccation. No bone marrow signal abnormalities are seen. The conus terminates at the level of T12-L1. The spinal cord demonstrates normal morphology and signal characteristics." The impression was "mild to moderate multilevel neuroforaminal narrowing as described" and "stable 20% anterior compression fracture at T8. Mild degenerative disc disease at T7-8 and T8-9, with mild spinal stenosis at T7-8. Probable osseous hemangiomas at T9 and T10." VA treatment records from July 2012 show that the Veteran complained of chronic mid and low back pain with radiation down his right lower extremity at times. He denied any muscle spasms. VA treatment records from April 5, 2013, show that the Veteran had "lumbar radiculopathy with severe spinal stenosis at L4-5 and moderate spinal stenosis at L3-4 and mild to moderate multilevel neuroforaminal narrowing." The Veteran had flexion to 90 degrees. VA treatment records from July 2013 show a diagnosis of cervical and lumbar radiculopathy with central canal and neural foraminal stenosis. An MRI from June 2014 shows that the Veteran had "redemonstration of multilevel degenerative changes of the lumbar spine resulting in severe spinal stenosis at L4-5 and mild/moderate spinal stenosis at L3-4 with varying degrees of neural foraminal narrowing. Other VA treatment records from June 2014 show that the Veteran complained of chronic low back pain with radiation down his bilateral lower extremities at times. He reported getting a local injection. VA treatment records from July 2014 show that the Veteran was given a bilateral lumbar facet steroid joint injection at L3-4, L4-5, and L5-S1; a left SI joint steroid injection; and a lumbar epidural steroid injection at L5-S1. The Veteran was afforded a VA examination for his spine in September 2014. He reported flare-ups that caused intense lower back pain with burning sensation, stinging, pain radiating down his buttocks, back of legs, and down to the sides of his feet. He reported losing time at work due to back pain. He had pain with sitting, prolonged walking, and standing. On examination, he had forward flexion to 65 degrees with pain beginning at 65 degrees; extension to 20 degrees with pain beginning at 20 degrees; bilateral lateral flexion to 20 degrees with pain beginning at 20 degrees; and bilateral lateral rotation to 20 degrees with pain beginning at 20 degrees. He was able to perform repetitive use testing with no additional loss of motion. The examiner noted that there were contributing factors of pain, weakness, fatigability and/or incoordination but no additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time. The Veteran had localized tenderness but did not have guarding or muscle spasms. Muscle strength testing was normal. Sensation to light touch was normal on the left but decreased in the right thigh/knee, lower leg/ankle, and foot/toes. Straight leg testing was negative bilaterally. The examiner noted that the Veteran did not experience any constant pain but had severe intermittent pain; mild paresthesias and/or dysesthesias; and mild numbness in the right lower extremity. The examiner opined that the severity of the Veteran's right lower extremity radiculopathy was mild and his left lower extremity was not affected. The Veteran did not report any other neurological abnormalities. The examiner noted that the Veteran had IVDS of the thoracolumbar spine but did not have any incapacitating episodes in the 12 months prior due to IVDS. VA treatment records from October 2014 document that the Veteran reported chronic lower back pain that radiated to his feet bilaterally. He reported his pain being eight out of 10. VA treatment records from November 2014 document that the Veteran complained of worsening lumbago pain as well as worsening numbness from his buttocks down his bilateral lower extremities in the "last few months." He stated he felt like he had "a dump truck on my lower back." He reported a burning sensation that went toward the front, scrotum area. VA treatment records from January 2015 document that the Veteran had lumbar spondylosis over L3/4, L4/5, L5/S1, with 3-6 months relief from lumbar facet injections. Severe central stenosis with neurogenic claudication at L4/5 was noted. Other VA treatment records from January 2015 show that the Veteran complained of worsening back pain. He stated that it was mostly in his lower left back. VA treatment records from January 20, 2015 indicate that the Veteran "ask[ed] for off work for this week until he sees the pain clinic doctor. Consulted with Dr. P for advise, MD advised that [the Veteran] needs to be seen by PWI for further evaluation before off work note is completed." VA treatment records from January 26, 2015 indicate that the Veteran underwent radiofrequency nerve ablation with fluoroscopy for his lower back pain. VA treatment records from February 2015 indicate that the Veteran experienced chronic low back pain with radiation down his bilateral extremities. He reported that his lower extremities had been "flaring up lately." He denied any bowel or bladder incontinence. Other VA treatment records from February 2015 indicate that "[the Veteran] may remain off work as heavy equipment operator (no prolonged standing; no bending/stopping/lifting/climbing) from 2/27-3/5/15." VA treatment records from March 2015 document that the Veteran reported 10 out of 10 pain that was reduced to six out of 10 back pain on medications. He stated facet steroid injections had given him four to six months relief in the past and that SI joint injections helped in the past with up to two months of relief. The Veteran was afforded another VA examination for his spine in April 2015. On examination, he reported having constant pain as well as stiffness with dull to sharp pain at times with a very sharp stabbing pain right in the middle of his back. He had constant pain throughout his entire spine (no flare-ups). On examination, he had forward flexion to 20 degrees with pain beginning at 20 degrees; extension to 15 degrees with pain beginning at 15 degrees; bilateral lateral rotation to 20 degrees with pain beginning at 20 degrees; and bilateral lateral flexion to 20 degrees with pain beginning at 20 degrees. He was able to perform repetitive use testing with no additional loss of motion. The examiner noted that the Veteran had guarding or muscle spasms severe enough to result in abnormal gait. He experienced moderate constant pain; no intermittent pain; moderate paresthesias; and moderate numbness due to his left lower extremity radiculopathy. The examiner stated that there were no signs or symptoms of radiculopathy of the right lower extremity. Muscle strength testing was 5/5 and there was no muscle atrophy bilaterally. Deep tendon reflexes were hypoactive bilaterally in the knee and ankle. Sensory findings were normal for the right lower extremity and decreased in the thigh/knee and foot/toes of the left lower extremity. The examiner opined that the Veteran's left lower extremity radiculopathy was mild. The examiner noted that the Veteran experienced IVDS of the thoracolumbar spine and that he had at least two weeks but less than four weeks of incapacitating episodes in the 12 months prior. (A) Rating in excess of 10 percent for thoracic spine compression fracture T6 with spondylosis T6-12, degenerative arthritis, and intervertebral disc syndrome, prior to April 3, 2015 Prior to April 3, 2015, the Veteran has been awarded a 10 percent rating for his thoracic spine compression fracture under Diagnostic Code 5243. The Veteran's attorney contends that the Veteran is entitled to a 20 percent evaluation from January 11, 2011, based on evidence of scoliosis caused by muscle spasms. First, the Board will consider whether the Veteran is entitled to a higher rating based on range of motion for the entire appeal period prior to April 3, 2015 (to include prior to January 11, 2011). Here, at worst, prior to April 3, 2015, the Veteran had forward flexion to 65 degrees with pain beginning at 65 degrees, even after repetitive use testing. The Veteran did not report, and the objective evidence does not show, any additional loss of function during flare-ups or repeated use over time. In addition, his combined range of motion was 165, greater than 120 degrees. Of note, while the Veteran had flexion to 65 degrees of VA examination in September 2014, all other range of motion testing showed flexion to 90 degrees. Further, at no time has the Veteran claimed or demonstrated favorable or unfavorable ankylosis. Thus, the medical evidence does not suggest that the Veteran's low back disability was of the severity to warrant a rating in excess of 10 percent for this period based on range of motion. The Board does not dispute that private and VA treatment records generally note the presence of chronic pain. However, the records do not show other symptomatology to warrant a higher rating based on limitation of motion. Even in consideration of pain, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent under DC 5242. In this regard, the Board has considered whether repetitive motion and/or flare-ups resulted in additional functional loss due to symptoms such as pain, swelling, weakness, fatigue, or incoordination. However, as demonstrated during the September 2014 VA examination, the Veteran had pain on motion, but there is no indication that such resulted in additional functional loss, to include a greater loss of flexion. Indeed, the Veteran did not report additional loss of motion during flare-ups at his September 2014 VA examination. Therefore, the Board finds that such factors do not result in functional loss more nearly approximating flexion limited to 60 degrees or a total range of motion of 120 degrees or less. See DeLuca, supra; Mitchell, supra. As such, the medical evidence indicates that a rating in excess of 10 percent is not warranted for the Veteran's thoracic spine disability prior to January 11, 2011. Additionally, a rating in excess of 20 percent is not warranted from January 11, 2011 based on range of motion. However, the Board finds that a 20 percent rating is warranted from January 11, 2011. Specifically, the evidence of record establishes that the Veteran was noted to have "paravertebral muscle spasm bilaterally, as well as flattening of the lumbar spine." Later x-rays confirmed mild lumbar spine curvature/scoliosis. The Board acknowledges that the evidence does not necessarily establish that the muscle spasms were the cause of the curvature, as required under the General Rating Formula for the spine. However, when resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence is sufficient to show that the Veteran had muscle spasms as well as spinal curvature during the same time; thus suggesting a relationship between the two. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014)("By requiring only an 'approximate balance of positive and negative evidence' the Nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits."). As a result, the Board finds that a 20 percent rating is warranted from January 11, 2011. This represents a full grant of the benefit sought by the Veteran, through his attorney, prior to January 20, 2015. See A.B. v. Brown, 6 Vet. App. 35 (1993) (a Veteran may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability). The Veteran's attorney has also contends that "the incapacitating episodes, which had a total duration of at least four weeks during the last 12 months, met the criteria for a 40 percent evaluation of IVDS earlier than April 3, 2015. As such, an earlier effective date of January 20, 2015, should be granted for the 40 percent evaluation." First, the Board does not dispute that the evidence of record is clear that the Veteran was put on "complete rest for acute chronic low back pain from February 27, 2015 to March 15, 2015" or for a 17 day period (in excess of two weeks). The Veteran's attorney further contends that "VA treatment records from January 2015 indicate that the Veteran was unable to work from January 20, 2015 to February 3, 2015, due to back pain." However, "incapacitating episodes" are clearly defined under the rating criteria as "a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." VA treatment records from January 20, 2015 show that the Veteran "ask[ed] for off work for this week until he sees the pain clinic doctor. Consulted with Dr. P for advise, MD advised that [the Veteran] needs to be seen by PWI for further evaluation before off work note is completed." Later records from January 26, 2015 note that the Veteran underwent radiofrequency nerve ablation with fluoroscopy for his lower back pain. This was administered by the VA pain clinic. There are no VA treatment records indicating that the Veteran was actually prescribed bedrest during this time period. Indeed, on VA examination in April 2015, the examiner specifically noted that the total duration of all incapacitating episodes in the 12 months prior was at least two weeks but less than four weeks. As noted, this is consistent with the evidence of record. Thus, because being unable to work does not necessarily equate to bedrest and there is no indication in the treatment records that the Veteran was actually prescribed bedrest from January 20, 2015 to February 3, 2015, the Board finds that the criteria for a 40 percent for IVDS based on incapacitating episodes is not warranted prior to April 3, 2015. The Veteran's attorney also contends that "the evidence of record supports staged ratings for radiculopathy of the left sciatic nerve and a separate evaluation for radiculopathy of the right lower extremity." The Veteran's attorney points to a December 16, 2011 MRI report. She contends that the MRI report diagnosed the Veteran with lumbar spinal stenosis, lumbar radiculopathy, and lumbar facet pain. The Board has carefully reviewed the extensive evidence of record, to specifically include the noted MRI report. A review of the MRI report indicates the reason for the examination was, inter alia, because the Veteran experienced numbness in the buttocks, scrotal area, and posterior leg down to feet. The findings state "there is anatomic alignment of the lumbar spine. The vertebral bodies heights are maintained. There is mild disc space narrowing at L3-4 and mild disc desiccation. No bone marrow signal abnormalities are seen. The conus terminate at the level of T12-L1. The spinal cord demonstrates normal morphology and signal characteristics." The MRI does not reference a diagnosis of "lumbar radiculopathy." Instead, VA treatment records from April 5, 2013, indicate "a/p [assessment/plan]: 1. Lumbar radiculopathy with severe spinal stenosis at L4-5 and moderate spinal stenosis at L3-4 and mild to moderate multilevel neuroforaminal narrowing". This is the first diagnosis of lumbar radiculopathy noted in the Veteran's treatment records. The examiner did not indicate which extremity was affected. However, resolving all reasonable doubt in favor of the Veteran, the Board finds that a separate rating for left lower extremity radiculopathy is warranted from April 5, 2013. The Veteran is already service-connected for right lower extremity radiculopathy from September 21, 2010. With regard to the severity of the Veteran's bilateral radiculopathy, the Board acknowledges the contentions put forth by the Veteran's attorney. Specifically she contends that "the evidence is demonstrative of more than mild incomplete paralysis . . . and a separate 20 percent evaluation should be assigned for moderate incomplete paralysis of the right lower extremity." She further contends that "as the Veteran was diagnosed with radiculopathy of the left lower extremity since December 16, 2011, he is entitled to at least a 20 percent evaluation from that date." And finally "an earlier effective date of July 19, 2013, should be granted for the 40% evaluation for radiculopathy of the left lower extremity based on evidence of an increase in severity requiring regular lumbar facet steroid joint injections." Here, prior to April 3, 2015, the Veteran's complaints related to his bilateral lower extremity radiculopathy have been wholly sensory. As noted, VA treatment records are replete with complaints of chronic lower back pain radiating to the bilateral lower extremities. Additionally, on VA examination in September 2014, the Veteran was noted to have no constant pain; severe intermittent pain; mild paresthesias; and mild numbness in the right lower extremity. The examiner opined that the Veteran's right lower extremity radiculopathy was mild in nature. The examiner additionally opined that the Veteran's left lower extremity was not affected. The September 2014 VA examination report shows that muscle strength testing was normal; there was no muscle atrophy; reflex examination was normal; and straight leg raise testing was negative. The rating criteria specifically state that the when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Here, the Board finds that a rating of 20 percent is warranted for right lower extremity radiculopathy prior to April 3, 2015 and for left lower extremity radiculopathy from April 5, 2013, as that is the first indication of a diagnosis of lumbar radiculopathy for the left lower extremity. While the VA examiner stated that the Veteran only experienced mild paresthesias and mild numbness in the right lower extremity, the Board notes that the Veteran had frequently complained of numbness radiating into his bilateral lower extremity that appeared to be more than mild. Specifically, VA treatment records from November 2014 document that the Veteran experienced a worsening of the numbness as well as a burning sensation that went toward the front, scrotum area. In addition, he has consistently reported chronic and extreme pain radiating into his bilateral extremities. Thus, the Board finds that prior to April 3, 2015, a 20 percent rating, but no more, for right lower extremity radiculopathy is warranted and from April 5, 2013, a separate 20 percent rating for left lower extremity radiculopathy is warranted. With regard to the arguments put forth by the Veteran's attorney that he is entitled to a rating of 40 percent prior to April 5, 2013, for his left lower extremity radiculopathy, the Board acknowledges that the Veteran experienced an increase in severity of his lower back pain which required lumbar facet steroid joint injections. However, as indicated by the Veteran's attorney, and supported by the VA treatment records, the Veteran's increase in injections was due to lower back pain. Even assuming that the pain radiated into the Veteran's lower extremities and the Veteran experienced severe constant pain; pain is a sensory symptom contemplated by the 20 percent rating. There is no evidence of symptoms which were more than sensory prior to April 3, 2015. Further, at no point did the Veteran demonstrate marked muscular atrophy or complete paralysis. Finally, the Board notes that at no point prior to April 3, 2015 did the Veteran complain of, nor does the evidence of record demonstrate, that he experienced any other neurological abnormalities related to his service-connected thoracic spine disability. In sum, a rating of 20 percent is warranted from January 11, 2011 for muscle spasms severe enough to result in abnormal spinal contour; a 20 percent rating is warranted for right lower extremity radiculopathy prior to April 3, 2015; and a separate 20 percent rating is warranted left lower extremity radiculopathy from April 5, 2013 to April 2, 2015. (B) Rating in excess of 40 percent for thoracic spine compression fracture T6 with spondylosis T6-12, degenerative arthritis, and intervertebral disc syndrome, since April 3, 2015. Since April 3, 2015, the Veteran's thoracic spine compression fracture is rated as 40 percent disabling under Diagnostic Code 5243. Under the General Rating Formula for Diseases and Injuries of the Spine, a higher 50 percent rating is warranted only when there is unfavorable ankylosis of the thoracolumbar spine, or a 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a. Initially, the Board notes that it is aware of the Court's decision in Correia v. McDonald, 28 Vet. App. 158 (2016) (holding that §4.59 requires that the listed range of motion testing be conducted to the extent practicable in all cases involving joint disabilities). The Board acknowledges that the Veteran's most recent VA examination does not contain testing on active and passive motion. However, given that the Veteran is receiving the maximum rating based on limitation of motion of the spine and a higher rating requires anklyosis, there is no prejudice to the Veteran in the VA examination not having conformed to 38 C.F.R. § 4.59 as interpreted by Correia and a remand would result in additional burdens to VA, with no additional benefit to the Veteran. The Court has held that such remands are to be avoided. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Generally, ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999). Note (5) of the General Rating Formula states that, for VA compensation purposes, unfavorable ankylosis is a condition in which the thoracolumbar spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin of the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in a neutral position (zero degrees) always represents favorable ankylosis. In this case, there have been no findings of ankylosis. Specifically, on VA examination in April 2015, although limited, the Veteran's spine had range of motion, and no ankylosis was noted. In addition, the Veteran, nor his attorney, has advanced any contentions indicating that his spine is now fixed. Indeed, the Veteran has submitted private treatment records from March 2017 indicating that he had chronic back pain that limits "much of his range of motion"; however, these records do not document that he has no range of motion at all. Collectively, these findings demonstrate that the Veteran's thoracic spine is not fixed, and there is no diagnosis of ankylosis of the thoracolumbar spine or the entire spine. Therefore, a rating higher than 40 percent from April 3, 2015, under the General Rating Formula is not warranted. The General Rating Formula also provides that neurologic abnormalities associated with a spine condition are to be rated separately. Here, the Veteran has been assigned a 40 percent rating for left lower extremity radiculopathy since April 3, 2015. In addition, the Board has awarded a 20 percent rating for the Veteran's right lower extremity radiculopathy. With regard to the Veteran's right lower extremity radiculopathy, the Board notes that on most recent examination, the examiner found that there was no radiculopathy involving the right lower extremity. However, private treatment records from March 2017 indicate that the Veteran continued to experience numbness and tingling in his bilateral lower extremities. Thus, the Board finds that a continuation of the 20 percent rating, and no more, is warranted for this time period. The Veteran has not demonstrated a worsening in severity of his right lower extremity radiculopathy. As noted, the Veteran's left lower extremity radiculopathy is rated as 40 percent disabling from April 3, 2015. In order to warrant a 60 percent rating, there must be marked muscular atrophy. As noted on VA examination, muscle strength testing was 5/5 and there was no muscle atrophy. Recent private treatment records also do not establish any atrophy, much less marked atrophy. Thus, a rating in excess of 40 percent for left lower extremity radiculopathy is not warranted. There are no other complaints or findings of additional neurologic abnormalities associated with the Veteran's service-connected spine disability. The Veteran has not complained of, or been treated for, bowel or bladder impairment during the period on appeal. Of note, he has denied such symptoms throughout the entire appeal period. Therefore, additional separate ratings for associated neurologic abnormalities, other than those already assigned, are not warranted. Finally, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes allows for a higher 60 percent rating if the Veteran's thoracic spine condition results in incapacitating episodes having a total duration of 6 weeks during a 12-month period. 38 C.F.R. § 4.71a. The evidence of record reflects that since April 3, 2015, the Veteran was prescribed bed rest from July 27, 2016 to August 8, 2016. This does not equate to incapacitating episodes having a total duration of 6 weeks during a 12-month period. As a result, a higher for IVDS based on incapacitating episodes is not warranted. The Board has also considered whether any additional Diagnostic Codes are applicable; however, the Board finds that the ratings for the spine and nerves are the most appropriate. In reaching these conclusions, the Board has considered any additional functional limitation due to factors such as pain, weakness, incoordination, or fatigability. See 38 C.F.R. §§ 4.40 and 4.45; Deluca v. Brown. In considering additional limitation of function, the Board acknowledges the Veteran's complaints of severe chronic pain. These complaints are well documented in the Veteran's treatment records. However, the Board has considered the Veteran's functional limitations based on pain and finds that the current rating appropriately compensates the Veteran for his symptoms. Indeed, whereas here, the Veteran is already receiving the maximum disability rating for limitation of motion, 38 C.F.R. §§ 4.40 and 4.45 are not applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). To the extent that the Veteran has asserted that his symptoms are more severe than what is represented by a 40 percent rating, the Board notes that the Veteran is competent to give evidence about what he experiences; for example, he is competent to discuss current pain and other experienced symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that the totality of the evidence indicates the current 40 percent rating appropriately compensates the Veteran's symptoms. The medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his disability. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation from April 3, 2015. For all these reasons, a rating higher than 40 percent for the Veteran's thoracic spine disability, from April 3, 2015, is not warranted. As the preponderance of the evidence reflects the symptoms of the Veteran's thoracic spine disability do not more nearly approximate the criteria for a rating higher than 40 percent, the benefit of the doubt doctrine is not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. (C) Extraschedular Consideration The Veteran's attorney has raised the issue of extraschedular consideration. Specifically, she contends that "referral for extraschedular consideration is warranted for marked interference with employment due to the frequency the Veteran has taken time off from work due to his back disability." The Board has considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration. 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. Here, the evidence suggests that the Veteran's symptomatology is reasonably contemplated by the schedular rating criteria discussed above. The Veteran's thoracic spine disability was applied to the applicable rating criteria, general counsel opinions, and case law. Although the Diagnostic Codes allow for higher ratings, the Board fully explained why higher schedular ratings were not warranted. Moreover, the evidence does not suggest that the Veteran's thoracic spine disability is unique or unusual in any way. There is no question that he experiences symptoms from his thoracic spine disability and associated neurological abnormalities including chronic radiating pain and limited range of motion. The Board has considered the Veteran's chronic pain and limited range of motion as well as associated pain and numbness in the bilateral lower extremities in the schedular ratings that are assigned, as the Board is required to consider functional limitations such as pain in assessing orthopedic injuries. See 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). As such, these symptoms were contemplated within the consideration of the schedular ratings. In addition, the Board notes that 38 C.F.R. § 4.1 specifically states that "generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." While the Veteran may experience some symptoms that are not specifically enumerated in the rating schedule, the Board is charged with considering how functionally impaired the Veteran's disabilities render him within the confines of the schedular rating that is assigned. The Board acknowledges that the Veteran has missed work to get lumbar facet injections to help with the pain associated with his lumbar spine disability and associated neurological abnormalities. However, this treatment does not suggest that an extraschedular rating is appropriate as injections are not a symptom of the Veteran's thoracic spine disability, but rather is a medical technique for treating symptoms associated with his disability, in this case, pain. The fact that the Veteran undergoes injection therapy does not make his thoracic spine disability unique or unusual, as it would be expected that someone who has chronic lumbar spine pain would receive injections intended to mitigate his symptomatology. As such, the schedular rating criteria reasonably describe the symptoms caused by the service-connected disabilities on appeal, and therefore referral for consideration of an extraschedular rating is not warranted. Finally, the issue of a total disability rating based on individual unemployability will be addressed in the remand portion of the decision below. ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for bilateral plantar fasciitis is granted. Entitlement to an initial rating in excess of 10 percent for thoracic spine compression fracture T6 prior to January 11, 2011, is denied. Entitlement to a rating of 20 percent from January 11, 2011 for thoracic spine compression fracture T6 is granted. Entitlement to a separate 20 percent rating for left lower extremity radiculopathy from April 5, 2013, is granted. Entitlement to a rating of 20 percent for right lower extremity radiculopathy prior to April 3, 2015, is granted. Entitlement to a rating in excess of 40 percent from April 3, 2015, for thoracic spine compression fracture T6, is denied. Entitlement to a rating in excess of 40 percent from April 3, 2015, for left lower extremity radiculopathy is denied. Entitlement to a rating in excess of 20 percent from April 3, 2015, for right lower extremity radiculopathy is denied. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. The Veteran seeks entitlement to service connection for a cervical spine disorder. On VA examination in April 2015, a diagnosis of spondylosis with degenerative disc disease and neuroforaminal narrowing, cervical spine, was noted. The Veteran contends that his cervical spine disorder is a result of his service-connected bilateral knee disabilities. The examiner opined that the Veteran's cervical spine disorder is less likely than not proximately due to or the result of the Veteran's service-connected bilateral knee disabilities. However, the examiner did not address whether his non-service connected cervical spine disorder was aggravated by his service-connected bilateral knee disabilities. In addition, as noted by the Veteran's attorney, the examiner did not address whether the Veteran's cervical spine disorder was directly related to service or as secondary to his service-connected thoracic spine disability. Therefore, an addendum opinion is necessary. In addition, throughout the appeal period, the records indicate that the Veteran continued to work as a heavy equipment operator. However, recent private treatment records state that the Veteran "has been unable to work for many years now because of the chronic back pain associated with numbness and tingling in his bilateral legs." On most recent examination in April 2015; however, the Veteran was noted to be working. In addition, the Veteran's attorney did not advance any argument with regard to a TDIU in her most recent brief. Further, the Veteran has not filed an application for a total disability rating based on individual unemployability (TDIU). Thus, the evidence of record is at best unclear if the Veteran is still working and if not, when he stopped working. Therefore, a remand is necessary to afford him an opportunity to file a VA Form 21-8940 and provide additional evidence as to when he stopped working. Further, given the grants of service-connection for sleep apnea and plantar fasciitis, the Board finds that deferral of consideration of TDIU is appropriate until those disabilities have been rated. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an opportunity to file a VA Form 21-8940 (application for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU)). In particular, the Veteran should indicate when he stopped working and which service-connected disabilities he believes are the cause. 2. Obtain an addendum opinion from the April 2015 VA examiner who provided an opinion on the Veteran's cervical spine disorder. The examiner is asked to consider the medical literature submitted by the Veteran's attorney which indicates that "adjacent segment disease can affect both the cervical and lumbar spine, stemming from existing spondylosis at adjacent levels, predisposed risk to degenerative changes, and altered biomechanical forces near a previous fusion site." The examiner should again review the Veteran's entire claims file and provide the following opinions: (a) Whether it is at least as likely as not that the Veteran's cervical spine disorder is directly due to service; (b) Whether it is at least as likely as not that the Veteran's service-connected bilateral knee disabilities aggravated his cervical spine disorder; (c) Whether it is at least as likely as not that the Veteran's service-connected back disability caused the Veteran's cervical spine disorder; (d) Whether it is at least as likely as not that the Veteran's service-connected back disability aggravated the Veteran's cervical spine disorder. A complete rationale for all opinions rendered must be provided. 3. Then readjudicate the claims on appeal. If the benefit sought is not granted, provide the Veteran and his attorney with a supplemental statement of the case (SSOC) and allow an appropriate opportunity to respond thereto before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs