Citation Nr: 1817023 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 10-01 795 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to service connection for a right hip/leg disorder. 4. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) since November 14, 2006. 5. Entitlement to an initial rating in excess of 10 percent for cervical spine degenerative arthritis since November 14, 2006, to include separate compensable ratings for right and left upper extremity radiculopathy. 6. Entitlement to an initial rating in excess of 20 percent for lumbar spine intervertebral disc syndrome (IVDS) since November 14, 2006, to include a rating in excess of 10 percent from October 17, 2007, to December 11, 2014, and a rating in excess of 20 percent thereafter for left lower extremity radiculopathy and a separate compensable rating for right lower extremity radiculopathy. 7. Entitlement to an initial rating in excess of 30 percent for bilateral pes planus since November 14, 2006. 8. Entitlement to a compensable rating for hypertension since November 14, 2006. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army from May 1999 to November 2006. He served in Southwest Asia. This matter came before the Board of Veterans' Appeals (Board) on appeal from February 2007, February 2008, March 2008, December 2008, April 2009, December 2009, and February 2015 decisions of the Louisville, Kentucky, Regional Office (RO) and the Appeals Management Center (AMC). In May 2014, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript is in the record. In October 2014, the Board remanded the appeal. In July 2016, the Board denied service connection for sleep apnea and remanded the other issues on appeal. The Veteran appealed the denial of service connection for sleep apnea to the United States Court of Appeals for Veterans' Claims (Court). In March 2017, the Court granted the Parties' Joint Motion for Remand (JMR); vacated the July 2016 Board denial; and remanded the Veteran's appeal to the Board. The Board notes that it has previously stated that the issues of service connection for a right hip/leg disorder and service connection for a left shoulder disorder require new and material evidence to reopen the claims. On reexamination of the file, however, the Board has determined that the initial rating decision was never final and has recharacterized the issues as they appear on the first page of this decision. The issue of service connection for sleep apnea is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Left shoulder bicipital tendonitis began in service and has continued since that time. 2. A right hip stress fracture was incurred in service and greater trochanteric bursitis began in service and has continued since that time. 3. The Veteran's PTSD required daily medication and caused the Veteran to be regularly distracted by thoughts of Iraq; hypnagogic hallucinations; memory difficulty; distraction and concentration difficulties; obsessive and ritualistic hand washing; depression, anger, irritability, sadness, guilt, shame, mood swings, anxiety, wanting to be left alone, avoidance of crowds, nightmares, decreased motivation, decreased interest in activities he once enjoyed, night sweats, impaired sleep, loss of appetite, nervousness, worry, avoidance, isolation and withdrawal from spouse and children, feelings of detachment or estrangement from others, decreased range of affect, emotional isolation, hypervigilance, panic attacks, hyperarousal, suspiciousness, and exaggerated startle response; marital difficulties and an episode of domestic violence; violent sleep behavior; belief that he would die prematurely; difficulty interacting with children; and suicidal ideation. 4. The Veteran's cervical spine disorder caused degenerative disc disease (DDD), degenerative joint disease (DJD), IVDS, chronic cervicalgia, bilateral upper extremity radiculopathy, straightening of the lordosis, and foraminal encroachment of the C6-C7 on the left; pain, tenderness on palpation, flare-ups, muscle spasms; moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity; difficulty turning the head, pushing, pulling, and driving; increased pain when sitting, walking or lying in bed for prolonged periods and with cold weather; required traction, steroid injections, lidocaine patches, ibuprofen, heat pad, TENS unit, and neck massages to help with pain relief; and flexion limited to 30 degrees, extension to 35 degrees, right lateral flexion to 10 degrees, left lateral flexion to 25 degrees, right lateral rotation to 45 degrees, and left lateral rotation to 55 degrees. 5. The Veteran's low back disorder caused DDD, IVDS, facet arthrosis, focal straightening, stenosis, arthritis, deformity of the L4 spinous process, bulging discs, and moderate bilateral lower extremity radiculopathy; urinary incontinence, urgency, and increased frequency of daytime voiding every 3 hours, nocturia of 2 voidings per night, and some bowel accidents, but did not require the wearing of absorbent material; erectile dysfunction; lower extremity numbness, paresthesias, unsteadiness, leg or foot weakness, falls; decreased motion, stiffness, weakness, spasms, severe daily flare-ups, tenderness, fatigue, guarding; spine fixed in a flexed position; gait with poor propulsion; decreased pain sensation and reflexes; a maximum of 5 incapacitating episodes in a 12 month period; required steroid injections, home and clinic-based traction, medication, a back brace, massage, ice, heat, rest, and assistance dressing and bathing; and flexion limited to 35 degrees with pain, extension to 5 degrees with pain, right lateral flexion to 10 degrees with pain, left lateral flexion to 10 degrees with pain, right lateral rotation to 20 degrees with pain, and left lateral rotation to 20 degrees with pain. 6. The Veteran's bilateral pes planus caused pain, swelling, and fatigability; decreased longitudinal arch height on weight-bearing; tenderness on palpation over both plantar arches; callouses indicating abnormal weight-bearing; objective evidence of marked deformity on both feet; and had marked pronation of both feet. 7. The Veteran's hypertension caused a high diastolic pressure reading of 96 and a high systolic pressure reading of 146 and required daily medication. CONCLUSIONS OF LAW 1. The criteria for service connection for left shoulder bicipital tendonitis have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2017). 2. The criteria for service connection for right hip stress fracture residuals and greater trochanteric bursitis have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2017). 3. The criteria for an initial rating of 70 percent, since November 14, 2006, for PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for an initial rating of 20 percent, since November 14, 2006, for cervical spine degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 5. The criteria for an initial rating of 40 percent, since November 14, 2006, for right (major) upper extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5242, 8512 (2017). 6. The criteria for an initial rating of 20 percent, since November 14, 2006, for left (minor) upper extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5242, 8512 (2017). 7. The criteria for an initial rating in excess of 20 percent, since November 14, 2006, for lumbar spine IVDS have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5238, 5243 (2017). 8. The criteria for an initial rating of 20 percent, since November 14, 2006, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5238, 5243, 8520 (2017). 9. The criteria for an initial rating of 20 percent, from November 14, 2006, to December 11, 2014, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5238, 5243, 8520 (2017). 10. The criteria for a rating in excess of 20 percent, since December 11, 2014, for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5238, 5243, 8520 (2017). 11. The criteria for a rating of 10 percent, since November 14, 2006, for bladder symptoms associated with lumbar spine IVDS have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.115a, 4.115b, Diagnostic Codes 5238, 5243, 7542 (2017). 12. The criteria for a rating of 10 percent, since November 14, 2006, for bowel symptoms associated with lumbar spine IVDS have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.114, Diagnostic Codes 5238, 5243, 7332 (2017). 13. The criteria for entitlement to special monthly compensation (SMC) based on loss of use of a creative organ have been met. 38 U.S.C. §§ 1114(k), 5107 (2012); 38 C.F.R. §§ 3.102, 3.350 (2017). 14. The criteria for an initial rating of 50 percent, since November 14, 2006 for bilateral pes planus have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.71a, Diagnostic Code 5276 (2017). 15. The criteria for an initial compensable rating since November 14, 2006, for hypertension have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and to Assist VA has a duty to notify claimants about the claims process and a duty to assist them in obtaining evidence in support of their claim. VA has issued several notices to the Veteran including a December 2006 notice which informed him of the evidence generally needed to support his claims; what actions he needed to undertake; and how VA would assist him in developing his claims. The December 2006 notice was issued to the Veteran prior to rating decisions from which the instant appeal arises. Additionally, where, as here, with the appeal for an initial compensable rating following the grant of service connection, the service connection claim is substantiated. No additional VCAA notice is required with respect to the downstream issue of the initial rating assigned to the now service-connected disability. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective dates); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). All identified and available relevant documentation has been secured to the extent possible and all relevant facts have been developed. There remains no question as to the substantial completeness of the claims. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VA's duties to notify and to assist have been met. II. Analyses A. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C. § 1154(b) (2012). 1. Left Shoulder Statements from the Veteran, fellow service members, and service treatment records indicate that the Veteran was injured by an improvised explosive device (IED) while stationed in Southwest Asia. The Veteran has repeatedly stated in the course of receiving treatment and in statements to VA that he injured his left shoulder in the IED explosion and has had pain since that time. On a June 2006 report of medical history, the Veteran indicated that he had a painful shoulder and a Medical Evaluation Board (MEB) examination completed at that time stated that his left shoulder range of motion was limited due to pain. An October 2006 VA examination report states that the Veteran had pain and stiffness; an X-ray study was normal. No diagnosis was advanced. A May 2007 VA treatment record indicates that the Veteran continued to have pain, stiffness, and loss of grip strength. He was diagnosed with bicipital tendonitis. At his May 2014 Board hearing, he testified that he continued to have left shoulder pain. As the Veteran was in combat, the Board presumes that his in-service injury occurred as reported. 38 U.S.C. § 1154(b). The Veteran has been diagnosed with bicipital tendonitis. As the Veteran has had continuous left shoulder complaints since his in-service injury, service connection is warranted and the claim is granted. 2. Right Hip/Leg The Veteran has repeatedly reported that he injured his right hip during basic training when he tripped over another service member's leg. Service treatment records beginning in August 1999 indicate complaints of hip pain. An October 1999 X-ray study was normal, but the clinician recommended that the Veteran undergo a bone scan to rule out a stress fracture. The Veteran reported in a January 2000 record that he underwent the bone scan and had had a small fracture. He was diagnosed at that time with greater trochanteric bursitis. The report of the October 2006 VA examination indicates that the Veteran had ongoing right hip pain, stiffness, and tenderness. An X-ray study was normal at that time and no diagnosis was advanced. A November 2007 VA examination report stated that the Veteran had no specific disorder of the hips. In May 2008, he reported ongoing right hip pain and it was noted that he injured his hip during basic training. VA treatment records and the May 2014 Board hearing transcript indicate that the Veteran has continued to report right hip pain. Given that the Veteran has had ongoing complaints of right hip pain since an in-service injury in 1999 and that he has been diagnosed with a stress fracture and greater trochanteric bursitis, service connection is warranted and the claim is granted. Service treatment records also indicate complaints of right leg numbness, pain, muscle spasms, and tingling. A January 2006 service treatment record states that the Veteran had bilateral lower extremity radiculopathy and paresthesias. The November 2007 VA examination noted pain radiating from the low back into the right leg. The examiner wrote that "[t]he disorder involving the legs appears to be clinically consistent with lumbosacral radiculopathy." VA treatment records since service separation indicate ongoing complaints of right leg pain, numbness, and tingling radiating from the back. There is no additional right leg diagnosis in the record. Therefore, the Board finds that the Veteran's right leg complaints are associated with radiculopathy and will be rated with the Veteran's low back disorder which is currently on appeal. B. Increased Ratings Disability evaluations are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Where, as here, the issue involves the assignment of an initial rating for a disability following the initial award of service connection for that disability, the entire history of the disability must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). 1. PTSD A 50 percent evaluation for PTSD requires 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. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, 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 work-like setting), and an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran has non-service-connected psychiatric disorders, in addition to his service-connected PTSD. No competent medical professional has separated the effects of the non-service-connected disorder from those associated with the service-connected disorder. Therefore, all of the Veteran's psychiatric symptoms will be attributed to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that when claimant has both service-connected and non-service-connected disabilities, Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability). The Veteran's August 2006 MEB proceedings form states that the Veteran had diagnoses of recurrent major depressive disorder and adjustment disorder with mixed anxiety and depressed mood. The MEB examination report states that the Veteran had a history of hypnagogic hallucinations after a deployment. He saw shadows and heard strange noises at night, but there was no indication of a true psychotic state. The clinician indicated that in-service psychiatric symptoms included nightmares, avoidance, being easily startled, being "on guard," and feeling numb and detached. In October 2006, November 2007, November 2009, September 2011, December 2014, November 2016, and December 2016, the Veteran was afforded VA examinations. He was diagnosed with PTSD and unspecified trauma and stressor related disorder. He was regularly distracted by thoughts of Iraq; had hypnagogic hallucinations; had memory difficulty; was easily distracted and had concentration difficulties; exhibited obsessive and ritualistic hand washing; had symptoms of depression, anger, irritability, sadness, guilt, shame, mood swings, anxiety, wanting to be left alone, avoidance of crowds, nightmares, decreased motivation, decreased interest in activities he once enjoyed, night sweats, impaired sleep, loss of appetite, nervousness, worry, avoidance, isolation and withdrawal from spouse and children, feelings of detachment or estrangement from others, decreased range of affect, emotional isolation, hypervigilance, panic attacks, hyperarousal, suspiciousness, and exaggerated startle response; believed that he would die prematurely; and had suicidal ideation. He reported difficulty interacting with children due to trauma memories related to injuries to children. He took daily medication to treat his symptoms. He had no delusions, paranoia, or homicidal ideation, and was properly groomed. He was a deacon at his church; played drums in the church choir; conducted a Bible study at a local jail; participated in a car club and attended their events; occasionally went out with his spouse; went to the gym; drew and built model cars, planes, and ships; completed a bachelor's and a master's degree; and was working. An April 2009 statement from the Veteran's spouse indicated that he had mood swings that caused her to fear that he would hurt her or their children. She reported that they had been to marital counseling through their church. He also acted violently in his sleep, swinging his arms, kicking his legs, falling out of bed, knocking things off the nightstand, and even striking his spouse. An August 2009 VA treatment record indicates that the Veteran had a domestic dispute several months prior with his spouse. He was court-ordered to undergo therapy and to reside separately from his spouse. At his May 2014 Board hearing, the Veteran testified that he had anger problems, suicidal ideation, depression, was socially isolated, had conflict with his ex-spouse regarding care of their child, and had punched a hole in a wall. He had been married to his current spouse for 10 years, despite some martial difficulties. He testified that he was working and had no trouble at his job. At his December 2016 examination, the Veteran reported that he and his spouse had separated the previous March but had had a couple of brief reconciliations. A May 2017 VA treatment record indicates that the Veteran had intermittent suicidal ideation. The Veteran's PTSD required daily medication and caused the Veteran to be regularly distracted by thoughts of Iraq; hypnagogic hallucinations; memory difficulty; distraction and concentration difficulties; obsessive and ritualistic hand washing; depression, anger, irritability, sadness, guilt, shame, mood swings, anxiety, wanting to be left alone, avoidance of crowds, nightmares, decreased motivation, decreased interest in activities he once enjoyed, night sweats, impaired sleep, loss of appetite, nervousness, worry, avoidance, isolation and withdrawal from spouse and children, feelings of detachment or estrangement from others, decreased range of affect, emotional isolation, hypervigilance, panic attacks, hyperarousal, suspiciousness, and exaggerated startle response; marital difficulties and an episode of domestic violence; violent sleep behavior; belief that he would die prematurely; difficulty interacting with children; and suicidal ideation. Given these facts, the Board finds that a 70 percent rating most closely approximates the Veteran's symptoms. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). A 100 percent rating is not warranted as the Veteran was not totally impaired. He was active in his church, participated in some activities he enjoyed, completed a bachelor's and a master's degree, and worked. 2. Cervical Spine Diagnostic Code 5242 provides ratings for degenerative arthritis of the spine. A 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or for the combined range of motion of the cervical spine not greater than 170 degrees; or, for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). There are also several relevant note provisions associated with Diagnostic Code 5242. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire 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 on 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 neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). Upper extremity radiculopathy is rated according to diagnostic code 8512. Mild incomplete paralysis warrants a 20 percent rating for radiculopathy in both the major and minor extremity. Moderate incomplete paralysis warrants a 30 percent rating for radiculopathy in the minor extremity and a 40 percent rating for radiculopathy in the major extremity. Severe incomplete paralysis warrants a 40 percent rating for radiculopathy in the minor extremity and a 50 percent rating for radiculopathy in the major extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8512. The Veteran has reported both that he is ambidextrous but his right hand is dominant. For purposes of determining which extremity is major and which is minor, the right upper extremity will be the major extremity because the Veteran has reported it as dominant several times; the left upper extremity will, therefore, be the minor extremity. The Veteran's August 2006 MEB examination report stated that he had forward flexion to 45 degrees, extension to 45 degrees, 80 degrees of rotation bilaterally, and 45 degrees of lateral bending bilaterally. He had no tenderness to palpation; no spasm; and motor, sensory, and neurological examinations were all within normal limits. Magnetic resonance imaging (MRI) revealed mild narrowing of two discs. He was diagnosed with neck pain. January 2006 imaging studies indicated straightening of the normal lordosis, probably due to spasm, and mild narrowing of two discs. The report of the October 2006 VA examination states that the Veteran had no spasm, no atrophy, no guarding, and no weakness, but did have pain with motion and tenderness. Motor testing and reflexes were normal, and there was no muscle atrophy. Nerve testing in the upper extremities was normal. There was no ankylosis. Active range of motion indicated flexion limitation to 60 degrees with pain, extension to 50 degrees with pain, right lateral flexion to 40 degrees with pain, left lateral flexion to 35 degrees with pain, right and left lateral rotation to 70 degrees on each side with pain. He was diagnosed with a bulging disc in the back. The report of the November 2007 VA examination states that the Veteran had constant aching and a stabbing pain when lifting or pushing. Turning his head in an automobile, working above his head, pushing, and pulling increased the pain. He could walk approximately 1/2 mile before his neck would hurt. On examination, there was no spasm or muscle weakness, and active and passive ranges of motion were the same. He had forward flexion to 40 degrees with pain, extension to 40 degrees with pain, left lateral flexion to 35 degrees with pain, right lateral flexion to 40 degrees with pain, left lateral rotation to 60 degrees with pain, and right lateral rotation to 70 degrees with pain. There was no guarding, weakness, fatigability, or incoordination. He was diagnosed with DDD and cervical strain. The report of the March 2010 VA examination states that the Veteran had intermittent aching and throbbing with occasional stabbing pain; the pain was constant. It was worsened by prolonged sitting and walking, and he had difficulty looking over his shoulder, which affected his driving. He underwent steroid injections. He had pain, numbness, tingling, and a prickly feeling radiating from his neck down to his left hand. He had weekly flare-ups that lasted several hours. He reported no incapacitating episodes in the prior 12 months. He had no ankylosis, spasm, atrophy, guarding, pain with motion, or weakness; he had tenderness. Motor, sensory, and reflex testing were normal. He had active range of flexion to 45 degrees, extension to 45 degrees, left lateral flexion to 45 degrees, left lateral rotation to 55 degrees, right lateral flexion to 55 degrees, and right lateral rotation to 55 degrees. There was pain on motion and pain following repeated use. An MRI study indicated straightening of the normal lordosis and degenerative changes. The report of the September 2011 VA examination indicates that the Veteran had constant neck pain with weekly flare-ups that caused pain and loss of range of motion. On examination, he had flexion to 45 degrees with pain, extension to 45 degrees, right lateral flexion limited to 35 degrees with pain, left lateral flexion limited to 35 degrees, right lateral rotation to 50 degrees with pain, and left lateral rotation to 70 degrees. He had no additional loss of range of motion following repeated use and no guarding or muscle spasm. He had functional impairment resulting in pain on movement and pain on palpation. Muscle strength testing was normal, there was no muscle atrophy, reflexes were normal, and sensory testing was normal. He had no radiculopathy or other neurologic abnormalities and no IVDS. Imaging studies indicated arthritis, straightening of the lordosis, and foraminal encroachment of the C6-C7 on the left. The examiner indicated that he had neck pain at work which required him to take breaks to stretch. The report of the December 2014 VA examination states that the Veteran had monthly pain flare-ups. He had steroid injections, used lidocaine patches, took ibuprofen, and got neck massages to help with pain relief. He had functional loss which resulted in an inability to turn his head as much as needed when driving and caused him to have to stretch at work due to neck stiffness when using a computer. He had flexion to 45 degrees, extension to 45 degrees, right lateral flexion to 35 degrees, left lateral flexion to 30 degrees, right lateral rotation to 70 degrees, and left lateral rotation to 60 degrees. He had pain on right lateral flexion and right lateral rotation, tenderness on palpation, and was able to perform repeated use testing. He had no muscle spasm; localized tenderness did not result in abnormal gait or spinal contour; no guarding; no muscle atrophy; and muscle strength, reflexes, and sensory testing were normal. He had no radiculopathy or other neurologic abnormalities, no ankylosis, and no IVDS. Neurologic testing indicated peripheral neuropathy in the bilateral upper extremities. The report of the January 2017 VA examination states diagnoses of degenerative arthritis and IVDS manifested as right upper extremity radiculopathy secondary to DJD. The Veteran had to put his arm behind the car seat while driving, used a heating pad, used an adjustable bed, took ibuprofen, used a TENS unit, and stretched to help relieve pain. He had daily flare-ups on the right side which caused tingling, coldness, and numbness to his fingers. He reported muscle spasms. He had flexion to 45 degrees, extension to 30 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, right lateral rotation to 45 degrees, and left lateral rotation to 55 degrees. He had pain with each range of motion but no functional loss. There was tenderness on palpation. He had additional loss of range of motion after repeated use with flexion to 30 degrees, extension to 35 degrees, right lateral flexion to 10 degrees, left lateral flexion to 25 degrees, right lateral rotation to 45 degrees, and left lateral rotation to 55 degrees. He had no guarding or muscle spasms and no muscle atrophy. Muscle strength testing, reflexes, and sensory testing were normal. His right upper extremity had moderate intermittent pain, paresthesias and/or dysesthesias, and numbness. He had no other neurologic abnormalities. He had IVDS but no incapacitating episodes in the prior 12 months. There was pain on passive range of motion testing and pain on non-weight-bearing. VA treatment records since service separation indicate that the Veteran had left and right upper extremity radiculopathy with symptoms of numbness, tingling, weakened grip strength, and pain; DDD; chronic cervicalgia; DJD; reversal of normal lordotic curvature; used an at-home traction machine; underwent steroid injections; and that his symptoms worsened with cold weather and lying in bed or sitting for a prolonged period of time. A May 2013 statement from the Veteran's spouse indicated that he used a traction machine for his neck at least one time per week. The Veteran's cervical spine disorder caused DDD, DJD, IVDS, chronic cervicalgia, bilateral upper extremity radiculopathy, straightening of the lordosis, and foraminal encroachment of the C6-C7 on the left; pain, tenderness on palpation, flare-ups, muscle spasms; moderate intermittent pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity; difficulty turning the head, pushing, pulling, and driving; increased pain when sitting, walking or lying in bed for prolonged periods and with cold weather; required traction, steroid injections, lidocaine patches, ibuprofen, heat pad, TENS unit, and neck massages to help with pain relief; and flexion limited to 30 degrees, extension to 35 degrees, right lateral flexion to 10 degrees, left lateral flexion to 25 degrees, right lateral rotation to 45 degrees, and left lateral rotation to 55 degrees. Given these facts, the Board finds that a 20 percent rating is warranted for the cervical spine disorder with flexion not greater than 30 degrees and with reversed lordosis. A 40 percent rating is also warranted for moderate right (major) upper extremity radiculopathy. A 20 percent rating is warranted for left (minor) upper extremity radiculopathy. 38 C.F.R. § 4.7. See Hart, 21 Vet. App. at 505. In making these determinations, the Board has considered, along with the schedular criteria, the Veteran's functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). A 30 percent rating is not warranted for the cervical spine disorder because flexion is not limited to 15 degrees or less and there is no ankylosis. A 50 percent rating is not warranted for right (major) upper extremity radiculopathy because the Veteran's symptoms were all moderate, not severe, at the January 2017 VA examination. A 30 percent rating is not warranted for left (minor) upper extremity radiculopathy as the Veteran's symptoms are intermittent and have not been detectable on his VA examinations. 3. Lumbar Spine Diagnostic Code 5238 provides ratings for spinal stenosis. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, for the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5238 (2017). There are also several relevant note provisions associated with Diagnostic Code 5238. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire 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 on 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 neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Code 5238 (2017). IVDS can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The method that results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25 is the method that should be utilized. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Note (1) provides that for purposes of evaluations under diagnostic code 5243, an incapacitating episode is 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. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Neurogenic bladder symptoms are rated as voiding dysfunction under 38 C.F.R. § 4.115a. 38 C.F.R. § 4.115b, Diagnostic Code 7542. A 10 percent rating is warranted for daytime voiding interval between two and three hours, or; awakening to void two times per night. A 20 percent rating is warranted for daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 20 percent rating is also warranted for disability requiring the wearing of absorbent materials which must be changed less than 2 times per day. 38 C.F.R. § 4.115a. Impairment of sphincter control of the rectum and anus is rated according to diagnostic code 7332. A 10 percent rating is warranted for constant slight loss of sphincter control, or occasional moderate leakage. A 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of pad. 38 C.F.R. § 4.114, Diagnostic Code 7332. Erectile dysfunction is not listed in the Rating Schedule. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the function affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2017). As such, erectile dysfunction is evaluated under diagnostic code 7522, which provides that deformity of the penis with loss of erectile power is entitled to a 20 percent rating. 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2017). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. VBA has indicated that a compensable rating under diagnostic code 7522 is not warranted in the absence of deformity, and instructs that such deformity be "evident." See M21-1, Part III.iv.4.I.2.a (Deformity of the Penis With Loss of Erectile Power). Additionally, a note to the rating criteria indicates that special monthly compensation (SMC) should be considered for loss of use of a creative organ. The Veteran is in receipt of SMC and, therefore, no further discussion of that issue is necessary. SMC under 38 U.S.C. § 1114(k) is payable for the anatomical loss or loss of use of one or more creative organs due to service-connected disability. This special compensation is payable in addition to the basic rate of compensation otherwise payable on the basis of degree of disability. 38 C.F.R. § 3.350(a)(1). A January 2003 service treatment record states that the Veteran reported recurrent low back pain with occasional shooting pain down the sides of both legs. A January 2006 service treatment record states that the Veteran had low back pain with bilateral lower extremity radiculopathy and paresthesia. The Veteran's August 2006 MEB states that he failed to meet retention standards due to chronic back pain. His MEB examination report indicates that he had a full range of motion, although he grimaced throughout. The October 2006 VA examination report states that the Veteran had a bulging disc. He reported that he got steroid injections while in service. He had urinary incontinence but did not require the wearing of absorbent material, urinary urgency, increased urinary frequency, numbness, paresthesias, and unsteadiness. The Veteran reported occasional urine leakage due to his spine disorder. He had decreased motion, stiffness, weakness, spasms, weekly flare-ups, and severe, constant pain which radiated to his right thigh. He had IVDS with 3 incapacitating episodes in the prior 12 months, lasting 1 day each. He used a back brace and could walk less than 1 mile. On examination, he had no spasm, atrophy, guarding, or weakness, but did have pain with motion and tenderness. The tenderness was not severe enough to cause an abnormal gait or spinal contour. There was no muscle atrophy and motor testing, sensory testing, and reflexes were normal. There was no ankylosis. He had flexion to 50 degrees with pain, extension to 30 degrees with pain, right lateral flexion to 35 degrees with pain, left lateral flexion to 35 degrees with pain, right lateral rotation to 40 degrees with pain, and left lateral rotation to 45 degrees with pain. He had pain after repeated use but no additional loss of range of motion. The report of the November 2007 VA examination states that the Veteran reported constant back pain that radiated constantly into the left leg and sometimes into the right leg. He had flare-ups that resulted in moderate to severe pain. Lifting, pushing, and pulling increased pain; massaging, ice, heat, rest, and pain medication provided relief. He used a back brace he bought at the store. The examiner noted that it was not a "true orthopedic brace." He could walk approximately 1/2 mile before his back started to hurt. He had flexion to 70 degrees with pain, extension to 30 degrees with pain, left lateral flexion to 40 degrees with pain, right lateral flexion to 40 degrees with pain, left lateral rotation to 60 degrees with pain, and right lateral rotation to 50 degrees with pain. Active and passive ranges of motion were the same. He had positive straight leg raise tests on both legs. He had pain but no grimacing or guarding. He had no weakness, fatigability, incoordination, or instability on repeated use. The examiner diagnosed DDD of the lumbar spine with radiation of tenderness into the left thigh today. In January 2008, the Veteran was afforded another VA spine examination. The examiner indicated a history of urinary frequency of every 3 hours, nocturia of 2 voidings per night, erectile dysfunction, numbness, paresthesias, leg or foot weakness, falls, and unsteadiness all related to the Veteran's low back disorder. The examiner also noted a history of fatigue, decreased motion, stiffness, weakness, spasms, and pain in the low back and that radiated into the tops of the legs. There were severe flare-ups daily. The examiner stated that the Veteran had IVDS and had incapacitating episodes of 5 days in the prior 12 months. On examination, he had no spasm, atrophy, or weakness, but did have guarding, pain with motion, and tenderness. The spasm, tenderness, and guarding were not severe enough to cause abnormal gait or spinal contour. His spine was fixed in a flexed position and his gait had poor propulsion. He had no abnormal spine curvature; motor testing was normal except for decreased left hip flexion; muscle tone was normal; and there was no muscle atrophy. He had decreased pain sensation bilaterally and reflexes were normal. He had flexion to 35 degrees with pain, extension to 5 degrees with pain, right lateral flexion to 10 degrees with pain, left lateral flexion to 10 degrees with pain, right lateral rotation to 20 degrees with pain, and left lateral rotation to 20 degrees with pain. He had pain after repeated use but it did not result in additional loss of range of motion. He was diagnosed with lumbar spine DDD with spinal stenosis. The report of the March 2010 VA peripheral nerves examination states that the Veteran took several pain medications and had numbness, dysesthesias, and pain in his right leg. He had decreased sensation and decreased reflexes in the right leg. He had difficulty with prolonged sitting or walking and had to stretch frequently when riding in a car or flying for long periods. His gait was normal. He was diagnosed with lumbar radiculopathy mild to moderate in severity. The report of the March 2010 VA spine examination states that the Veteran needed to continually use a back brace for prolonged walking, driving, and exercising. He had a constant aching pain in his low back with radiation into both lower extremities. He was treated with medication, traction, and steroid injections. He had no urinary symptoms or erectile dysfunction, but did have numbness, paresthesias, and leg or foot weakness. He also had fatigue, decreased motion, stiffness, spasms, and pain with prolonged sitting or walking. He had IVDS but no incapacitating episodes in the prior 12 months. He used an orthotic insert and brace and was able to walk 1 to 3 miles. On examination, his gait was normal. He had no abnormal spine curvatures, ankylosis, spasm, atrophy, guarding, pain with motion, or weakness, but did have tenderness. Motor testing was normal. Sensory testing was normal except for decreased sensation to light touch on the right shin. Reflexes were normal. He had flexion to 90 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, left lateral rotation to 30 degrees, right lateral flexion to 30 degrees, and right lateral rotation to 30 degrees. There was no objective evidence of pain on active range of motion and no additional limitation after repeated use. An MRI study indicated degenerative disease, stenosis, and deformity of the L4 spinous process. The examiner noted that the Veteran used an orthotic "pincher" for assistance putting on his socks, his spouse had to wash his back, and he could not take baths because he could not sit in a bathtub. The examiner stated that the Veteran's IVDS was moderate in severity. The report of the September 2011 VA examination indicates that the Veteran had constant low back pain. He wore a brace 2 to 3 days per week and his spouse would sometimes walk on his back to "pop" it and help relieve the pain. He had flare-ups resulting in decreased range of motion and decreased function. He had flexion to 75 degrees with pain, extension to 30 degrees or greater with pain, right lateral flexion to 30 degrees or greater with pain, left lateral flexion to 30 degrees or greater, right lateral rotation to 30 degrees or greater, and left lateral rotation to 30 degrees or greater. Following repeated use, he had flexion to 75 degrees, extension to 30 degrees or greater, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 30 degrees or greater, and left lateral rotation to 30 degrees or greater. He had functional loss resulting in less movement than normal and pain on movement after repeated use. He had tenderness on palpation and no guarding or muscle spasm. Muscle strength testing, sensory testing, and reflexes were normal. Straight leg testing was negative. He had moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in his left lower extremity. He had incapacitating episodes of a total of less than 1 week during the prior 12 months. He had arthritis. The report of the January 2017 VA examination states that the Veteran had low back pain and spasms with prolonged standing or riding in a car. Playing drums at church, working out, cold weather, twisting, bending, and stair climbing increased his pain. He slept in an adjustable bed and no longer flew or mowed his lawn due to back pain. He saw a chiropractor, used a TENS unit, got massages, stretched, and took ibuprofen to help relieve pain. His pain was sometimes so severe that it caused him to cry. He had flexion to 90 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 40 degrees, and left lateral rotation to 45 degrees. He had pain with each range of motion that caused functional loss. He had pain on palpation, no pain on weight-bearing, and pain on repeated use but it did not cause additional functional loss or loss or range of motion. He had no guarding, muscle spasm, or ankylosis. Muscle strength testing, sensory testing, and reflexes were normal. Straight leg raising test was negative. He had moderate intermittent pain, paresthesias and/or dysesthesias, and numbness of the left lower extremity. He had no other neurologic abnormalities. He had had no incapacitating episodes in the prior 12 months. He regularly used a back brace. He had arthritis, evidence of pain on passive range of motion testing, and evidence of pain on non-weight-bearing. VA treatment records since service separation indicate that the Veteran had DDD, facet arthrosis, focal straightening, degenerative changes, stenosis, and bulging discs; was treated with traction at home and in physical therapy, and with steroid injections; had low back pain with radicular pain and tingling radiating to the right and left legs; symptoms were worse with cold weather, bending, lifting, when sneezing, and when driving for a prolonged period. A May 2013 statement from the Veteran's spouse indicated that she assisted him with using his traction machine and TENS unit 2 to 3 times per week, she manually "popped" his back to relieve pain and stiffness daily, and she helped him dress and bathe. At his May 2014 Board hearing, the Veteran testified that he had some bowel and bladder accidents and his physician was investigating whether they were caused by his back disorder. The Veteran's low back disorder caused DDD, IVDS, facet arthrosis, focal straightening, stenosis, arthritis, deformity of the L4 spinous process, bulging discs, and moderate bilateral lower extremity radiculopathy; urinary incontinence, urgency, and increased frequency of daytime voiding every 3 hours, nocturia of 2 voidings per night, and some bowel accidents, but did not require the wearing of absorbent material; erectile dysfunction; lower extremity numbness, paresthesias, unsteadiness, leg or foot weakness, falls; decreased motion, stiffness, weakness, spasms, severe daily flare-ups, tenderness, fatigue, guarding; spine fixed in a flexed position; gait with poor propulsion; decreased pain sensation and reflexes; a maximum of 5 incapacitating episodes in a 12 month period; required steroid injections, home and clinic-based traction, medication, a back brace, massage, ice, heat, rest, and assistance dressing and bathing; and flexion limited to 35 degrees with pain, extension to 5 degrees with pain, right lateral flexion to 10 degrees with pain, left lateral flexion to 10 degrees with pain, right lateral rotation to 20 degrees with pain, and left lateral rotation to 20 degrees with pain. Given these facts, the Board finds that the current 20 percent rating adequately reflects the Veteran's lumbar spine limitation of motion and functional impairment during the relevant period. 38 C.F.R. § 4.7. See Hart, 21 Vet. App. at 505. In making this determination, the Board has considered, along with the schedular criteria, the Veteran's functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206-207. A 40 percent rating is not warranted because the Veteran does not have forward flexion of 30 degrees or less, does not have ankylosis, and has not had any 12 month period where he had incapacitating episodes of a total duration between 4 to 6 weeks. 38 C.F.R. 4.71a, Diagnostic Codes 5238, 5243. The Board also finds that a 20 percent rating is warranted for moderate right lower extremity radiculopathy. A rating of 20 percent for left lower extremity radiculopathy is warranted for the period prior to December 11, 2014. A 40 percent rating is not warranted for either lower extremity at any time because the Veteran's symptoms are never noted to be worse than moderate. 38 C.F.R. § 4.124a, Diagnostic Code 8520. A 10 percent rating is warranted for neurogenic bladder resulting in daytime voiding every 3 hours and awakening to void 2 times per night. The Veteran does not void every 1 to 2 hours during the day, wake 3 to 4 times per night to void, or require the wearing of absorbent materials, and a 20 percent rating is not warranted. 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7542. A 10 percent rating is warranted for bowel symptoms resulting from the low back disorder, including some bowel accidents. A 30 percent rating is not warranted as the Veteran's symptoms do not necessitate wearing a pad. 38 C.F.R. § 4.114, Diagnostic Code 7332. The Veteran's erectile dysfunction does not warrant assignment of a separate rating as his disorder does not meet the minimum requirement for a compensable rating. 38 C.F.R. § 4.31, 4.115b, Diagnostic Code 7522. SMC for loss of use of a creative organ is warranted, however. 4. Pes Planus A 30 percent rating is warranted for severe bilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 50 percent rating is warranted for pronounced bilateral pes planus with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2017). In March 2010, December 2014, and January 2017, the Veteran was afforded VA examinations. He had pain, swelling, and fatigability; decreased longitudinal arch height on weight-bearing; tenderness on palpation over both plantar arches; callouses indicating abnormal weight-bearing; objective evidence of marked deformity on both feet; and had marked pronation of both feet. Given these facts, the Board finds that the Veteran's symptoms most closely approximate a 50 percent rating. 38 C.F.R. § 4.7. See Hart, 21 Vet. App. at 505. This is the maximum rating for this disorder. 5. Hypertension A 10 percent rating is warranted for hypertension with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Note (1) to the diagnostic code states: Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Note (2) states : Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states: Evaluate hypertension separately from hypertensive heart disease and other types of heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2017). VA treatment records since service separation indicate that the Veteran's highest diastolic pressure reading was below 90 and his highest systolic pressure reading was 146. In October 2006, March 2010, December 2014, and January 2017, the Veteran was afforded VA examinations. He took daily medication to control his blood pressure. His blood pressure readings at the examinations were 144/96, 124/78, 146/96, 102/70, 102/72, 102/70, 120/82, 116/78, 124/84, 127/69, 130/79, 141/[71]. He reported occasional symptoms of nausea, lightheadedness, or dizziness when his blood pressure was elevated, requiring him to leave work to rest. Given these facts, the Board finds that the current noncompensable rating adequately reflects the Veteran's symptoms. 38 C.F.R. § 4.7. See Hart, 21 Vet. App. at 505. A 10 percent rating is not warranted because the Veteran has never had a diastolic pressure of 100 or more or a systolic pressure of 160 or more. ORDER Service connection for left shoulder bicipital tendonitis is granted. Service connection for right hip stress fracture residuals and greater trochanteric bursitis is granted. An initial rating of 70 percent is granted for PTSD since November 14, 2006. An initial rating of 20 percent is granted for cervical spine degenerative arthritis since November 14, 2006. An initial rating of 40 percent is granted for right (major) upper extremity radiculopathy since November 14, 2006. An initial rating of 20 percent is granted for left (minor) upper extremity radiculopathy since November 14, 2006. An initial rating in excess of 20 percent for lumbar spine IVDS since November 14, 2006, is denied. An initial rating of 20 percent for right lower extremity radiculopathy since November 14, 2006, is granted. An initial rating of 20 percent for left lower extremity radiculopathy is granted from November 14, 2006, to December 11, 2014. A rating in excess of 20 percent for left lower extremity radiculopathy since December 11, 2014, is denied. A 10 percent rating for bladder symptoms associated with lumbar spine IVDS is granted since November 14, 2006. A 10 percent rating for bowel symptoms associated with lumbar spine IVDS is granted since November 14, 2006. SMC for loss of use of a creative organ is granted since November 14, 2006. An initial rating of 50 percent is granted for bilateral pes planus since November 14, 2006. An initial compensable rating for hypertension since November 14, 2006, is denied. REMAND The Board has determined that additional development is necessary and the case is REMANDED as directed below. 1. The Board has no discretion and must remand the instant appeal for compliance with the Court's March 2017 JMR. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006). The JMR directed the Board to obtain additional VA medical opinions as to service connection for sleep apnea. 2. Return the file to the VA examiner who conducted the December 2014 VA examination. If the examiner is not available, have the file reviewed by a similarly-qualified examiner. If necessary to respond to the inquiries below, schedule the Veteran for a VA sleep apnea examination to obtain an opinion as to the nature and etiology of his sleep apnea. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: a. whether sleep apnea was caused by any service-connected disorder. b. whether sleep apnea was aggravated by any service-connected disorder. c. If the answer to questions (a) and (b) is no, please provide an opinion as to the etiology of sleep apnea. If no etiology can be determined or it is unknown, please so state. Service connection is currently in effect for PTSD; bilateral pes planus; lumbar spine IVDS with bowel and bladder symptoms and left and right lower extremity radiculopathy; cervical spine degenerative arthritis with left and right upper extremity radiculopathy; hypertension; bicipital tendonitis; and right hip stress fracture residuals and greater trochanteric bursitis. The examiner's attention is drawn to the following: *March 2004 Post-Deployment Health Assessment questionnaire where the Veteran denied "still feeling tired after sleeping." The Veteran endorsed symptoms during his deployment of difficulty breathing, but denied any contemporaneous respiratory symptoms. *February 2006 service psychiatric treatment record where the Veteran reported insomnia with nightmares, which he attributed to a custody dispute with his former spouse. *May 2006 service psychiatric treatment record which states the Veteran reported trouble sleeping due to high levels of pain, specifically that the pain wakes him up at night. *June 2006 Report of Medical History form on which the Veteran reported frequent trouble sleeping. The Veteran also noted difficulty breathing due to pollen, dust, and exposures to smoke and chemicals while deployed in Iraq. *August 2006 service psychiatric examination, completed by Dr. J.A. and performed in connection with the MEB which indicates that the Veteran reported sleep problems, restless symptoms at night, difficulty falling asleep, nightmares with panic-appearing wake-ups as witnessed by his current spouse. The service psychiatrist specifically indicated that the Veteran's profile was "negative for sleep apnea symptoms." *October 2006 service Health Questionnaire for Dental Treatment on which the Veteran reported taking medications for anxiety, depression, and sleep disturbances. *Post-service Army psychiatric treatment records, completed by Dr. J.A. and other mental health care professionals, which indicate continued complaints regarding sleep quality. These records reflect continued nightmares, but also improved sleep with the prescribed medications. *January 2007 psychiatric treatment record which states that the Veteran "most likely has sleep problems due to pain issues." *November 2007 VA psychiatric examination report which indicates that the Veteran reported ongoing sleep problems with nightmares and trouble falling asleep. The VA examiner indicated that when the Veteran had difficulty falling asleep "it is related to physical tension as well as ruminative thoughts having to do with daily responsibilities, bills, war experiences, and ongoing political issues." *May 2008 VA treatment record which indicates that the Veteran reported excessive daytime sleepiness since returning from Iraq in 2004. The VA clinician indicated that the Veteran likely had obstructive sleep apnea due to his symptoms, obesity, and physical examination findings (partial nasal obstruction, throat architecture). The VA clinician also noted that "underlying PTSD and anxiety are definite contributing factors," further noting that treatment for sleep apnea may help his symptoms, "but as long as his mental health doesn't improve, his sleep quality might not reach adequate quality." The VA clinician referred the Veteran for a sleep study. *August 2008 VA sleep study consultation report which reflects that the Veteran reported excessive daytime sleepiness since returning from Iraq in 2004. The VA clinician also noted that the Veteran's anxiety interferes with his ability to fall asleep, and that he has frequent nightmares and was currently taking medication for sleep difficulty. The VA clinician noted loud snoring, witnessed apnea, choking and gasping during sleep, and that the Veteran reported waking up tired. The VA clinician diagnosed mild obstructive sleep apnea *April 2009 statement from the Veteran's spouse stating that the Veteran "does not sleep well at night, he has trouble falling asleep, and when he does get to sleep he is very restless." She further noted that she had to "wake him several times because he stops breathing while he is sleeping and sometimes he wakes up coughing and choking." *August 2012 statement in which the Veteran wrote that he was diagnosed with sleep apnea during service by Dr. J.A. *May 2014 Board hearing during which the Veteran testified that he was diagnosed with sleep apnea by Dr. J.A. prior to service separation. The Veteran indicated that he had sleep problems, nightmares, and that he would stop breathing in his sleep, often resulting is his spouse having to shake him to see if he was still breathing. The Veteran further indicated that he was prescribed medication by Dr. J.A. for his sleeping problems, and that he was currently taking the same medication. 3. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran 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 or by Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs