Citation Nr: 1819688 Decision Date: 04/03/18 Archive Date: 04/12/18 DOCKET NO. 13-34 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial compensable rating for service-connected headaches. 2. Entitlement to an initial rating in excess of 10 percent for service-connected gastroesophageal reflux disease (GERD) with diarrhea. 3. Entitlement to a rating in excess of 10 percent for a service-connected left wrist disability from August 22, 2012. 4. Entitlement to a rating in excess of 10 percent for a service-connected right wrist disability from August 22, 2012. 5. Entitlement to a rating in excess of 10 percent for a service-connected left hip disability from August 22, 2012. 6. Entitlement to a rating in excess of 10 percent for a service-connected right hip disability from August 22, 2012. 7. Entitlement to a rating in excess of 10 percent for a service-connected cervical spine disability from August 22, 2012, to April 17, 2017, and in excess of 20 percent afterwards. 8. Entitlement to a rating in excess of 10 percent for a service-connected lumbar spine disability from August 22, 2012. 9. Entitlement to a rating in excess of 20 percent for a service-connected right shoulder disability from April 22, 2010, to March 7, 2017, and from June 1, 2017. 10. Entitlement to a total disability rating based on individual unemployability as a result of service connected disabilities (TDIU). REPRESENTATION Veteran represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD T. Berryman, Associate Counsel INTRODUCTION The Veteran had active service in the Army from December 1984 to February1994 and had active service in the Air Force from September 1996 to February 1997 and July 1999 to July 2009, to include service in Southwest Asia. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Subsequently, the St. Petersburg, Florida, RO assumed jurisdiction. . In December 2014, the Veteran requested a hearing before a Veterans Law Judge. A hearing was scheduled in November 2015. A review of the file indicates that the Veteran submitted a request to withdraw the hearing in November 2015. Thus, the hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d) (2017). In February 2016, the Board remanded the Veteran's claims for further development. The Board is satisfied that there was at the very least substantial compliance with its remand directives. See Dyment v. West, 13 Vet. App. 141, 146-157 (1999). In December 2017, the RO granted service connection for an acquired psychiatric disability, claimed as chronic fatigue syndrome. This represents a complete grant of his appeal in regard to this claim. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). This issue is no longer before the Board. The issues of entitlement to an increased rating for a right shoulder disability and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's headaches have not been productive of characteristic prostrating attacks averaging one in two months over last several months. 2. The Veteran's GERD with diarrhea does not result in diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress; or persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. 3. From August 22, 2012, the Veteran's left wrist disability does not result in ankylosis. 4. From August 22, 2012, the Veteran's right wrist disability does not result in ankylosis. 5. From August 22, 2012, the Veteran's left hip disability does not result in any ankylosis, hip flail joint, impairment of the femur, limitation of abduction, limitation of adduction, limitation of rotation, limitation of extension to 5 degrees, or limitation of flexion to 30 degrees. 6. From August 22, 2012, the Veteran's right hip disability does not result in any ankylosis, hip flail joint, impairment of the femur, limitation of abduction, limitation of adduction, limitation of rotation, limitation of extension to 5 degrees, or limitation of flexion to 30 degrees. 7. From August 22, 2012, to April 17, 2017, range of motion testing, even contemplating functional limitation due to pain, weakness, stiffness, fatigability, lack of endurance, and repetitive motion etc., was not shown to functionally limit the forward flexion of the Veteran's cervical spine to 30 degrees or less or functionally limit the combined range of motion of the cervical spine to 170 degrees or less; muscle spasms, guarding, or localized tenderness was not shown; vertebral body fracture with loss of 50 percent or more of height was not shown; ankylosis of the spine was not shown; and incapacitating episodes having a total duration of at least two weeks during a 12 month period were not shown. 8. Beginning April 17, 2017, range of motion testing, even contemplating functional limitation due to pain, weakness, stiffness, fatigability, lack of endurance, and repetitive motion etc., was not shown to functionally limit the forward flexion of the Veteran's cervical spine to 15 degrees or less or functionally limit the combined range of motion of the cervical spine to 120 degrees or less; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour were not shown; ankylosis of the spine was not shown; and incapacitating episodes having a total duration of at least four weeks during a 12 month period were not shown. 8. From August 22, 2012, range of motion testing, even contemplating functional limitation due to pain, weakness, stiffness, fatigability, lack of endurance, and repetitive motion etc., was not shown to functionally limit the forward flexion of the Veteran's lumbar spine to greater than 30 degrees but not greater than 60 degrees or a combined range of motion of the lumbar spine not greater than 120 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour were not shown; ankylosis of the spine was not shown; and incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period were not shown. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). 2. The criteria for an initial rating in excess of 10 percent for GERD with diarrhea have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, Diagnostic Codes 7319, 7346 (2017). 3. From August 22, 2012, the criteria for a rating in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5214-15 (2017). 4. From August 22, 2012, the criteria for a rating in excess of 10 percent for a right wrist disability have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5214-15 (2017). 5. From August 22, 2012, the criteria for an initial rating in excess of 10 percent for a left hip disability have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5250-55 (2017). 6. From August 22, 2012, the criteria for an initial rating in excess of 10 percent for a right hip disability have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5250-55 (2017). 7. The criteria for ratings in excess of those assigned for a cervical spine disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 8. From August 22, 2012, the criteria for an initial rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In this case, required notice was met, and neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, adjudication of the claims at this time is warranted. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA treatment records, Social Security Administration (SSA) records, and private treatment records have been obtained. Additionally, the Veteran was schedule to testify at a hearing before the Board, but he withdrew his request for a hearing. The Veteran was also provided VA examinations and neither the Veteran, nor his representative, has objected to the adequacy of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Headaches In July 2009, the Veteran filed a service-connection claim for his headaches. In a December 2009 rating decision, he was granted service connection for his headaches at a noncompensable rate effective July 2, 2009, the day after his separation from active service. The Veteran disagrees with the assigned initial rating asserts that asserts that he is entitled to a higher rating. The Veteran's headaches are evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. A noncompensable rating is warranted for headaches with less frequent characteristic prostrating attacks. A 10 percent rating is warranted for headaches with characteristic prostrating attacks averaging one in two months over last several months. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent is warranted for headaches with very frequently completely prostrating and prolonged attacks productive of severe economic inadaptability. In October 2009, the Veteran was afforded a VA examination. He reported headache pain at 3/10. He denied having an aura, photophobial, phonophobia, or nausea. He was diagnosed with jaw clencher's headache. In April 2010, May 2010, June 2010, August 2010, and September 2010, the Veteran reported having headaches. In August 2012, the Veteran was afforded a VA examination. The examiner indicated that the Veteran did not take medications for his headaches. The examiner indicated that the Veteran experienced pulsating or throbbing head pain and pain on both sides of head. The examiner indicated that the Veteran did not have prostrating attacks of headache pain. The examiner indicated that the Veteran's headaches did not impact his ability to work. While the Veteran's treatment records show that he often denied having headaches, such as in April 2013, August 2013, July 2013, April 2014, June 2014, December 2015, and June 2016. In July 2014, he reported having occasional headaches. In March 2016, he reported having headaches two to four times per week. In April 2016, he reported having worsening headaches and his medications were adjusted. In June 2006, he denied having a headache. In December 2016, he reported having headaches a couple times per week. In April 2014, the Veteran was afforded a VA examination. He reported worsening headaches. He reported bright light triggered the headaches. The examiner indicated that the Veteran had constant head pain that lasted less than one day. The examiner indicated that the Veteran did not have characteristic prostrating attacks. The examiner indicated that the Veteran's headaches did not impact his ability to work. In July 2017, the Veteran reported having headaches eight to ten times per month. In July 2014, he reported having occasional headaches. As such, the Veteran's medical records and the findings at multiple VA examinations fail to establish that a higher disability rating is warranted as they do not show he has headaches with characteristic prostrating attacks. The Board is sympathetic to the concerns that have been voiced, and notes that the Veteran's headaches undoubtedly cause impairment as is suggested by the noncompensable rating that is assigned. However, the record contains no evidence showing that his headaches rise to the level of assignment of a compensable rating. The rating schedule was created as a guide to evaluating disability resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. 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. Here, the Veteran has not specifically identified any headache symptoms which would merit a higher schedular rating. The Veteran reported that light could cause headaches. However, the Veteran's medical record does not show that his headaches have resulted in characteristic prostrating attacks, which would be equivalent to a compensable rating. Accordingly, the criteria for a schedular compensable rating for the Veteran's headaches have not been met, and the Veteran's claim is denied. GERD with Diarrhea In July 2009, the Veteran filed a service-connection claim for his GERD with diarrhea. In a December 2009 rating decision, he was granted service connection for his headaches at a noncompensable rate effective July 2, 2009, the day after his separation from active service. In February 2016, the Board granted an increased initial rating of 10 percent, which was effectuated by an April 2016 rating decision. In December 2017, the Veteran was notified that his diarrhea was combined with his GERD as certain coexisting diseases within the digestive system do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle related to pyramiding. Therefore, when certain disabilities within the digestive system are closely related, a single evaluation will be assigned under the Diagnostic Code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. As the Veteran's GERD and diarrhea are considered to be closely related and, and as such, are evaluated together as one disability. The Veteran's GERD with diarrhea is evaluated under 38 C.F.R. § 4.114, Diagnostic Code 7319-7346. Under Diagnostic Code 7319, a noncompensable rating is warranted for disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is warranted for diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Under Diagnostic Code 7346, a 10 percent rating is warranted for GERD with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for GERD with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for GERD with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The examiner indicated that the Veteran's diarrhea and GERD did not impact his ability to work. The Veteran's treatment records do not show symptoms of either diarrhea or GERD that is equivalent to higher ratings. In October 2009, the Veteran was afforded a VA examination. He denied having abdominal pain or cramps or dysphagia, pyrolysis, epigastric pain, or retrosternal pain when taking medications. He reported having reflux and regurgitation of food if he lay down within two hours of eating. On examination, he had normal abdominal findings. In August 2012, the Veteran was afforded a VA examination. He reported having loose stools 14 to 16 times per day and that medications did not help at all. He reported that his GERD was controlled with medications and diet. The examiner indicated that the Veteran did not have abdominal distress. The examiner indicated that the Veteran's GERD resulted in pyrosis. The examiner indicated that the Veteran's GERD did not result in substernal arm or shoulder pain. The Board is sympathetic to the concerns that have been voiced, and notes that the Veteran's GERD with diarrhea undoubtedly causes some impairment as is suggested by the 10 percent rating that is assigned. However, the record does not show that his GERD with diarrhea rises to the level of assignment of a rating in excess of 10 percent. The rating schedule was created as a guide to evaluating disability resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Here, the Veteran has not specifically identified any GERD with diarrhea symptoms which would merit a higher schedular rating. The claims files fails to establish that the Veteran's GERD results in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation that is accompanied by substernal arm or shoulder pain. Of note, the VA examiner in August 2012 specifically found no arm or shoulder pain. In addition, the record does not show that the Veteran's diarrhea results in abdominal distress. Accordingly, the criteria for a schedular rating in excess of 10 percent for the Veteran's GERD with diarrhea have not been met, and the Veteran's claim is denied. Bilateral Wrist Disabilities In July 2009, the Veteran filed a service-connection claim for his left and right wrists. In a December 2009 rating decision, he was granted service connection for his left and right wrist disabilities at a noncompensable rate effective July 2, 2009, the day after his separation from active service. In February 2016, the Board granted an increased initial rating of 10 percent for each wrist prior to August 22, 2012, which was effectuated by an April 2016 rating decision. With respect to disabilities of the wrists, 38 C.F.R. § 4.71a, Diagnostic Codes 5214 through 5215 set forth relevant provisions. Upper extremity ratings depend on whether the disabled extremity is the major or minor extremity. The major extremity is the one predominantly used by the Veteran. Only one extremity may be considered to be major. 38 C.F.R. § 4.69. The Veteran is right handed. Therefore, his right wrist is his major extremity and his left wrist is his minor extremity. Diagnostic Code 5214 evaluates ankylosis of the wrist. No VA examiner has noted ankylosis of the wrists, and VA treatment records fail to suggest the presence of ankylosis. Moreover, the Veteran has not alleged symptomatology that would suggest the presence of ankylosis. Diagnostic Code 5215 evaluates wrist limitation of motion. A 10 percent rating is assigned for dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. The Veteran is already in receipt of the maximum rating under this Diagnostic Code. Wrist dorsiflexion is measured from 0 degrees to 70 degrees and wrist palmar flexion is measured from 0 degrees to 80 degrees. 38 C.F.R. § 4.71a, Plate I. The Veteran's treatment records fail to establish that higher disability ratings are warranted after August 22, 2012. While the Veteran was afforded a VA examination in August 2012, the Veteran asserted that the VA examination findings were inaccurate. As such, in February 2016, the Board remanded the Veteran's claims for a new VA examination. In April 2017, the Veteran was afforded a VA examination. He reported pain in both wrists. On examination, he demonstrated normal left and right wrist range of motion. Repetitive use testing did not result in additional loss of function or range of motion in either wrist. He retained normal 5/5 strength in both wrists with no muscle atrophy. He had no wrist ankylosis. The Veteran is in receipt of the maximum rating allowed based range of motion. The only rating available is a 20 percent rating for ankylosis of the wrist. However, there is no medical evidence showing ankylosis and the Veteran has not argued to the contrary. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, where, as here, a musculoskeletal disability is evaluated at the highest rating available based upon limitation of motion, further DeLuca analysis is foreclosed. Johnston v. Brown, 10 Vet. App. 80 (1997). Accordingly, the criteria for a schedular rating in excess of 10 percent for left and right wrist disabilities from August 22, 2012, have not been met. As such, the claims are denied. Bilateral Hip Disabilities In July 2009, the Veteran filed a service-connection claim for his left and right hips. In a December 2009 rating decision, he was granted service connection for his left and right wrist hips at a noncompensable rate effective July 2, 2009, the day after his separation from active service. In February 2016, the Board granted an increased initial rating of 10 percent for each hip prior to August 22, 2012, which was effectuated by an April 2016 rating decision. With respect to disabilities of the hip, 38 C.F.R. § 4.71a, Diagnostic Codes 5250 through 5255 set forth relevant provisions. Diagnostic Code 5250 evaluates ankylosis of the hip. No VA examiner has noted ankylosis of the right hip, and VA treatment records fail to suggest the presence of ankylosis. Moreover, the Veteran has not alleged symptomatology that would suggest the presence of ankylosis. Therefore, this Diagnostic Code is not applicable and will not be discussed further. Diagnostic Code 5251 evaluates limitation of extension. A 10 percent rating is assigned for extension limited to 5 degrees. Diagnostic Code 5252 evaluates limitation of flexion. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 20 degrees. A 40 percent rating is assigned for flexion limited to 10 degrees. Diagnostic Code 5253 evaluates an impairment of the thigh. A 10 percent rating is assigned for limitation of rotation to 15 degrees or limitation of adduction resulting in an inability to cross legs. A 20 percent rating is assigned for loss of abduction beyond 10 degrees. Diagnostic Code 5254 evaluates hip flail joint. The medical record does not document a right hip flail joint. Therefore, this Diagnostic Code is not applicable and will not be discussed further. Diagnostic Code 5255 evaluates an impairment of the femur. The medical record does not document an impairment of the right femur. Therefore, this Diagnostic Code is not applicable and will not be discussed further. Hip flexion is measured from 0 degrees to 125 degrees; abduction is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Veteran's treatment records fail to establish that a higher disability rating is warranted after August 22, 2012. In April 2017, the Veteran was afforded a VA examination. He reported having lain in the joints but nothing specific to the hips or sacroiliac joints. On examination, he demonstrated normal range of motion in both hips. Repetitive use testing resulted in no additional limitation of motion or functional loss. He had no evidence of pain with weight bearing. He retained normal 5/5 strength with no muscle atrophy. He had no hip ankylosis. Regarding limitation of flexion and extension, the Veteran's treatment records do not document flexion limited to 30 degrees or extension limited to 5 degrees. At the April 2017 VA examination, he had normal range of motion. Thus, the Veteran does not meet the criteria for a rating in excess of 10 percent for limitation of flexion or limitation of extension. Regarding an impairment of the thigh, again, the Veteran's treatment records do not document limitation of abduction, adduction, or rotation sufficient to merit a higher rating. At the April 2017 VA examination, he had normal range of motion. Thus, the Veteran does not meet the criteria for a compensable rating for an impairment of the thigh. Where a diagnostic code is predicated on loss of motion, VA must also consider 38 C.F.R. § 4.40, regarding functional loss due to pain, and 38 C.F.R. § 4.45, regarding weakness, fatigability, incoordination, or pain on movement of a joint. DeLuca, 8 Vet. App. 202. However, a rating in excess of 10 percent for the Veteran's service-connected left and right hip disabilities are not warranted on the basis of functional loss due to pain or weakness in this case. The Veteran's medical records show that he reported hip pain, but no functional loss was noted. The Board recognizes that at the April 2017 VA examinations, neither pain nor repetitive use were shown to so functionally limit the Veteran's range of motion as to support the assignment of even the lowest schedular rating. Nevertheless, the Veteran was properly assigned an initial disability rating of 10 percent in recognition of his right hip pain. A higher disability for the Veteran's left and right hip disabilities are not warranted. The record contains no evidence showing that his left or right hip disability rises to the level of assignment of a rating in excess of 10 percent. The rating schedule was created as a guide to evaluating disability resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. 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. Here, the Veteran has not specifically identified any left or right hip symptoms which would merit a higher schedular rating (such as ankylosis or a hip replacement). Rather, the hip symptoms that have been described, mainly pain, are consistent with a 10 percent rating. To this end, the Veteran was given a 10 percent rating each for his left and right hip disabilities. However, such a rating was assigned based on application of 38 C.F.R. § 4.59 which provides that painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Accordingly, the criteria for a schedular rating in excess of 10 percent for left and right hip disabilities from August 22, 2012, have not been met. As such, the claims are denied. Cervical Spine Disability In July 2009, the Veteran filed a service-connection claim for his cervical spine. In a December 2009 rating decision, he was granted service connection for his cervical spine disability at a noncompensable rate effective July 2, 2009, the day after his separation from active service. In February 2016, the Board granted an increased initial rating of 10 percent for his cervical spine disability prior to August 22, 2012, which was effectuated by an April 2016 rating decision. In a December 2017 rating decision, he was granted a 20 percent rating for his cervical spine disability effective April 17, 2017. Neck disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12 month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12 month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12 month period on appeal. 38 C.F.R. § 4.71a, 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The evidence of record does not show that the Veteran experienced IVDS for his cervical spine disability. The April 2017 VA examiner indicated that the Veteran did not have IVDS. There is also no evidence showing that the Veteran had been prescribed bed rest to treat his cervical spine disability. There is no contention to the contrary. Prescribed bed rest is a fundamental element for an evaluation under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating under these criteria. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran's cervical spine disability under the General Rating Formula for Diseases and Injuries of the Spine for the period. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted if forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or if there is muscle spasm 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 evaluation is warranted if forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees, the combined range of motion of the cervical spine not greater than 170 degrees; or if there is 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 evaluation is warranted if forward flexion of the cervical spine is 15 degrees or less or there is favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the cervical spine are flexion from 0 to 45 degrees, extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, and lateral rotation from 0 to 80 degrees. 38 C.F.R. § 4.71, Plate V. The Veteran's clinical records show that he was treated for neck pain, but do not describe the results of any specific range of motion testing or findings consistent with muscle spasm or guarding, abnormal spinal contour, reversed lordosis, or abnormal kyphosis from August 22, 2012. While the Veteran was afforded a VA examination in August 2012, the Veteran asserted that the VA examination findings were inaccurate. As such, in February 2016, the Board remanded the Veteran's claim for a new VA examination. In April 2017, the Veteran was afforded a VA examination. He reported neck pain that interfered with driving, recreational activities, and certain type of work. He denied having any numbness or tingling in his upper extremities. On examination, he demonstrated flexion to 30 degrees, extension to 20 degrees, left and right lateral flexion to 20 degrees, and left and right rotation to 40 degrees. The examiner indicated that there was evidence of pain with weight bearing. Repetitive use testing did not result in any additional loss of function or range of motion. He retained normal 5/5 upper extremity strength with normal reflexes and sensation. The examiner reported that a neurological examination was unremarkable. As such, from August 22, 2012, to April 17, 2017, the medical records show that the Veteran did not demonstrate either forward flexion or combined range of motion that was so functionally limited as to be consistent with a 20 percent rating. There was also no showing that the Veteran's cervical spine caused any alteration in gait or abnormal spinal contour. The medical record does not demonstrate findings consistent with a higher 20 percent evaluation. As such, a rating in excess of 10 percent is not warranted from August 22, 2012, to April 17, 2017. Beginning April 17, 2017, the medical records show that the Veteran did not demonstrate either forward flexion or combined range of motion that was so functionally limited as to be consistent with a 30 percent rating. There was also no showing that the Veteran's cervical spine caused any alteration in gait or abnormal spinal contour. The medical record does not demonstrate findings consistent with a higher 30 percent evaluation. As such, a rating in excess of 20 percent is not warranted beginning April 17, 2017. Furthermore, the VA examiner noted there was no evidence of radiculopathy. As such, a separate rating for radiculopathy is not warranted. The Board has considered whether higher disability evaluations are warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The Veteran reported neck pain that interfered with driving, recreational activities, and certain type of work. However, he retained cervical spine range of motion equivalent to the assigned ratings. In addition, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43. While the Veteran reported pain, repetitive use testing did not reveal additional limitation that would warrant higher ratings. Overall, the Veteran's treatment records do not demonstrate any additional functional limitations that would support the assignment of higher ratings. Accordingly, a schedular rating in excess of 10 percent from August 22, 2012, to April 17, 2017, and in excess of 20 percent afterwards, for a cervical spine disability is not warranted. As such, the claim is denied. Lumbar Spine Disability In July 2009, the Veteran filed a service-connection claim for his lumbar spine. In a December 2009 rating decision, he was granted service connection for his lumbar spine disability at a noncompensable rate effective July 2, 2009, the day after his separation from active service. In February 2016, the Board granted an increased initial rating of 10 percent for his lumbar spine disability prior to August 22, 2012, which was effectuated by an April 2016 rating decision. Back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Under the current Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a 10 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least one week but less than two weeks during a 12 month period on appeal. A 20 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least two weeks but less than four weeks during a 12 month period on appeal. A 40 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12 month period on appeal. A 60 percent rating is assigned when IVDS causes incapacitating episodes having a total duration of at least six weeks during a 12 month period on appeal. 38 C.F.R. § 4.71a, 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The evidence of record does not show that the Veteran experienced IVDS for his lumbar spine disability. The April 2017 VA examiner indicated that the Veteran did not have IVDS. There is also no evidence showing that the Veteran had been prescribed bed rest to treat his lumbar spine disability. There is no contention to the contrary. Prescribed bed rest is a fundamental element for an evaluation under this section of the rating schedule, the absence of any prescribed bed rest precludes a rating under these criteria. As such, a rating based on IVDS is not appropriate, and it is therefore more beneficial to evaluate the Veteran's lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is 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 20 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or if there is muscle spasm or guarding not resulting in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and lateral rotation from 0 to 30 degrees. 38 C.F.R. § 4.71, Plate V. The Veteran's clinical records show that he was treated for back pain, but do not describe the results of any specific range of motion testing or findings consistent with muscle spasm or guarding, abnormal spinal contour, reversed lordosis, or abnormal kyphosis from August 22, 2012. While the Veteran was afforded a VA examination in August 2012, the Veteran asserted that the VA examination findings were inaccurate. As such, in February 2016, the Board remanded the Veteran's claims for a new VA examination. In April 2017, the Veteran was afforded a VA examination. He reported having back pain all the time. On examination, he demonstrated flexion to 115 degrees, normal extension to 30 degrees, normal left and right lateral flexion to 30 degrees, and normal left and right rotation to 30 degrees, all without objective evidence of pain. The examiner indicated that there was no evidence of pain with weight bearing. Repetitive use testing resulted in no additional limitation or functional loss. He retained normal 5/5 lower extremity strength with no muscle atrophy. He had hypoactive reflexes and normal sensation but for the left lower leg, ankle, foot, and toes. The examiner indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The medical records show that the Veteran did not demonstrate either forward flexion or combined range of motion that was so functionally limited as to be consistent with a 20 percent rating. At the April 2017 VA examination, he demonstrated flexion greater than 60 degrees, had a combined range of motion greater than 235 degrees. The medical record does not demonstrate findings consistent with a higher 20 percent evaluation. As such, a rating in excess of 10 percent is not warranted. Furthermore, the VA examiner noted there was no evidence of radiculopathy. As such, a separate rating for radiculopathy is not warranted. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2016). Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (2016) (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45 (2016). The April 2017 VA examiner reported that the Veteran did not have pain on range of motion testing. In addition, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell, 25 Vet. App. 32, 36-38. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43. Repetitive testing did not reveal additional limitation that would warrant a 20 percent rating. Overall, the Veteran's treatment records do not demonstrate any additional functional limitations that would support the assignment of a higher rating. Accordingly, the criteria for a schedular rating in excess of 10 percent for a lumbar spine disability from August 22, 2012, have not been met. As such, the claim is denied. ORDER An initial compensable rating for headaches is denied. A rating in excess of 10 percent for GERD with diarrhea is denied. A rating in excess of 10 percent for a left wrist disability from August 22, 2012, is denied. A rating in excess of 10 percent for a right wrist disability from August 22, 2012, is denied. A rating in excess of 10 percent for a left hip disability from August 22, 2012, is denied. A rating in excess of 10 percent for a right hip disability from August 22, 2012, is denied. A rating in excess of those assigned for a cervical spine disability is denied. A rating in excess of 10 percent for a lumbar spine disability from August 22, 2012, is denied. REMAND The Veteran was last afforded a VA examination for his right shoulder disability in April 2017. However, he was granted a temporary 100 percent evaluation for convalescence from March 17, 2017, to June 1, 2017. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). Where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). As such, a new examination is required to evaluate the current nature and severity of the Veteran's right shoulder disability since his period of convalescence has ended. In addition, the issue of a TDIU is inextricably intertwined with the adjudication of the other remanded issues, and therefore it too will be remanded. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected right shoulder disability. In so doing, the examiner should ensure, consistent with 38 C.F.R. § 4.59, that the examination report include the results of the Veteran's active and passive motion, in addition to the results following repetitive motion testing. If it is not possible to complete any of the range of motion testing described above, it should be explained why. Failure to do so will result in an examination report being found inadequate. 2. Then readjudicate the appeal. If the claims remain denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the 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. §§ 5109B, 7112 (2012). ____________________________________________ KELLI A. KORDICH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs