Citation Nr: 20021878 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 17-16 719A DATE: March 27, 2020 ORDER The petition to reopen the claim for entitlement to service connection for right knee pain is granted. The petition to reopen the claim for entitlement to service connection for left knee pain is granted. Entitlement to a disability rating in excess of 40 percent for fibromyalgia is denied. Entitlement to a rating in excess of 40 percent for herniated discs, L4-5 and L5-S1, facet joint arthritis and degenerative disc disease lumbar spine (lumbar spine disability) is denied. From August 13, 2015, entitlement to a disability rating for left lower extremity radiculitis of 40 percent, but no higher, is granted. From August 13, 2015, entitlement to a disability rating for right lower extremity radiculitis in excess of 40 percent, but no higher, is granted. Entitlement to a total disability rating based upon individual employability (TDIU) is granted. REMANDED Entitlement to service connection for a bilateral knee disability is remanded. FINDINGS OF FACT 1. The Veteran’s claim for service connection for left knee pain was denied by a September 2013 rating decision. The Veteran did not perfect an appeal of this decision, and it became final. 2. Since the September 2013 rating decision, the Veteran has submitted new evidence that relates to a previously unestablished element of the claim and raises a reasonable possibility of substantiating the claim. 3. The Veteran’s claim for service connection for right knee pain was denied by a September 2013 rating decision. The Veteran did not perfect an appeal of this decision, and it became final. 4. Since the September 2013 rating decision, the Veteran has submitted new evidence that relates to a previously unestablished element of the claim and raises a reasonable possibility of substantiating the claim. 5. The Veteran’s fibromyalgia results in such symptoms as widespread musculoskeletal pain and tender points stiffness, muscle weakness, fatigue, sleep disturbance, paresthesias, headache, and Raynaud’s-like symptoms that are contemplated by the rating schedule. 6. The Veteran’s headaches do not result in very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability; and the symptoms are contemplated by her rating for service-connected fibromyalgia. 7. The Veteran’s lumbar spine disability has not more nearly approximated unfavorable ankylosis of the lumbar spine or the entire spine; or incapacitating episodes having a total duration of at least six weeks within a 12-month period. 8. From August 13, 2015, the Veteran’s left lower extremity radiculitis has been productive of moderately severe incomplete paralysis; the evidence does not establish severe incomplete paralysis or complete paralysis of the left lower extremity due to radiculitis. 9. From August 13, 2015, the Veteran’s right lower extremity radiculitis has been productive of moderately severe incomplete paralysis; the evidence does not establish severe incomplete paralysis or complete paralysis of the right lower extremity due to radiculitis. 10. The Veteran’s service-connected disabilities rendered her unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The September 2013 rating decision that denied the Veteran’s claims for service connection for left and right knee pain is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The evidence received since the September 2013 rating decision is new and material, and the claims for service connection for left and right knee pain are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for a disability rating in excess of 40 percent for fibromyalgia have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.71a, Diagnostic Code (DC) 5025, 4.124a, 8100. 4. The criteria for entitlement to a rating in excess of 40 percent for lumbar spine degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5242-5237. 5. From August 13, 2015, the criteria for a 40 percent rating, but no higher, for left lower extremity radiculitis have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1-4.7, 4.14, 4.124, 4.124a, DC 8520. 6. From August 13, 2015, the criteria for a 40 percent rating, but no higher, for right lower extremity radiculitis have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1-4.7, 4.14, 4.124, 4.124a, DC 8520. 7. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1987 to September 1991. New and Material Evidence, Generally Generally, a claim that has been denied by an unappealed RO decision or an unappealed Board decision may not thereafter be reopened. 38 U.S.C. §§ 7104 (b), 7105(c). An exception to this rule exists for cases in which new and material evidence is presented or secured with respect to a claim that has been disallowed, in which case the claim must be reopened, and the former disposition reviewed. 38 U.S.C. § 5108. “New” evidence means evidence not previously submitted to agency decision makers, and “material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). This is a “low threshold” in which the phrase “raises a reasonable possibility” should be interpreted as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). The credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). The Veteran’s claim for service connection for a left and right knee pain was denied by a September 2013 rating decision. The RO stated that the medical evidence did not show that the Veteran’s right or left knee disabilities were related to her service-connected back condition. As evidence of a nexus between the Veteran’s knee disabilities and her service-connected disabilities were not found, service connection was denied. The decision was not appealed and the denial of the Veteran’s claim for service connection for left and right knee pain became final. 38 U.S.C. § 7105. Since the September 2013 rating decision, additional evidence has been associated with the claims file. In January 2020, the Veteran provided testimony that during service she was in the back of the plane prior to takeoff and she fell onto her knees injuring them. She reported that she did not seek treatment at that time but that she believed her current arthritis was related to her in-service injury. This evidence is new, as it was not part of the record at the time of the prior denial of the claim. It is also material, as it relates to the previously unestablished element of whether a nexus exists between her knee disabilities and an incident of her period of service. When viewed with the previous evidence of record, this evidence indicating that the Veteran suffered an injury to her knees during service and a potential direct relationship between her osteoarthritis of her knees is neither cumulative nor redundant and raises a reasonable possibility of substantiating her claim. As such, new and material evidence has been received, and reopening the claim is warranted. Entitlement to a disability rating in excess of 40 percent for fibromyalgia The Veteran has contended that a rating in excess of 40 percent is warranted for her service-connected fibromyalgia. The Veteran’s condition has been assigned a 40 percent rating pursuant to Diagnostic Code (DC) 5025 for fibromyalgia (fibrositis, primary fibromyalgia syndrome). 38 C.F.R. § 4.71a. Under DC 5025, fibromyalgia is described with symptoms of widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms. A maximum 40 percent rating is assigned for symptoms which are constant, or nearly constant, and refractory to therapy. A 40 percent rating is the maximum schedular rating available under DC 5025, and thus, a higher rating is not available under that code. 38 C.F.R. § 4.71a, DC 5025. Furthermore, the Board finds that a separate or higher rating is not warranted under any other diagnostic code. According to fibromyalgia disability benefits questionnaire submitted by the Veteran, dated in January 2020, the Veteran’s fibromyalgia results in such reported symptoms as widespread musculoskeletal pain, stiffness, muscle weakness, fatigue, sleep disturbance, paresthesias, headache, and Raynaud’s-like symptoms. The examiner also noted that the Veteran’s condition causes polyarthralgia and joint pain. Such symptoms are contemplated by the rating criteria found within Diagnostic Code 5025. While the Veteran suffers from symptoms of headaches, the Board finds that a separate rating or higher rating based upon her headaches alone is not warranted. Under DC 8100, a 50 percent rating is warranted for migraines or headaches that very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. Here, the evidence does not establish that the Veteran’s headaches on their own are productive of such symptoms. The Veteran did not report such headache symptoms during her January 2020 Board hearing, and they are not documented by her May 2017 fibromyalgia examination or the DBQ submitted in January 2020. As such a higher rating is not warranted pursuant to 38 C.F.R. § 4.124a, 8100. The Board notes that it may not assign separate ratings for the same manifestations of disability under multiple diagnoses, as such would compensate the Veteran twice for the same symptomatology and “would overcompensate the claimant for the actual impairment of his earning capacity.” Brady v. Brown, 4 Vet. App. 203, 206 (1993). Such would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. See also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (“two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology”). Particularly, the Board finds that separate rating for headaches under DC 8100 is not warranted as headaches are specifically contemplated under the Veteran’s 40 percent rating for fibromyalgia under DC 5025. The Board has also considered the assignment of staged ratings but finds this is not warranted given that the maximum schedular evaluation is being assigned for the entire period on appeal. 38 C.F.R. § 4.14. Additionally, the Board finds that with respect to an extraschedular rating under 38 C.F.R. § 3.321 (b)(1), the applicable rating criteria adequately contemplates the manifestations of the Veteran’s fibromyalgia - namely, widespread pain, headaches, and fatigue, and the evidence does not show anything unique or unusual about the Veteran’s fibromyalgia disability that would render the schedular criteria inadequate. There are no additional symptoms of her fibromyalgia disability that are not addressed by the various provisions of the Rating Schedule or already contemplated by other service-connected disabilities. The rating criteria are thus adequate to evaluate the disability, and referral for consideration of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Entitlement to a rating in excess of 40 percent for herniated discs, L4-5 and L5-S1, facet joint arthritis and degenerative disc disease lumbar spine The Veteran has contended that a rating in excess of 40 percent is warranted for her service-connected lumbar spine disability. The Veteran’s lumbar spine disc disease has been rated under DC 5242-5237. The Veteran’s condition can either be evaluated according to the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or according to the Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episodes Formula). 38 C.F.R. § 4.71a, DC 5235-5243. Under the General Formula, a 40 percent evaluation is warranted under the General Formula when there is forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted where there is unfavorable ankylosis of the entire spine (meaning when considering the adjacent cervical segment as well). See 38 C.F.R. § 4.71a, DC 5237, General Formula. 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. See id., Note (5). The General Formula applies for rating purposes with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. When rating according to the General Formula, any associated objective neurologic abnormalities are rated separately under their respective diagnostic codes. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Veteran’s lumbar spine disability can also be rated using the Incapacitating Episodes Formula. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. This formula allows for a rating of 20 percent if there have been incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months; a 40 percent evaluation was assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past twelve months; and a 60 percent evaluation was assigned for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Incapacitating Episodes Formula. For the purposes of this formula, 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. Id. at Note (1). The Board finds that a rating in excess of 40 percent is not warranted throughout the appeal period. In order to warrant a rating in excess of 40 percent under the schedular rating criteria for a lumbar spine disability, the Veteran must demonstrate evidence of unfavorable ankylosis of the thoracolumbar spine, incapacitating episodes of at least six weeks within a 12-month period, or unfavorable ankylosis of the entire spine. The evidence does not support such a finding. First, none of the competent, credible evidence of record indicates that the Veteran has ankylosis (favorable or unfavorable) of the Veteran’s spine. The August 2015 and June 2017 examiners each denied that ankylosis of the Veteran’s spine was present during the examination. Further, while the Veteran was noted to have severe limitation of motion of the lumbar spine during both examinations, both examiners reported that the Veteran has retained some ability to bend her lumbar spine. To the extent that the Veteran reports that she is unable to bend her spine without pain, the Board notes that a higher 50 percent or 100 percent rating are only warranted for unfavorable ankylosis of the thoracolumbar spine or the entire spine. As the evidence does not indicate that the Veteran’s spine is permanently fixed in a non-favorable position, her condition would not more nearly approximate unfavorable ankylosis of the lumbar spine. VA treatment records also do not indicate that the Veteran suffers from ankylosis of the lumbar spine, or that she has been prescribed bed rest for at least 6 weeks during the prior 12 months. While the Veteran reported requiring bed rest approximately 2-3 days per month during her Board hearing, the Board notes that such restrictions would not equate to at least six weeks over a 12-month period. Further, separate ratings are not warranted for neurological manifestations under the IVDS. As will be discussed below, the Veteran is in receipt of two separate 40 percent ratings for left and right lower extremity radiculopathy under the General Formula. As these ratings with the Veteran’s 40 percent rating would rate in excess of 60 percent, the Board finds that a higher rating based upon the IVDS is not warranted. In conclusion, the Board finds that a rating in excess of 40 percent based upon the Veteran’s lumbar spine disability is not warranted throughout the appeal period. See 38 C.F.R. § 4.3; 4.71a, DC 5242-5237. Entitlement to a disability rating for left lower extremity radiculitis in excess of 10 percent prior to February 15, 2017; and in excess of 20 percent, thereafter Entitlement to a disability rating for right lower extremity radiculitis in excess of 10 percent As discussed above, under the General Formula, associated objective neurologic abnormalities are rated separately under their respective diagnostic codes. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). As such, entitlement to an increased rating for left lower extremity radiculitis and right lower extremity radiculitis is considered part and parcel of the Veteran’s increased rating claim for her lumbar spine disability and will be considered since the Veteran’s August 13, 2015 claim for an increase. After resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran’s left and right lower extremity radiculitis each warrant a 40 percent rating, but no higher, from August 13, 2015. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is assignable for moderately severe incomplete paralysis. A 60 percent rating is assignable for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is assignable for complete paralysis of the sciatic nerve, in which the foot dangles and drops and there is no active movement possible of muscles below the knee, flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. The terms “mild,” “moderate,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The term “incomplete paralysis” indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Throughout the appeal period, the Veteran has complained of significant left and right lower extremity radiculopathy symptoms. During the Veteran’s August 2015 VA back examination, the examiner stated that the Veteran had left and right radiculopathy symptoms that resulted “moderate” constant pain and “mild” intermittent pain, numbness, and paresthesias and dysesthesias. The examiner also noted reduced deep tendon reflexes and decreased sensation of the lower extremities bilaterally. The examiner reported that the overall condition resulted in “moderate” impairment of the left and right lower extremities. However, due to potential overlapping symptoms with the Veteran’s service-connected fibromyalgia, a medical opinion was obtained regarding the etiology of her radicular symptoms to determine the extent of her symptoms due to her service-connected back condition to avoid impermissible pyramiding. See 38 C.F.R. § 4.14. In November 2015, the VA examiner opined that bilateral lower extremity radicular symptoms and degenerative disc disease in conjunction with her lumbar spine disabilities. The examiner noted that the findings were compatible with her service-connected bilateral radiculopathy and are unrelated to her fibromyalgia symptoms. The examiner stated that there is overlap between her lumbar radiculopathy and her fibromyalgia pain, to the extent that separately listing the fibromyalgia symptoms from the radicular symptoms would require resorting to conjecture. The examiner opined that the radiculopathy symptoms by themselves are mild, but in combination with the fibromyalgia symptoms enough to warrant a moderately severe diagnosis. The Board finds that the examiner could not clearly separate the Veteran’s lower extremity radicular symptoms related to her back condition from those caused by her fibromyalgia. The Board may not compensate the Veteran twice for the same symptoms and impairment. 38 C.F.R. § 4.14 (avoidance of pyramiding); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (stating that the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). While the examiner attempted to provide an opinion regarding the relative severity of each condition, the examiner indicated that it would be resorting to mere speculation to do so and the examiner provided no substantive rationale for the allocation of each percentage to the Veteran’s respective conditions. The Board notes that any overlap of symptomatology should have resulted in the lack of separate ratings. See id. The Board finds, however, that the Veteran should be granted the higher of the two options. The examiner indicated that the total manifestations of the Veteran’s radiculopathy would result in moderately severe incomplete paralysis, which would warrant a 40 percent rating for each extremity, rather than a single 40 percent rating for fibromyalgia pursuant to DC 5025. (Even separate ratings of 40 percent (fibromyalgia), 20 percent (left lower extremity radiculitis), and 10 percent (right lower extremity radiculitis) as currently assigned would have a lower combined rating than two separate 40 percent ratings. See 38 C.F.R. § 4.25. As such, the Board finds that separate 40 percent ratings should be assigned for the Veteran’s left and right lower extremity radiculopathy since the Veteran’s date of claim, August 13, 2015. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. The Board, however, finds that a rating in excess of 40 percent for radiculitis of the left and right lower extremities is not warranted during the appeal period. Under DC 8520, a 60 percent rating is only warranted for “severe” incomplete paralysis with marked muscle atrophy and an 80 percent rating is assignable for complete paralysis of the sciatic nerve. The Veteran has not been diagnosed with muscle atrophy of the bilateral lower extremities due to her radiculitis and the June 2017 examination did not demonstrate reduced muscle strength of either the left or right lower extremity. As such, the Veteran’s condition more nearly approximates “moderately severe” radiculopathy of the left and right lower extremity. In sum, the Board finds that from August 13, 2015 a rating 40 percent, but no higher, is warranted for “moderately severe” left lower extremity radiculitis. Additionally, a rating 40 percent, but no higher, is warranted for “moderately severe” right lower extremity radiculitis. 38 C.F.R. §§ 4.3, 4.124a, DC 8520. To the extent that the Veteran seeks a rating in excess of 40 percent for left or right lower extremity radiculitis, the Board finds that the preponderance of the evidence is against a rating in excess of 40 percent. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1991). Entitlement to a total disability rating based upon individual employability The Veteran seeks a total rating based on individual unemployability, claiming that she has been unable to work as a result of her service-connected disabilities. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to secure and follow substantially gainful employment. See 38 C.F.R. § §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran is now service-connected for a lumbar spine disability, rated as 40 percent disabling; left lower extremity radiculitis, rated as 40 percent disabling; right lower extremity radiculitis, rated as 40 percent disabling; focal segmental glomerulosclerosis with proteinuria and hypertension, rated 30 percent disabling; as well as for fibromyalgia and a scar of the right breast. The Veteran has a combined disability rating in excess of 70 percent and at least one disability rated 40 percent disabling. Therefore, she meets the percentage requirements set forth in section 4.16(a) for consideration of TDIU. Thus, the next question for consideration is whether her service-connected disabilities prevent her from securing and following substantially gainful employment. For the following reasons, a TDIU is warranted. During her January 2020 Board hearing, the Veteran reported that she had been unable to secure gainful employment since 2006 due to her service-connected disabilities. She reported that she had a high school education and that she had worked for 12 years prior to 2006 as a postal employee. She stated that the job was very physical in nature and that she was no longer able to meet the physical demands of the job. She stated that she applied for (and received) Social Security Disability benefits after losing her job with the Postal Service due to problems with her feet and her shoulders. In January 2020, the Veteran submitted a Fibromyalgia DBQ completed by B.W., M.D. The examiner stated that the Veteran was last able to work in 2006. The examiner opined that all of her painful symptoms and fatigue limit her ability to perform activities of daily living. The examiner noted that her low back pain, knee pain, and shoulder pain limit her functional mobility. The examiner also opined that the totality of her symptoms prevent her from any work duties. The “applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner.” Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The Board finds that the evidence of record reflects that the Veteran’s service-connected fibromyalgia and lumbar spine disability (along with its associated neurological impairments) precluded her from securing substantially gainful employment given her educational and occupational history. The Board finds that the Veteran’s pain and fatigue caused by her fibromyalgia, as well as, her pain and functional limitations due to her lumbar spine disability (and associated radicular symptoms) would preclude her from obtaining and maintaining substantially gainful employment. The fact that nonservice-connected disabilities may have also impacted the Veteran’s ability to work does not affect the Board’s analysis, as nonservice-connected disabilities cannot be considered under the above cited regulations in adjudicating the issue of entitlement to a TDIU. The Board, however, finds that the Veteran’s unemployability is due to both her fibromyalgia and her service-connected back disability. To the extent that the 2020 examiner indicated that the symptoms of her fibromyalgia alone resulted in unemployability, the Board notes that the examiner specifically cited the Veteran’s back symptoms (report as due to fibromyalgia) as one of the reasons for the opinion provided and stated that the “totality” of her symptoms prevent her from any work duties. The Board finds that it is too difficult to attribute to parse the symptomatology of the Veteran’s fibromyalgia and her service-connected lumbar spine disability to determine that one condition or the other on its own would result in her inability to secure or maintain gainful employment. Particularly, the Board notes that (as discussed above) an examiner in 2015 opined that they would need to resort to mere speculation to determine whether the Veteran’s lower extremity symptoms are due to her low back disability or her fibromyalgia. This is supported by the indications from the 2020 DBQ examiner that some overlapping back symptoms would impact the Veteran’s inability to secure or maintain substantially gainful employment. As such, the Board finds that the Veteran’s fibromyalgia and her lumbar spine disability have rendered her unable to secure or follow substantially gainful employment in light of her education and employment history. Therefore, entitlement to a TDIU is warranted. 38 C.F.R. § 4.16 (a). The Board will not specify the effective date of the TDIU to allow the RO to do so in the first instance. See Urban v. Principi, 18 Vet. App. 143, 145 (2004) (per curiam order) (“To the extent that [the appellant] is arguing that the Board must assign, sua sponte, an effective date once it awards a rating of TDIU on appeal from an RO decision, such an argument is unavailing unless an notice of disagreement is then of record as to the downstream issue of an effective date for the assignment of that rating.”) REASONS FOR REMAND Entitlement to service connection for a bilateral knee disability is remanded. The record does not obtain an adequate opinion on whether the Veteran’s currently diagnosed osteoarthritis of the bilateral knees is etiologically related to her active service. The Veteran has reported a fall during service on her knees, which she contends may have resulted in residual disability and no opinion regarding the etiology of these conditions has been provided. Further, the Board finds that the secondary opinion provided in October 2012 is inadequate to address the Veteran’s claim. The examiner stated that “based on the Veteran’s previous lumbar examination her current strength, range of motion, gait pattern, and sensation are too functional too cause bilateral knee pathology… Moreover, the medical literature does not substantiate a nexus between lumbar disease and bilateral knee pathology.” The examiner first indicates that the Veteran’s lumbar disability was not significant enough at that time to support a link between her lumbar spine condition and her bilateral knee arthritis, but then states that “medical literature does not substantiate a nexus between lumbar disease and bilateral knee pathology.” This opinion appears to be internally inconsistent stating that the conditions that would need to be met for a lumbar spine condition to cause a knee disability have not been met, but then also asserting that medical science does not support such a link. The Board finds that new opinion with a comprehensive rationale should be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). The matters are REMANDED for the following action: 1. The Veteran must be afforded an examination with an appropriate clinician to determine the etiology of any current disability of her bilateral knees. The claims file and all electronic records must be made available to the examiner. The examiner is specifically asked to provide the following opinions: Is it at least as likely as not (a 50 percent probability) that any current disability of the Veteran’s knees is due to, or the result of, any incident of her period of active service. Is it at least as likely as not (a 50 percent probability) that any current disability of the Veteran’s knees is due to, or the result of, any service-connected disability, to include her lumbar spine. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must also indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.M. Johnson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.