Citation Nr: 20032408 Decision Date: 05/07/20 Archive Date: 05/07/20 DOCKET NO. 14-22 144 DATE: May 7, 2020 ORDER Prior to June 22, 2016, subject to the laws and regulations governing the award of monetary benefits, entitlement to an initial rating of 20 percent for degenerative joint disease (DJD) of the sacrococcygeal joints is granted. From June 22, 2016, subject to the laws and regulations governing the award of monetary benefits, entitlement to a 40 percent rating, but no higher, for degenerative joint disease (DJD) of the sacrococcygeal joints is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to June 22, 2016, the Veteran's back disability more nearly approximated painful limitation of forward flexion more than 30 degrees but not greater than 60 degrees with abnormal gait. 2. From June 22, 2016, the Veteran’s back disability more nearly approximates painful limitation of forward flexion to 30 degrees or less without ankylosis. 3. From June 22, 2016, the Veteran’s back disability has not been manifested by unfavorable ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating of 20 percent for degenerative joint disease (DJD) of the sacrococcygeal joints prior to June 22, 2016 have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.59, 4.71a, Diagnostic Code 5236 (2018). 2. The criteria for entitlement to a 40 percent rating, but no higher, for degenerative joint disease of the sacrococcygeal joints from June 22, 2016 have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.59, 4.71a, Diagnostic Code 5236 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from May 1959 to May 1963. This appeal to the Board of Veteran’s Appeals (Board) arose from a December 2011 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran has perfected a timely appeal. See May 2012, Notice of Disagreement; March 2014, Statement of the Case (SOC); April 2014, Substantive Appeal (VA Form 9). The Veteran requested a hearing before the Board. The requested hearing was conducted in January 2017 by the undersigned Veterans Law Judge. A transcript of the hearing is associated with the file. At the hearing, the issue of entitlement to a TDIU rating was raised as part and parcel of the claim for an increased rating for his service-connected low back disability. The Board assumed jurisdiction over this derivative claim of TDIU as a component of the Veteran’s increased rating claim pursuant to Rice v. Shinseki, 22 Vet. App. 477 (2009). In July 2017, the Board denied entitlement to an increased rating for the Veteran’s service-connected low back disability and TDIU rating. The Veteran appealed the July 2017 Board decision to the Court of Appeals for Veterans Claims (CAVC or Court), which vacated the decision and remanded it back to the Board for further development in June 2018, pursuant to a Joint Motion for Remand (JMR). In December 2018, the Board remanded the claims for further evidentiary development. In an April 2020 rating decision, the RO granted an increased rating of 40 percent for DJD of the sacrococcygeal joints, effective April 16, 2019. Because the maximum benefit was not granted now or during the pendency of the appeal period, the issue of entitlement to a higher evaluation remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that in response to the April 2020 Supplemental Statement of the Case (SSOC), the Veteran, through his representative, waived the 30-day period allowed for a response and submission of evidence. See April 2020 Report of General Information (VA Form 27-0820). In May 2020, the Veteran expressed that he did not want to wait for the 30 days to expire and “accept the decision.” See May 2020 Report of General Information (VA Form 27-0820). Regarding the statement of “accept the decision”, the Board construes this as that the Veteran does not have any more evidence or argument to submit in support of his claim, not as a withdrawal of the claims on this appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2018). 38 U.S.C.§ 7107 (a)(2) (2012). Increased (Initial) Rating 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. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Prior to April 16, 2019, entitlement to an initial rating in excess of 10 percent, and from April 16, 2019, a rating in excess of 40 percent, for degenerative joint disease (DJD) of the sacrococcygeal joints. The Veteran is seeking a higher rating for his low back disability. The Veteran’s disability is rated under Diagnostic Code 5236, which evaluates sacroiliac injury and weakness. Prior to April 16, 2019, the Veteran was assigned a 10 percent rating. From April 16, 2019, the Veteran is assigned a 40 percent rating. This disability is rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, 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 disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Turning now to the evidence of the record, in a February 2009 VA treatment record, the Veteran complained of low back pain. The Veteran reported that he injured his back when he was in service and the pain worsened in the past week. In July 2009, the Veteran reported continuing low back pain. The Veteran stated that he went walking yesterday and felt pain and numbness in his legs. The Veteran had not taken any medication to control the pain. There was no focal tenderness in the spine. Straight leg testing elicited pain in the right leg. Sensation was intact. The Veteran denied saddle anesthesia, bowel, or bladder problems. Buddy Statements from the Veteran’s family and friends submitted in September 2010 outlined the observations of the Veteran experiencing back pain. They witnessed how the Veteran’s back disability limited the Veteran’s movement and activities. In the July 2011 Statement in Support of Claim, the Veteran expressed that he could not stand for any length of time or walk for any distance without pain. At the July 2011 VA examination, the Veteran reported injuring his back in 1960 when he slipped, fell, and broke his “tail bone. The Veteran reported experiencing discomfort intermittently since the injury. The Veteran reported the pain radiating into his buttocks bilaterally. The Veteran reported that it was too painful to hyperextend the lower back. The Veteran reported experiencing pain when he sat in a particular type of chair. The Veteran tried to wear a lower back brace occasionally. There were no reported associated bowel or bladder incontinence issues. At the December 2011 VA examination, it was noted that during his service, the Veteran saw a doctor due to injuring his back. The Veteran reported that he had on and off low back pain between the 1960’s and 1990’s. The Veteran described the current near constant low back pain as aching, in the mid coccygeal region. The Veteran took Aleve two to three times per week to alleviate the pain. The Veteran was unable to walk more than one block without having to stop or stand more than ten minutes without having to sit down due to discomfort. The Veteran did not report any flare-ups. The range of motion was noted as follows: forward flexion was 90 degrees with pain; extension was 30 degrees, with pain noted; right lateral flexion 30 degrees with pain; left lateral flexion was 30 degrees with pain; right rotation was 30 degrees; left rotation was 30 degrees. The Veteran was able to perform repetitive-use testing. There was no change in the range of motion after repetitive-use testing. The Veteran did not have functional loss or impairment of his back. The Veteran did not have localized tenderness or pain on palpation of joints or soft tissue. The Veteran did not have guarding or muscle spasm. The Veteran's muscle strength was normal. His reflexes were normal, and his sensory examination results were normal. Straight leg raising test results were negative. The Veteran did not have radiculopathy. The Veteran did not have any neurologic abnormalities or intervertebral disc syndrome (IVDS). The Veteran did not use assistive devices. Arthritis was noted. The Veteran had a vertebral fracture, but the Veteran did not lose any percentage of vertebral body. A December 2011 imaging record showed that the views of the sacrococcygeal segments degenerative arthrosis changes at the junction. It was suggestive of fairly healed previous fracture deformity about the sacrococcygeal junction. No obvious recent fracture of other localizing signs of bone or soft tissue abnormality were seen from the imaging scans. In an August 2012 correspondence, the Veteran’s neighbor expressed that the Veteran complained about his back. The neighbor stated that the Veteran used a shopping cart as his walker due to the pain in his back. In September 2012, a doctor stated that the Veteran came to the facility for his back pain in 1985 for a few months. The doctor endorsed that the Veteran was in severe pain. In a January 2014 VA examination, the Veteran reported continuing low back pain since service. The Veteran was advised against taking Aleve for treatment. The Veteran took ibuprofen, which he felt did not work at all. The Veteran reported experiencing sharp pain at times. The Veteran did not report any flare-ups. The range of motion was noted as follows: forward flexion was 90 degrees; extension was 30 degrees; right lateral flexion 30 degrees; left lateral flexion was 30 degrees; right rotation was 30 degrees; left rotation was 30 degrees. The Veteran was able to perform repetitive-use testing. There was no change in the range of motion after repetitive-use testing. The Veteran did not have functional loss or impairment of his back. The Veteran did have localized tenderness or pain on palpation of joints or soft tissue. The Veteran did not have guarding or muscle spasm. The Veteran's muscle strength was normal. His reflexes were hypoactive in his ankles. His sensory examination results were normal. Straight leg raising test results were all negative. The Veteran did not have radiculopathy. The Veteran did not have any ankylosis. The Veteran did not have any neurologic abnormalities or intervertebral disc syndrome (IVDS). The Veteran did not use assistive devices. Arthritis was not documented. Regarding functional impact, the Veteran reported for the last several years, there has been pain with prolonged sitting and standing. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability either during flare-ups or when the sacro-coccygeal joint is used repeatedly over a period of time. The examiner noted that a healed sacral fracture without historical objective evidence with chronic issues would not be the cause of limited range of motion 50 years later. Any limitation in the spine’s range of motion is more strongly related to the changes associated with the aging process. In an April 2014 Buddy Statement, the Veteran’s friend asserted observing the Veteran’s experiences with his back pain. The friend expressed that the Veteran’s walk had changed and that he did not have the same gait as before. In the June 2016 VA examination, the Veteran did not report any flare-ups but reported experiencing functional loss and impairment. The range of motion was noted as follows: forward flexion was 65 degrees; extension was 20 degrees; right lateral flexion 30 degrees; left lateral flexion was 30 degrees; right rotation was 30 degrees; left rotation was 30 degrees. Pain was noted in all planes. The abnormal range of motion contributed to functional loss, described as slow movement. Pain noted on the examination caused functional loss. There was evidence of pain with weight-bearing. The Veteran did have localized tenderness or pain on palpation of joints or soft tissue. The Veteran was able to perform repetitive-use testing. There was no change in the range of motion after repetitive-use testing. The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, fatigue, lack of endurance, and incoordination significantly limited functional ability with repeated use over time. The examiner could not describe the limitation in terms of range of motion without resorting to speculation. The Veteran did have guarding that resulted in abnormal gait or abnormal spinal contour. The Veteran's muscle strength was normal. He did not have muscle atrophy. His reflexes were normal, and his sensory examination results were normal. Straight leg raising test results were all negative. The Veteran did not have radiculopathy. He did not have ankylosis. The Veteran did not have any neurologic abnormalities or intervertebral disc syndrome (IVDS). The Veteran used a brace regularly for an assistive device. Regarding functional impact, limitation of bodily function was noted as moderate and limitation of performing activities of daily living disability was noted as moderate. At the January 2017 Board Hearing, Veteran asserted that his back symptoms have worsen over time. The Veteran also endorsed weakness and numbness in his lower extremities. In a June 2018 Buddy Statement, the Veteran’s neighbor stated witnessing the Veteran have difficulty walking and standing due to his back problems. The Veteran’s friend also endorses witnessing the Veteran have difficulty walking due to his back pain when they both were walking to the dentist’s office. At the April 2019 VA examination, the Veteran reported taking over the counter medication for his back pain. The Veteran reported flare-ups, describing that during the flare-up, he has difficulty doing everything. The Veteran experienced functional loss, describing it as difficulty walking. Range of motion was noted as follows: forward flexion was 10 degrees; extension was 10 degrees; bending to both sides was 10 degrees; right rotation was 20 degrees; left rotation was 15 degrees. Abnormal range of motion contributed to functional loss. Pain was noted for all planes. Pain and pulling contributed to functional loss. Non-weightbearing range of motion was noted as follows: forward flexion was 10 degrees; extension was 10 degrees; bending to both sides was 10 degrees; right rotation was 10 degrees; left rotation was 10 degrees. No evidence of pain with weightbearing. The Veteran walked with a normal gait. There were no areas of palpatory tenderness. The examiner noted that passive range of motion is contraindicated in painful spinal disorders. The Veteran was able to perform repetitive-use testing. There was no change in the range of motion after repetitive-use testing. The Veteran was being examined immediately after repetitive use over time. The examination was not conducted during a flare-up. The examination was neither medically consistent nor inconsistent with the Veteran's statements regarding functional loss during flare-ups. The examiner stated that after taking the history, conducting the examination, and reviewing the available records, there was no basis to offer additional losses of function or motion when it comes to repetitive use during a flare-up. The Veteran did not have guarding or muscle spasm. There were no additional factors contributing to the disability. The results of the muscle strength testing was noted as follows: Grade 4+ for hip flexors bilaterally with low back pain; Grade 5 for quadriceps; Grade 2+ for hamstrings with low back pain; Grade 4+ for ankle dorsiflexors and extensor hallucis longus bilaterally with low back pain; Grade 5 for ankle plantar flexes. The Veteran did not have muscle atrophy. Reflex examination showed +1 to the knees and ankles. Sensory examination was normal. Straight leg raising test results were all negative. The Veteran did not have radiculopathy. He did not have ankylosis. Regarding neurologic abnormalities, there was no bowel or bladder incontinence. The Veteran reported that he had some problems with his urinary stream not being strong and the examiner advised that he discussed that issue with his primary care doctor. The Veteran did not have IVDS. The Veteran used a cane regularly for an assistive device. The examiner remarked that the Veteran complained of pain that radiated to his right buttock. It was intermittent and described as severe. He reported right lower extremity weakness. The current level of severity was noted to be mild to moderate. At the November 2019 VA examination, the Veteran reported increased pain in his back. The Veteran took Aleve, as he felt it was the most effective medication for him. He reported that the pain was always present, having some good and bad days. The Veteran experienced increased pain with standing and walking. He took hot showers when the pain was severe. The Veteran described pain shooting up his back to his forehead sometimes. The Veteran would sleep in the chair when that pain occurred. At the examination, the Veteran described pain that radiated to his right buttocks. The Veteran reported flare-ups, describing them as being difficult to move some days. Functional loss and impairment were described as limited walking and standing. Range of motion was noted as follows: forward flexion was 10 degrees; extension was 10 degrees; right lateral flexion 10 degrees; left lateral flexion was 10 degrees; right rotation was 15 degrees; left rotation was 15 degrees. Abnormal range of motion contributed to functional loss, described as decreased ability to bend in all directions. Pain was noted in all planes, but it did not result in or cause functional loss. There was evidence of pain with weightbearing. The Veteran did have localized tenderness or pain on palpation of joints or soft tissue. The Veteran was able to perform repetitive-use testing. There was no change in the range of motion after repetitive-use testing. The Veteran was not being examined immediately after repetitive use or during a flare-up. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time or during a flare-up. Pain significantly limited functional ability with repeated use and during a flare-up. Range of motion was estimated to be the same as previously noted. The Veteran did not have guarding or muscle spasm. Less movement than normal was an additional factor contributing to the Veteran’s disability. Muscle strength was reduced in the knees and ankles. The Veteran did not have muscle atrophy. Reflexes were hypoactive in the knees and ankles. Sensory examination results were normal. Straight leg raising results were negative. The Veteran did not have radiculopathy. He did not have ankylosis. The Veteran did not have any neurologic abnormalities or intervertebral disc syndrome (IVDS). The Veteran used a brace regularly and a cane constantly for assistive devices. There was no pain noted on non-weightbearing. Passive range of motion and weightbearing could not be performed or was medically inappropriate. The examiner concluded that after listening to the complete history, subjective complaints, and review of the available records, there was no basis to offer additional losses of function or motion when it pertained to repetitive use or during a flare-up. After a thorough consideration of the evidence, prior to June 22, 2016, the Board determines that the Veteran’s symptoms more nearly approximate the severity level contemplated by the 20 percent rating criteria. The Board acknowledges that prior to June 2016, the Veteran’s forward flexion did not approximate between 30 degrees and 60 degrees or that he was not found to have guarding or muscle spasm that resulted in abnormal gait. However, the Board also acknowledges contentions regarding the Veteran’s gait and having at times to use a shopping cart due to his back pain. The Veteran also used a brace occasionally. The Board has also considered the Veteran’s pain, weakness, flare-ups, and limitation of movement that may at times result in additional functional loss than objectively demonstrated. Based on this evidence, prior to June 22, 2016, the Board finds that the Veteran is entitled to a 20 percent rating for his low back disability. The Board does not find that the Veteran’s symptoms approximated the severity level contemplated by the 40 percent rating criteria prior to June 22, 2016. The Veteran’s forward flexion did not approximate 30 degrees or less or exhibited favorable ankylosis. The Board notes that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). See also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, NOTE (5). Prior to June 2016, the Veteran only used a brace occasionally for an assistive device. The Board acknowledges that the Veteran is rated at 40 percent from April 16, 2019, the date of the VA examination exhibiting forward flexion 30 degrees or less. However, after reviewing the medical and lay evidence in its totality, the Board determines that the Veteran is entitled to a 40 percent rating from June 22, 2016, which is a date of the VA examination showing worsening in the Veteran’s symptoms. The Board acknowledges that the Veteran’s forward flexion was noted to be 65 degrees. However, when taking into consideration the Veteran's reported limitation during flare-ups and repetitive use, functional impairment, and limitation due to pain, weakness, and lack of endurance, the Board resolves all reasonable doubt in favor of the Veteran. The Veteran's lower back disability has more closely approximated the criteria contemplated in the 40 percent criteria. Pain, fatigue, lack of endurance, and incoordination significantly limited the Veteran’s functional ability with repeated use over time. The June 2016 examiner was not able to estimate the range of motion due to those factors. The Board is taking into consideration any additional limited range of motion due to those factors. The Veteran is not entitled to a 50 percent rating. A 50 percent rating contemplates when the Veteran exhibits unfavorable ankylosis of the entire thoracolumbar spine. There has been no evidence to establish that the Veteran has ankylosis of any kind. The Board notes that unfavorable ankylosis is defined as a condition in which the entire thoracolumbar spine is fixed in flexion or extension and 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 dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Even when considering the effects of pain and other factors of functional loss, the medical evidence does not indicate that the Veteran's range of motion findings are anything akin to unfavorable ankylosis. Experiencing difficulties in standing, walking, bending, and getting out of bed is not an implication of unfavorable ankylosis, which requires the spine to be frozen in a position other than the neutral position of 0 degrees flexion. The Veteran has not contended, nor does the evidence indicate, that his limitations result in mouth opening restriction, gastrointestinal symptoms, breathing difficulties, difficulty walking due to sight limitation, or neurological symptoms. The Board has also considered whether a higher evaluation may be warranted due to incapacitating episodes associated with intervertebral disc syndrome (IVDS). See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 6. However, the lay and medical evidence of record is against a finding that the Veteran has or ever had IVDS. From June 22, 2016, the Veteran is now in receipt of the maximum evaluation available for limitation of motion of the spine under the rating schedule, 38 C.F.R. §§ 4. 40, 4.45, and 4.59 are not applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Also, a 40 percent rating is assigned for favorable ankylosis. Thus, the 40 percent rating contemplates any episodes in which the Veteran's disability is so severe that he cannot move his back. The Board has also considered whether the Veteran is entitled to separate ratings for associated objective neurological abnormalities. However, the examinations noted that the Veteran does not display any neurological abnormalities, such as bowel or bladder incontinence, related to his low back disability. The Veteran has reported feeling weakness and numbness in his lower extremities, specifically his right lower extremity. However, the Veteran has never been diagnosed with radiculopathy. The Veteran’s straight leg test results have been negative. The Veteran’s sensory examination have shown intact sensation and he does not have muscle atrophy. Therefore, since the Veteran has not been diagnosed with radiculopathy, separate ratings for radiculopathy is not warranted. In summation, prior to June 22, 2016, the Veteran is entitled to a 20 percent rating for his back disability. From June 22, 2016, the Veteran is entitled to a 40 percent rating, but no higher, for his back disability. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. After a review of the evidence, the Board finds that the evidence warrants a referral for consideration of a TDIU rating on an extraschedular basis. In order for the Veteran to be eligible for consideration of a TDIU rating under 38 C.F.R. § § 4.16, the Veteran's disability rating must meet the schedular criteria. In this matter, the Veteran does not meet the schedular criteria under 4.16(a). Nevertheless, the Board must consider whether the evidence otherwise warrants a referral to the Director of Compensation Service for entitlement to a TDIU rating on an extraschedular basis under the provisions of 38 C.F.R. § 4.16 (b). Turning now to the evidence of the record, at the July 2011 VA examination, the Veteran reported that he used to sell cars. When selling cars, he would experience pain with prolonged walking. In that examination, the Veteran reported experiencing pain when he would sit a particular way in a chair. At the January 2014 VA examination, the Veteran reported experiencing pain with prolonged sitting and standing. At the June 2016 VA examination, the examiner indicated that the Veteran could perform sedentary work. Regarding physical work, the examiner reported that the Veteran could perform light physical work. On the March 2019 Veterans Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran indicated that his back injury prevented him from securing or following any substantially gainful occupation. All of the Veteran’s jobs have been in sales (cars and beds). The Veteran reported leaving his last job due to his back disability. The Veteran tried to obtain employment since becoming too disabled to work. The Veteran obtained his GED. The Veteran attended real estate school. The Veteran explained that his last employment as a car salesman was terminated due to experiencing pain with walking and standing. The Veteran also explained that his job at a bed store ended due to the inability to move the mattresses and furniture. At the April 2019 VA Examination, the examiner opined that the Veteran would have difficulty performing jobs that require more than moderate amounts of walking, standing, and bending. The examiner opined that the Veteran should be able to perform sedentary occupations provided he is given the proper ergonomic modifications. The examiner at the November 2019 VA examination indicated that the Veteran would require a sedentary position. Considerating the Veteran’s limitations due to his disability, in conjunction with his educational background and employment history, the evidence does show an indication that the Veteran's low back disability renders him unable to secure or follow substantially gainful employment. There is evidence showing that the Veteran may be unable to perform even light physical work that just involves sitting. The Veteran has reported multiple times experiencing pain with sitting as well. Where there is plausible evidence that a claimant seeking extraschedular TDIU is unable to secure or follow a substantially gainful occupation and there is no affirmative evidence to the contrary, the Board is required to remand the claim for referral to the Director, Compensation Service to consider entitlement on an extraschedular basis. Bowling v. Principi, 15 Vet. App. 1 (2001). Therefore, referral to the Director, Compensation Service for consideration of entitlement to extraschedular TDIU is warranted. 38 C.F.R. § § 4.16 (b). The matter is REMANDED for the following action: 1. Forward this case to the Director, Compensation Service for consideration of the assignment of a TDIU due his service-connected disabilities on an extra-schedular basis, pursuant to the provisions of 38 C.F.R. § § 4.16 (b). In connection with the referral, the Regional Office / Appeals Management Center should include a full statement outlining the Veteran's service connected disabilities, employment history, educational attainment, and all other factors having a bearing on the issue during the applicable timeframe. 2. After the development has been completed, review the file and ensure that all development sought in this REMAND is completed. Arrange for any further development indicated by the results of the development requested above. Then, readjudicate the issue of entitlement to extraschedular TDIU. If the determination remains adverse to the Veteran, a supplemental statement of the case (SSOC) should be provided to the Veteran and his representative. After they have given an adequate opportunity to respond, the case should be returned to the Board for appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Middleton, Associate 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.