Citation Nr: 20033751 Decision Date: 05/14/20 Archive Date: 05/14/20 DOCKET NO. 20-12 246 DATE: May 14, 2020 ORDER For the entire period on appeal, entitlement to an initial rating of 40 percent, but no higher, for lumbar strain status-post foraminotomy/laminotomy (hereinafter “lumbar spine disability”) is granted. For the appellate period prior to June 21, 2017, entitlement to a separate rating of 10 percent, but no higher, for radiculopathy of the right lower extremity is granted. Beginning June 21, 2017, entitlement to a rating higher than 20 percent for radiculopathy of the right lower extremity is denied. For the appellate period prior to April 9, 2018, entitlement to a separate rating of 10 percent, but no higher, for radiculopathy of the left lower extremity is granted. Beginning April 9, 2018, entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the left lower extremity is granted. For the entire period on appeal, entitlement to a total disability rated based upon individual unemployability (TDIU) is granted. From November 23, 2016 through December 31, 2017, entitlement to special monthly compensation (SMC) at the housebound rate is granted. FINDINGS OF FACT 1. Resolving any reasonable doubt in the Veteran’s favor, for the entire period on appeal, his lumbar spine disability has been manifested by forward flexion to 30 degrees or less, with consideration of pain, but not by unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes of intervertebral disc syndrome (IVDS) having a total duration of at least six weeks during the past 12 months. 2. The Veteran’s radiculopathy of the bilateral lower extremities are neurological manifestations of the service-connected lumbar spine disability. 3. For the appellate period prior to June 21, 2017, the Veteran’s radiculopathy of the right lower extremity was no more than mild in nature. 4. Beginning June 21, 2017, the Veteran’s radiculopathy of the right lower extremity was no more than moderate in nature. 5. From June 30, 2017 to July 31, 2017, the Veteran was in receipt of a temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability. 6. From March 20, 2018 to June 30, 2018, the Veteran was in receipt of a temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability. 7. For the appellate period prior to April 9, 2018, the Veteran’s radiculopathy of the left lower extremity was no more than mild in nature. 8. Beginning April 9, 2018, the Veteran’s radiculopathy of the left lower extremity was no more than moderate in nature. 9. For the entire period on appeal, the Veteran has been rendered unable to maintain gainful employment due to his service-connected disabilities. 10. From November 23, 2016 through December 31, 2017, the Veteran has a service-connected disability rated as total (status post hemiarthroplasty with non-prosthetic glenoid arthroplasty, rotator interval plication and proximal numeral bone grafting with local bone, left shoulder) and his other service-connected disabilities are rated as at least 60 percent disabling. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for an initial rating of 40 percent, but no higher, for a lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.7, 4.71a, Diagnostic Code (DC) 5237. 2. For the appellate period prior to June 21, 2017, the criteria for a separate rating of 10 percent, but no higher, for radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124, DC 8520. 3. Beginning June 21, 2017, the criteria for a rating higher than 20 percent for radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124, DC 8520. 4. For the appellate period prior to April 9, 2018, the criteria for a separate rating of 10 percent, but no higher, for radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124, DC 8520. 5. Beginning April 9, 2018, the criteria for a separate rating of 20 percent, but no higher, for radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124, DC 8520. 6. For the entire period on appeal, the criteria for an award of a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16. 7. From November 23, 2016 through December 31, 2017, the criteria for SMC at the housebound rate have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from February 1983 to August 1990, October 1990 to February 1991, October 25, 2001 to October 27, 2001, July 2004 to May 2006, April 2007 to December 2008, June 2009 to July 2009, October 5, 2009 to October 26, 2009, April 2010 to September 2010, and March 2011 to November 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated February 2017 and July 2017 of a Department of Veterans Affairs (VA) Regional Office (RO). The issue of entitlement to SMC at the housebound rate for the appellate period between November 23, 2016 and December 31, 2017 has been raised by the record and added to the appeal. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Procedural History As detailed below, this case has a complicated procedural history. In a February 2017 rating decision, the RO granted service connection for a lumbar spine disability and assigned a 20 percent disability rating under DC 5237, effective January 22, 2016. In a July 2017 rating decision, the RO assigned a temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability, effective June 30, 2017. Effective August 1, 2017, the RO restored the 20 percent rating for the Veteran’s lumbar spine disability. The RO also granted service connection for right lower extremity radiculopathy and assigned a 20 percent rating under DC 8520, effective June 21, 2017, and denied service connection for left lower extremity radiculopathy. In December 2017, the Veteran filed a Notice of Disagreement (NOD) as to all of the aforementioned issues. In correspondence dated March 2018, the Veteran, through his representative, noted that no Statement of the Case (SOC) had been received in relation to his December 2017 NOD. In a May 2018 rating decision, the RO assigned a temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability, effective March 20, 2018. Effective June 1, 2018, the RO restored the 20 percent rating for the Veteran’s lumbar spine disability. In a January 2020 rating decision and SOC, the RO extended the duration of the temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability to June 30, 2018 and restored the 20 percent rating for the lumbar spine disability, effective July 1, 2018. In a March 14, 2020 SOC, the RO denied a rating in excess of 20 percent for the Veteran’s lumbar spine disability. In a March 16, 2020 SOC, the RO found that the issue of entitlement to a TDIU was rendered moot. In a March 18, 2020 SOC, the RO denied entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy, denied an extension of the temporary total rating for post-surgical convalescence due to his service-connected lumbar spine disability, and denied service connection for left lower extremity radiculopathy. The Veteran filed a VA Form 9 on March 19, 2020. In an attachment to the VA Form 9, the Veteran, through his representative, wrote he was appealing the issue of entitlement to an increase in evaluation for his lumbar spine disability, currently evaluated as 20 percent disabling from June 1, 2018. Increased Ratings Disability evaluations are determined by comparing a Veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Where a Veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). 1. Entitlement to a rating in excess of 20 percent for a lumbar spine disability The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasms, and tenderness. See 38 C.F.R. § 4.71a, DCs 5235-5243. The General Rating Formula provides for a 10 percent rating where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; a combined range of motion (ROM) of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined ROM of the thoracolumbar spine is not greater than 120 degrees; or 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 40 percent rating is warranted where there is forward flexion of the thoracolumbar spine is 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is available for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is available for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined ROM refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined ROM of the thoracolumbar spine is 240 degrees. The normal ROMs for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined ROM. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (2); see also Plate V. 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. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (5). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion (ROM) testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). IVDS (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5243. A 20 percent rating requires incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating requires incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, and a 60 percent rating requires incapacitating episodes having a total duration of at least six weeks during the past 12 months. An “incapacitating episode” is defined as 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, DC 5243, Note (1). In this matter, the Veteran is currently in receipt of an initial rating of 20 percent for his lumbar spine disability. He asserts that a higher rating is warranted. Turning to the relevant evidence, in a January 2016 private treatment record, the Veteran endorsed low back pain. ROM testing revealed “lumbar flexion” to 43 degrees and “lumbar extension” to 18 degrees. There is no indication of whether these measurements took into consideration any ROM loss due to pain. In a February 2016 private treatment record, the Veteran endorsed low back pain. ROM testing revealed “lumbar flexion” to 45 degrees and “lumbar extension” to 25 degrees. There is no indication of whether these measurements took into consideration any ROM loss due to pain. In a March 2016 private treatment record, the provider noted “limited AROM of lumbar spine” with flexion to 15 degrees and extension to 12 degrees. In private treatment record dated later in March 2016, the provider noted “limited AROM of lumbar spine” with flexion to 25 degrees and extension to 13 degrees. In an April 2016 private treatment record, the Veteran endorsed a constant ache and intermittent burning pain in the lumbar spine. The provider noted “limited AROM of lumbar spine” with flexion to 25 degrees and extension to 16 degrees. The provider further noted, “Pt presents with continued limitation into lumbar spine AROM due to pain c/o.” In February 2017, the Veteran was provided a VA examination to assess his claimed lumbar spine disability. The VA examiner diagnosed the Veteran with lumbar strain. The Veteran reported flare-ups of the thoracolumbar spine and stated that he was following up with pain management and is receiving epidural injections in the lower back. The Veteran reported having functional loss or functional impairment of the thoracolumbar spine, indicating that he is not able to sit or walk “for long hours secondary to low back pain.” Initial ROM findings were as follows: flexion to 45 degrees, extension to 5 degrees, and 15 degrees for right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The VA examiner indicated that pain was noted on examination of all ROMs except for lateral rotations and caused functional loss. The examiner noted evidence of pain with weight bearing but found no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The examiner indicated that the Veteran was unable to perform repetitive use testing with at least three repetitions due to low back pain. She noted that the Veteran was not being examined immediately after repetitive use over time and that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. When asked whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time, the examiner indicated she was unable to say without mere speculation, explaining, “NOT SEEN AFTER REPETITIVE USE.” The examiner noted that the examination was not conducted during a flare-up and that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups. When asked whether pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups, the examiner indicated she was unable to say without mere speculation, explaining, “NOT SEEN DURING FLAREUP AND NO RECORDS FROM DURING FLAREUP FOR REVIEW AT THIS TIME.” The examiner found that the Veteran did not have guarding or muscle spasm of the thoracolumbar spine or ankylosis. She noted the following additional contributing factors of disability: “Disturbance of locomotion, Interference with sitting, Interference with standing.” The VA examiner found that the Veteran had IVDS of the thoracolumbar spine and noted that the Veteran has not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. In July 2017, the Veteran was provided another VA examination to assess the severity of his lumbar spine disability. The VA examiner indicated that the Veteran did not report flare-ups of the thoracolumbar spine. The Veteran reported having functional loss or functional impairment of the thoracolumbar spine, describing difficulty walking. The VA examiner did not provide any ROM findings because “exam is requested for radiculopayhy (sic).” The examiner noted no ankylosis. He found that the Veteran had IVDS of the thoracolumbar spine and noted that the Veteran has had episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months, explaining, “PATIENT SAYS HE HAD LEMINECTOMY (sic) AS OUTPATIENT AND NEEDED ONE WEEK REST.” In April 2018, the Veteran was provided another VA examination to assess the severity of his lumbar spine disability. The Veteran endorsed constant back pain and indicated that his back has been aggravated by “rehab of his shoulder repair.” The VA examiner indicated that the Veteran did not report flare-ups of the thoracolumbar spine. The Veteran reported having functional loss or functional impairment of the thoracolumbar spine, stating that he is unable to bend, lift heavy objects, or twist and reported difficulty with walking, standing, and sitting for long periods of time. The Veteran refused to undergo ROM testing due to his recent back surgery the month prior. The VA examiner indicated that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare-ups and noted that she was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups. The VA examiner also noted that it was not possible to describe functional loss in terms of ROM, explaining, “It is not possible to determine, without resorting to mere speculation, to estimate loss of range of motion, because there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions.” The examiner found no guarding or muscle spasm, no ankylosis, and no IVDS of the thoracolumbar spine. The examiner noted the Veteran occasionally used a brace for his back. In November 2018, the Veteran was provided an additional VA examination to assess the severity of his lumbar spine disability. The VA examiner diagnosed the Veteran with degenerative arthritis of the spine and IVDS. The examiner indicated that the Veteran did not report flare-ups of the thoracolumbar spine. The Veteran reported having functional loss or functional impairment of the thoracolumbar spine, noting functional impairment due to chronic pain and difficulty walking. Initial ROM findings were as follows: flexion to 20 degrees, extension to 0 degrees, right lateral flexion to 10 degrees, left lateral flexion to 5 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 20 degrees. The examiner noted that the ROM itself did not contribute to functional loss and that pain was noted on examination of all ROMs and caused functional loss. She noted evidence of pain with weightbearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine located at the paraspinous musculature of the lumbar spine bilaterally and describing it as severe and directly caused by the Veteran’s lumbar spine disability. The VA examiner indicated that the Veteran was able to perform repetitive-use testing with at least three repetitions and that there was additional loss of function or ROM after three repetitions, noting the following ROM findings: forward flexion to 15 degrees, extension to 0 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 30 degrees, left lateral rotation to 20 degrees. The examiner noted that the factor causing this functional loss was pain. She indicated that the Veteran was not being examined immediately after repetitive use over time and that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner indicated that pain significantly limits functional ability with repeated use over a period of time and that she was able to describe in terms of ROM, providing the following findings: flexion to 15 degrees, extension to 0 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 30 degrees, left lateral rotation to 20 degrees. The examiner noted that the Veteran had muscle spasm and guarding of the thoracolumbar spine resulting in abnormal gait or abnormal spine contour. She found no ankylosis and noted that the Veteran had although the Veteran had IVDS of the thoracolumbar spine, there were no episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The examiner noted that the Veteran occasionally used a cane as an assistive device. In a December 2018 private treatment record, the provider noted normal flexion and extension with “no pain with motion” on active ROM testing. The provider also noted tenderness to palpation of the sacrum and the left sacroiliac joint. In a March 2019 Statement in Support of Claim, the Veteran indicated that he is in constant pain from his lumbar spine disability, that he pays for a massage therapist every week for his lumbar spine, and he goes to the VA for physical therapy to treat his condition. In a July 2019 Statement in Support of Claim, the Veteran wrote, “My lower back hurts at the level of a 5 on a day to day basis, when it flares up I can’t stand up straight...I can't go to work permanently. I can’t sit more than 20 to 30 minutes at a time...my back pain will wake me up...” In March 2020 Third Party Correspondence, the Veteran, through his representative, stated, “[The Veteran] suffers from pain and limited motion of his lower back. A surgery was performed on his back March 20, 2018; however, the results of this surgery did not allow for increased flexibility or flexion. [The Veteran] stated he is unable to perform any backward motion, and his forward motion is extremely limited. He is also diagnosed with spondylolisthesis of the lower back creating more restrictive movement. VA did not conduct a comp and pen exam in connection to [the Veteran’s] Notice of Disagreement to determine the level of disability of his lower back. [The Veteran] requests the Board remand his appeal to VA and order a comp and pen examination.” On review, and after resolution of all reasonable doubt in the Veteran’s favor, the Board finds that the manifestations of the Veteran’s lumbar spine disability more nearly approximate the criteria for an initial 40 percent rating under the General Rating Formula for the entire period on appeal. While the Board acknowledges ROM findings of “lumbar flexion” to 43 degrees and 45 degrees, respectively, in private treatment records dated January 2016 and February 2016, there is no indication of whether these measurements took into consideration any ROM loss due to pain, and accordingly, the Board will not rely upon these findings. Notably, in private treatment records dated March and April 2016, the provider noted “limited AROM of lumbar spine” with flexion ranging between 15 and 25 degrees. In an April 2016 private treatment record, the provider wrote, “Pt presents with continued limitation into lumbar spine AROM due to pain c/o.” (emphasis added). Furthermore, the Board finds that the only VA examination which provided adequate ROM findings was the November 2018 VA examination. The February 2017 VA examination was not compliant with Sharp v. Shulkin, 29. Vet. App. 26, 35 (2017) as the VA examiner did not elicit relevant information as to the Veteran’s flare-ups or ask him to describe the additional functional loss, if any, he suffered during flare-ups and then estimate the Veteran’s functional loss due to flare-ups based on all the evidence of record, including the Veteran’s lay information, or explain why she could not do so. The February 2017 VA examination was also inadequate under Mitchell, 22 Vet. App. at 44, as the VA examiner did not identify at what point during the ROMs the Veteran experienced any limitation of motion that was specifically attributable to pain. No ROM findings were provided in the July 2017 VA examination report because, as the VA examiner explained, “exam is requested for radiculopayhy (sic),” and no ROM testing was completed during the April 2018 VA examination because the Veteran refused to undergo testing due to his recent back surgery the month prior. In the November 2018 VA examination report, the VA examiner found that after repetitive use testing and after repetitive use over a period of time, flexion was limited to 15 degrees, with consideration of functional loss due to pain. The evidence does not demonstrate unfavorable ankylosis of the entire thoracolumbar spine to warrant a rating higher than 40 percent under the General Rating Formula. Thus, the criteria for a 40 percent rating under the General Rating Formula is more nearly approximated. As 40 percent is the highest schedular rating for limitation of motion, consideration of whether the Veteran is entitled to a higher disability rating because of functional loss under §§ 4.40 and 4.45 is not for application. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In Johnston, the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). For the same reasons, as the Veteran is currently in receipt of the highest schedular rating for limitation of motion, the Court’s holding in Correia v. McDonald, 28 Vet. App. 158 (2016) is not applicable here. See also Sharp, 29 Vet. App. at 33 (finding orthopedic examination inadequate with regard to flare-ups where the examination was the basis for a denial of a higher disability rating and the Veteran was not receiving the maximum schedular rating based on limitation of motion). Moreover, the evidence does not show that the Veteran has had incapacitating episodes of IVDS having a total duration of at least six weeks during the past 12 months, such that he would be entitled to a higher rating under DC 5243. Although the February 2017, July 2017, and November 2018 VA examiners diagnosed the Veteran with IVDS of the thoracolumbar spine, only the July 2017 VA examiner found that the Veteran had episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months, explaining, “PATIENT SAYS HE HAD LEMINECTOMY (sic) AS OUTPATIENT AND NEEDED ONE WEEK REST.” To the extent the Veteran’s laminectomy, and period of rest thereafter, was necessitated by his IVDS and was prescribed by a physician, this still does not satisfy the criteria for a higher rating under DC 5243, which, as indicated above, requires incapacitating episodes having a total duration of at least six weeks during the past 12 months. Thus, a higher rating is not warranted under DC 5243. For these reasons, the Board finds that the evidence supports an initial rating of 40 percent, but no higher, for the Veteran’s lumbar spine disability for the entire period on appeal. 2. Entitlement separate compensable ratings for radiculopathy of the bilateral lower extremities Separate ratings for neurological manifestations may be warranted under 38 C.F.R. § 4.124a if supported by objective medical evidence. In this matter, the RO has assigned a 20 percent rating for radiculopathy of the right lower extremity under DC 8250, effective June 21, 2017. As to radiculopathy of the right lower extremity, the Veteran asserts that a separate compensable rating is warranted prior to June 21, 2017 and that a separate rating in excess of 20 percent is warranted thereafter. As to radiculopathy of the left lower extremity, he asserts that a separate compensable rating is warranted. DC 8520 provides ratings for incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124, DC 8520. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is warranted with complete paralysis of the sciatic nerve. Id. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “mild,” “moderate,” “moderately severe,” and “severe.” Sellers v. Wilkie, 30 Vet. App. 157 (2018) (“DC 8520 does not define ‘mild,’ ‘moderate,’ ‘moderately severe,’ or ‘severe,’ or generally associate those terms with specific symptoms”). It should also be noted that use of terminology such as “mild” and “moderate” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Turning to the relevant evidence, in a January 2016 private treatment record, the provider, a physical therapist, diagnosed the Veteran with bilateral low back pain without sciatica. In a private treatment record dated later in January 2016, the Veteran reported having increased pain into the lateral right hamstring and endorsing constant aching pain in his hips. In a February 2016 private treatment record, the Veteran reported that being in the car for approximately 30 minutes caused increased pain into the right hip and knee, and that the pain decreased once he began walking around. In a private treatment record dated later in February 2016, the Veteran complained of intermittent pain into his bilateral hamstrings and a constant ache into the right greater trochanter. In a March 2016 private treatment record, the Veteran reported he was “[s]till having a lot of lower back pain and left hamstring pain.” The provider noted severe tenderness to palpation over the right psoas muscle and moderate tenderness in the left lateral hamstring. In a private treatment record dated later in March 2016, the Veteran endorsed “shooting pain into the right hip and aching into the left hip and glut.” A March 2016 private magnetic resonance imaging (MRI) report of the lumbar spine noted a history of lumbar radiculopathy and found, in pertinent part, “left L4 nerve root impingement.” Later in March 2016, the Veteran received an interlaminar lumbar epidural steroid injection at L4-5 and the “medical necessity” for the procedure was noted as “The patient has radiating low back pain.” See March 2016 private treatment record. In April 2016, the Veteran received an interlaminar lumbar epidural steroid injection at L5-S1 and the “medical necessity” for the procedure was noted as “The patient has radiating low back pain.” See April 2016 private treatment record. In an April 2016 private treatment record, the provider, a physical therapist, diagnosed the Veteran with bilateral low back pain without sciatica. In a May 2016 private treatment record, the Veteran received a caudal epidural steroid injection and the “medical necessity” for the procedure was noted as “The patient has radiating low back pain.” The provider noted diagnoses of lumbar radiculopathy, pain in pelvis, and pain in coccyx. See May 2016 private treatment record. In a May 2016 private treatment record, the provider noted that the Veteran described referred pain into his bilateral lower extremities. In February 2017, the Veteran was provided a VA examination to assess his lumbar spine disability and any associated neurological manifestations. The VA examiner found normal muscle strength upon testing, no muscle atrophy, a normal sensory examination, and a negative straight leg raising test. The examiner found that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy and that he had no other neurologic abnormalities or findings related to his lumbar spine disability. In the “Remarks” section, the examiner noted that a January 2015 “EMG” showed “no evidence of right lumbar radiculopathy.” The Board notes that “EMG” is an abbreviation for electromyography. In a June 2017 private operative report, the surgeon noted a history of “right LE L5 radiculopathy refractory to medical mgt.” In a June 2017 VA neurology consultation, the provider wrote, “Patient has history of back pain for more than 10 years. On January 2016 he went to chiropracter (sic), and they made him to have severe back pain with radiating pain to the legs R >L. Since then he has debilitating pain. He took lyrica 50mg qhs, and tizanidine for pain, but due to the weight gain, he has to stop the lyrica. He has tried physical therapy, that make the pain worse. He tried acupuncture (sic) with minimal improvement. He had epidural 4x. last one on October with temporary pain relief for 2 month on the left side, but not for the right side.” Ultimately, the provider assessed the Veteran with chronic back pain and lumbar radiculopathy and noted that a neurological examination was normal. In July 2017, the Veteran was provided an additional VA examination to assess his lumbar spine disability and any associated neurological manifestations. The VA examiner diagnosed the Veteran with “S/P LEMINECTOMY (sic) DUE TO LUMBER (sic) RADICULOPATHY INVOLVING RIGHT LEG” and noted the date of diagnosis as 2017. In describing the history of his condition, the Veteran reported that he started getting bilateral leg pain radiating from his back and occasional burning in his feet, more in his right leg than his left. He also reported that he had surgery on his back due to chronic right leg radiculopathy. On physical examination, the VA examiner noted normal muscle strength testing results, no muscle atrophy, normal reflexes, and a negative straight leg raise test. Sensory examination was normal except for decreased sensation to light touch in the right foot/toes. The examiner found that the Veteran had radicular pain or any other signs or symptoms due to radiculopathy, noting symptoms of mild constant pain, moderate intermittent pain, mild paresthesias/dysesthesias, and mild numbness of the right lower extremity. The examiner noted involvement of the sciatic nerve and indicated the level of severity of the right lower extremity radiculopathy was mild. The examiner found no further signs or symptoms of radiculopathy or neurologic abnormalities. The examiner opined that the Veteran’s claimed sciatica of the right lower extremity was at least as likely as not proximately due to or the result of his service-connected lumbar spine disability, reasoning, “Patient is s/c for degenerative disease of lumbosacral spine which after a period can pinch the nerve.” The examiner also opined that the Veteran’s claimed sciatic of the left lower extremity was less likely than not proximately due to or the result of the Veteran’s lumbar spine disability, reasoning, “There is no objective evidence of lumber (sic) radiculopathy involving left lower extremity as per current exam.” In a March 2018 private treatment record, the provider noted a discharge diagnosis of lumbar radiculopathy and both pre-operative and post-operative diagnoses of “left radiculopathy.” In April 2018, the Veteran was provided an additional VA examination to assess his lumbar spine disability and any associated neurological manifestations. The Veteran reported bilateral sciatica and a progression of his back pain. The VA examiner noted normal muscle strength upon testing, normal reflexes, normal sensory examination results, and negative straight leg raising test results. The examiner found that the Veteran had radicular pain or any other signs or symptoms due to radiculopathy, noting symptoms of moderate constant pain in the bilateral lower extremities, moderate intermittent pain in the bilateral lower extremities, severe paresthesias/dysesthesias in the bilateral lower extremities, and moderate numbness in the bilateral lower extremities. The examiner noted involvement of sciatic nerve on both sides and found that the severity of the radiculopathy was moderate for both right and left extremities. The examiner noted no further neurologic abnormalities. In a September 2018 Supplemental Claim, the Veteran reported that his current symptoms of his left lower extremity radiculopathy “include pain in the upper pelvic area and mild numbness in lower extremity, possibly affecting function of the foot.” In November 2018, the Veteran was provided an additional VA examination to assess his lumbar spine disability and any associated neurological manifestations. The VA examiner noted that sciatica was an additional diagnosis pertaining to the Veteran’s thoracolumbar spine conditions. The examiner provided the following history specific to the Veteran’s left lower extremity radiculopathy: “The date of onset of the symptoms is 1/2016. The claimant states the above condition began with back pain while in the service in 1984. He was treated multiple times for back pain while in the service. He was diagnosed with a bulging disc and spinal stenosis in 2016. The condition has gotten somewhat better since his laminectomy.” On physical examination, the VA examiner found no muscle atrophy and noted that muscle strength was normal upon testing except for hip flexion and knee extension of the left lower extremity, which was rated as 4/5 in strength, described as active movement against some resistance. The sensory examination was normal except for decreased sensation to light touch in the left lower leg/ankle and foot/toes. The examiner noted positive straight leg raising tests. The VA examiner found that the Veteran had radicular pain and other signs or symptoms due to radiculopathy, noting symptoms of moderate constant pain in the bilateral lower extremities, moderate intermittent pain in the bilateral lower extremities, mild paresthesias/ dysesthesias in the bilateral lower extremities, and mild numbness in the bilateral lower extremities. The examiner noted involvement of the sciatic nerve of both sides and found that the severity of the Veteran’s right lower extremity radiculopathy was mild, and the severity of the left lower extremity radiculopathy was moderate. The examiner noted no further neurologic abnormalities. In a November 2018 VA medical opinion, the VA examiner found that it was at least as likely as not that the Veteran’s left lower extremity radiculopathy (diagnosed as sciatica) was proximately the result of his lumbar strain status post foraminotomy/laminotomy, reasoning as follows: “MRI of the claimant's lumbar spine was provided which showed spinal stenosis with nerve root impingement, disc herniation, and spondylolisthesis. Therefore, based on his medical records, his presented history and his physical examination, I opine that it is at least as likely as not that his current back condition is a continuum of the prior back condition.” In a November 2018 private treatment record, the Veteran reported he had been having some left hip and sacroiliac joint pain radiating to the buttock and some left leg numbness. In a January 2019 private treatment record, the Veteran endorsed “low back pain on the left” which he has had for 18 months. In a March 2019 private treatment record, the Veteran endorsed right leg and low back pain. The provider noted an onset of lumbar radiculopathy in May 2017. The Veteran endorsed numbness, tingling, stiffness of the low back, and heaviness of the legs. He denied lower extremity weakness, bowel or bladder dysfunction, lumbar spasms, loss of motor control, calf pain upon ambulation, or interference with sleep. In a February 2020 VA primary care outpatient note, the Veteran endorsed chronic low back pain with bilateral radiculopathy. On review, the Board finds as follows: (1) for the appellate period prior to June 21, 2017, the criteria for a separate rating of 10 percent for radiculopathy of the right lower extremity are more nearly approximated; (2) beginning June 21, 2017, the criteria for a separate rating of 20 percent for radiculopathy of the right lower extremity are more nearly approximated; (3) for the appellate period prior to April 9, 2018, the criteria for a separate rating of 10 percent for radiculopathy of the left lower extremity are more nearly approximated; (4) beginning April 9, 2018, the criteria for a separate rating of 20 percent for radiculopathy of the left lower extremity are more nearly approximated. First, for the appellate period prior to June 21, 2017, the medical evidence reflects the Veteran’s repeated reports regarding radicular symptoms beginning in the low back and radiating into his right lower extremity. See private treatment records dated January 2016 to May 2016. This radicular pain is an observable symptom that the Veteran is competent to report. Layno, 6 Vet. App. at 469. In addition, a March 2016 private MRI report of the lumbar spine noted a history of lumbar radiculopathy and a May 2016 private treatment record included diagnoses of lumbar radiculopathy, pain in pelvis, and pain in coccyx. During this period, the Board finds that a rating higher than 10 percent for radiculopathy of the right lower extremity is not warranted, as private treatment records reflect symptoms no more than mild in nature. In this regard, the Veteran’s right lower extremity symptoms were shown to be wholly sensory, manifested by symptoms such as constant aching in his hip or intermittent pain in his hamstring. See February 2016 private treatment record. In the February 2017 VA examination report, the VA examiner found normal muscle strength upon testing, no muscle atrophy, a normal sensory examination, and a negative straight leg raising test. The examiner found that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy and that he had no other neurologic abnormalities or findings related to his lumbar spine disability. In the “Remarks” section, the examiner noted that a January 2015 “EMG” showed “no evidence of right lumbar radiculopathy.” Accordingly, Board finds that the Veteran’s symptoms and impairment more nearly approximate the criteria for a separate 10 percent rating, but no higher, for his right lower extremity radiculopathy before June 21, 2017. Second, beginning June 21, 2017, the RO has already awarded a 20 percent rating radiculopathy of the right lower extremity under DC 8520, and the Board finds that this rating is consistent with the medical evidence. While the July 2017 VA examiner found the severity of the Veteran’s right lower extremity radiculopathy was mild, he also found decreased sensation to light touch in the right foot/toes on sensory examination, and the April 2018 examiner found that the severity was moderate. Additionally, while the November 2018 VA examiner found the severity of the right lower extremity radiculopathy was mild in severity, she noted a positive straight leg raising test as well as symptoms of moderate constant and intermittent pain in the bilateral lower extremities. In a March 2019 private treatment record, the Veteran endorsed right leg and low back pain, the provider noted an onset of lumbar radiculopathy in May 2017, and the Veteran endorsed numbness, tingling, stiffness of the low back, and heaviness of the legs. He denied lower extremity weakness, bowel or bladder dysfunction, lumbar spasms, loss of motor control, calf pain upon ambulation, or interference with sleep. Thus, during this period, the Veteran’s symptoms more nearly approximate a moderate level of radiculopathy, warranting the currently assigned 20 percent rating. The evidence however does not meet or approximate a finding of radicular impairment to a moderately severe degree in the right lower extremity. Third, for the appellate period prior to April 9, 2018, the medical evidence reflects the Veteran’s repeated reports regarding radicular symptoms beginning in the low back and radiating into his left lower extremity. See private treatment records dated February 2016 to May 2016. As noted above, this radicular pain is an observable symptom that the Veteran is competent to report. Layno, 6 Vet. App. at 469. In addition, a March 2016 private MRI report of the lumbar spine noted a history of lumbar radiculopathy and found, in pertinent part, “left L4 nerve root impingement,” and a May 2016 private treatment record included diagnoses of lumbar radiculopathy, pain in pelvis, and pain in coccyx. Also, in the November 2018 VA examination report, the examiner noted that the date of onset of the Veteran’s symptoms of left lower extremity radiculopathy was January 2016. During this period, the Board finds that a rating higher than 10 percent for radiculopathy of the left lower extremity is not warranted, as private treatment records reflect symptoms no more than mild in nature. In this regard, the Veteran’s left lower extremity symptoms were shown to be wholly sensory, manifested by symptoms such as constant aching in his hip or intermittent pain in his hamstring. See February 2016 private treatment record. In the February 2017 VA examination report, the VA examiner found normal muscle strength upon testing, no muscle atrophy, a normal sensory examination, and a negative straight leg raising test. The examiner found that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy and that he had no other neurologic abnormalities or findings related to his lumbar spine disability. Accordingly, Board finds that the Veteran’s symptoms and impairment more nearly approximate the criteria for a separate 10 percent rating, but no higher, for his left lower extremity radiculopathy before April 9, 2018. Fourth, beginning April 9, 2018, the criteria for a separate rating of 20 percent for radiculopathy of the left lower extremity are more nearly approximated. Notably, the April 2018 VA examiner found that the severity of the Veteran’s left lower extremity radiculopathy was moderate, noting symptoms of moderate constant and intermittent pain, severe paresthesias/dysesthesias, and moderate numbness of the left lower extremity. In a September 2018 Supplemental Claim, the Veteran reported that his current symptoms of his left lower extremity radiculopathy “include pain in the upper pelvic area and mild numbness in lower extremity, possibly affecting function of the foot.” During the November 2018 VA examination, the VA examiner found no muscle atrophy and noted that muscle strength was normal upon testing except for hip flexion and knee extension of the left lower extremity, which was rated as 4/5 in strength, described as active movement against some resistance. The sensory examination was normal except for decreased sensation to light touch in the left lower leg/ankle and foot/toes. The examiner noted positive straight leg raising test results. In a November 2018 private treatment record, the Veteran reported he had been having some left hip and sacroiliac joint pain radiating to the buttock and some left leg numbness. In a March 2019 private treatment record, the Veteran endorsed right leg and low back pain, the provider noted an onset of lumbar radiculopathy in May 2017, and the Veteran endorsed numbness, tingling, stiffness of the low back, and heaviness of the legs. He denied lower extremity weakness, bowel or bladder dysfunction, lumbar spasms, loss of motor control, calf pain upon ambulation, or interference with sleep. Thus, during this period, the Veteran’s symptoms more nearly approximate a moderate level of radiculopathy, warranting a 20 percent rating. The evidence however does not meet or approximate a finding of radicular impairment to a moderately severe degree in the right lower extremity. Finally, the competent evidence does not reflect any other objective neurologic abnormalities associated with the lumbar spine disability, such as any in the bladder or bowel, so as to warrant any additional separate ratings. In addition, the Board notes that the RO has awarded a noncompensable rating under DC 7805 for a lumbar surgical scar, effective June 30, 2017. To date, there is no indication that the Veteran has disagreed with the rating assigned. Moreover, there is no evidence to award a compensable rating as the linear scar is shown to be non-painful and stable. See VA examination reports dated July 2017, April 2018, and November 2018. 3. Entitlement to a TDIU It is the established policy of VA that all Veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. § 3.340(a)(1). Controlling laws provide that a TDIU may be assigned when a Veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. See 38 U.S.C. § 1155. Here, the Veteran is service-connected for lumbar strain (rated as 40 percent disabling from January 22, 2016, as granted herein, 100 percent disabling from June 30, 2017 to July 31, 2017, 40 percent disabling from August 1, 2017 to March 19, 2018, 100 percent disabling from March 20, 2018 to June 30, 2018, and 40 percent disabling from July 1, 2018), right lower extremity radiculopathy (rated as 10 percent disabling prior to June 21, 2017, as granted herein, and 20 percent disabling beginning June 21, 2017), left lower extremity radiculopathy (rated as 10 percent disabling prior to April 9, 2018 and 20 percent disabling beginning April 9, 2018, as granted herein), right hip bursitis status post arthroplasty (rated as 100 percent disabling from November 13, 2014 and 30 percent disabling from January 1, 2016), gastroesophageal reflux disease (rated as 0 percent disabling from March 3, 2012 and 30 percent disabling from September 12, 2018), left shoulder degeneration, post-surgical changes, mild rotator cuff impingement, and calcific tendinitis, arthrofibrosis and joint synovitis (rated as 20 percent disabling from May 22, 2013, 100 percent disabling from September 25, 2013, and 20 percent disabling from March 1, 2014 to November 23, 2016), right shoulder glenohumeral arthritis (rated as 100 percent disabling from February 4, 2015 and 20 percent disabling from May 1, 2015), left shoulder scapulohumeral articulation with ankylosis (rated as 20 percent disabling from May 22, 2013 to September 25, 2013, 20 percent disabling from March 1, 2014, 10 percent disabling from July 1, 2016, and 20 percent disabling from September 30, 2016 to November 23, 2016), status post hemiarthroplasty with non-prosthetic glenoid arthroplasty, rotator interval plication and proximal numeral bone grafting with local bone, left shoulder (rated as 100 percent disabling from November 23, 2016 and 20 percent disabling from January 1, 2018), tinnitus (rated as 10 percent disabling from June 1, 2006), right hip bursitis associated with chondromalacia of the patella/right knee strain status post arthroscopic surgery (rated as 10 percent disabling from July 24, 2013 to November 13, 2014), right knee synovitis status post chondroplasty of patella, synovectomy and flap repair (rated as 10 percent disabling from October 22, 2013, 100 percent disabling from September 21, 2017, and 10 percent disabling from November 1, 2017), post-operative rupture, left achilles tendon (rated 0 percent disabling from September 1, 1990), high frequency sensorineural hearing loss, right ear (rated as 0 percent disabling from September 1, 1990), hemorrhoids, external, mild (rated as 0 percent disabling from September 1, 1990), right knee scar associated with chondromalacia of the patella/right knee strain status post arthroscopic surgery (rated as 0 percent disabling from March 3, 2012), chondromalacia of the patella/right knee strain status post arthroscopic surgery (rated as 0 percent disabling from March 3, 2012, 100 percent disabling from May 31, 2012, 0 percent disabling from July 1, 2012, and 0 percent disabling from July 27, 2012 to October 22, 2013), left shoulder scar near right anterior axillary fold associated with left shoulder degeneration (rated as 0 percent disabling from April 20, 2015), surgical scar, right shoulder associated with right shoulder glenohumeral arthritis (rated as 0 percent disabling from April 20, 2015), residual scar status post hemiarthroplasty with non-prosthetic glenoid arthroplasty, rotator interval plication and proximal numeral bone grafting with local bone, left shoulder (rated as 0 percent disabling from November 23, 2016), and lumbar scar associated with lumbar strain status post foraminotomy/laminotomy (rated as 0 percent disabling from June 30, 2017). Therefore, the Veteran meets the schedular requirement for a TDIU under 38 C.F.R. § 4.16(a) for the entire period on appeal. The Board notes that, relevant to the period on appeal, the Veteran is in receipt of a temporary total rating for post-surgical convalescence between November 23, 2016 and December 31, 2017 and from March 20, 2018 to June 30, 2018. The Veteran is already in receipt of SMC at the housebound rate between June 30, 2017 to August 1, 2017, September 21, 2017 to November 1, 2017, and March 20, 2018 to July 1, 2018. As discussed in the section below, the Veteran is entitled to SMC at the housebound rate for the entirety of the appellate period between November 23, 2016 and December 31, 2017 (not just the periods for which he has been already awarded SMC) based on the temporary total rating for post-surgical convalescence from his left shoulder surgery, and other service-connected disabilities being independently ratable as at least 60 percent disabling. Thus, a TDIU is not necessary to establish entitlement to SMC at the housebound rate for the periods from November 23, 2016 to December 31, 2017 and from March 20, 2018 to June 30, 2018, and accordingly, entitlement to a TDIU during those periods is moot. Nevertheless, entitlement to a TDIU remains on appeal for the periods between January 22, 2016 and November 22, 2016, from January 1, 2018 to March 19, 2018, and from July 1, 2018 to the present. The remaining question is whether any of his service-connected disabilities preclude the Veteran from securing and following a substantially gainful occupation. See 38 C.F.R. § 4.16(a). The fact that a Veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his disability makes it difficult for him to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he is incapable “of performing the physical and mental acts required” to be employed. Id. at 363. Thus, the central question is whether a Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a Veteran could find employment. Id. Consideration may be given to a Veteran’s education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. To determine whether a TDIU is warranted, the Board must consider all evidence of record to determine the earliest date as of which, within the one year prior to the filing of an informal or formal claim for TDIU, an increase in disability is ascertainable. See Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). For the reasons expressed below, the Board finds that the Veteran was unable to maintain substantially gainful occupation due to his service-connected disabilities. Turning to the relevant evidence, in a December 2015 VA primary care physician outpatient note, the Veteran indicated that his occupation was a commercial airline pilot but that he was not currently working. In a December 2015 VA acupuncture consultation, the provider noted that the Veteran was an ex-pilot who could not work not because of pain in his shoulder and hips. In a July 2016 email correspondence between the Veteran and his representative, the Veteran wrote, “Unfortunately, I am not service connected for my spine...this and GWI are the two reasons why I would not go back to work.” The Board notes that “GWI” is an abbreviation for Gulf War illness. In an August 2016 letter from Dr. R.L., the Veteran's private physician, she wrote, “[The Veteran] has been disabled by a back injury since February of this year.” In a November 2016 VA mental health outpatient consultation, the provider wrote, “The veteran stated that he has been out of work for two years due to having multiple medical problems. He previously worked as a pilot. He described experiencing significant chronic pain. He reported that while he was in physical therapy recently, he experienced an (sic) another injury which has exacerbated his experience of pain. The veteran will be traveling out of state in two days to undergo shoulder surgery. He stated that after he recovers from his shoulder surgery, he will likely have surgery on his back. He stated that his ultimate goal is to return to work as a pilot.” In the February 2017 VA examination report, the Veteran reported having functional loss or functional impairment of the thoracolumbar spine, stating that he was not able to sit or walk for long hours secondary to low back pain. The examiner noted additional factors contributing to disability of disturbance of locomotion and interference with sitting and standing. Ultimately, the VA examiner opined that the Veteran’s thoracolumbar spine condition impacted his ability to work, reiterating the Veteran’s report that he is not able to sit or walk for long hours secondary to his low back pain. In a June 2018 VA psychology pain progress note, the Veteran reported feeling that chronic pain impacts multiple aspects of his life, including his overall health. He said that he has difficulty with exercise, which has reportedly led to weight gain, as well as having to stop working as a pilot. The provider wrote, “He said he received a great deal of fulfillment from his work (he is on disability now) and would like to go back to work as a commercial airline pilot.” In a July 2018 VA mental health note, the provider noted, “Veteran also spent significant time processing the loss of working as an airline pilot and how this has affected his identity.” In a January 2019 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, the Veteran indicated that the service-connected disabilities that prevent him from securing or following any substantially gainful occupation were “Lumbar strain and sciatica, right knee synovitis and arthritis, severe right shoulder arthritis, [and] significant stiffness from left shoulder arthroplasty.” He reported that the date his disability affected full-time employment was January 10, 2016, the date he last worked full-time was December 1, 2014, and the date he became too disabled to work was June 30, 2017. He indicated that he worked for American Airlines at Miami International Airport as a pilot from May 5, 2000 to January 18, 2015, for AVENGE Aviation as a pilot and in aviation from August 1, 2012 to May 5, 2013, and in the United States Air Force Reserves as a pilot and staff officer from August 1, 1990 to November 20, 2013. He indicated that his total earned income for the past 12 months was $0. He reported that he completed 4 years of college as well as the following training before he became too disabled to work: USAF Pilot Training, Commercial Airline Pilot Training, Private Jet Training, and Military Contract Pilot Training. In the “Remarks” section, the Veteran explained, “The medications I take, specifically LYRICA and TIZANADINE for back and nerve pain, make it unlawful for me to perform my duties as a commercial pilot. I have chronic swelling and irritation of my right knee for the past 12 months which precludes me from any exercise, step climbing or extended walking such as would be done in an airport moving between my departure gates. It would also make climbing in and out of the Pilot seat difficult...” In a February 2019 VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, the Veteran’s former employer, Flight Administration, Miami International Airport, indicated that the Veteran’s beginning date of employment was October 2000 as a commercial pilot. The former employer indicated that the Veteran was still employed “but on Disability,” indicating that the date he last worked was November 10, 2014. In a July 2019 Statement in Support of Claim, the Veteran wrote, “My lower back hurts at the level of a 5 on a day to day basis, when it flares up I can't stand up straight...I can't go to work permanently. I can't sit more than 20 to 30 minutes at a time...my back pain will wake me up...” After careful consideration of the record, the Board finds the Veteran is unemployable by reason of his service-connected disabilities for the entire period on appeal (except for the aforementioned periods during which entitlement to a TDIU is moot). Specifically, considering the Veteran’s occupational and educational background along with the above-mentioned evidence, which suggests that his inability to work was impacted, at least in part, by his service-connected disabilities, the Board finds that the Veteran would not have been able to maintain any type of employment that was relevant to his educational background and work experience. In this regard, the Board notes that in a recent precedential decision, Ray v. Wilkie, the Court defined the term “unable to secure and follow a substantially gainful occupation” in § 4.16(b) to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the Veteran’s history, education, skill, and training, whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue, and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. See Ray v. Wilkie, 31 Vet. App. 58 (2019). As to the economic component of a substantially gainful occupation, the evidence shows that the Veteran has not worked since 2014. See January 2019 VA Form 21-8940; February 2019 VA Form 21-4192. Thus, the Board finds that the Veteran did not work in a gainful capacity at any point during the period on appeal, which began January 22, 2016. As to the non-economic component of a substantially gainful occupation, the Veteran’s work history was as a pilot, which required a high-level of skill and concentration, the ability for sit for long hours, the ability to walk between departure gates at an airport, and the ability to get in and out of the pilot’s seat. These skills were impacted by the Veteran’s service-connected disabilities of the bilateral shoulders, lumbar spine, right hip, and bilateral lower extremities and their associated symptoms of chronic pain, stiffness, numbness, and limitation of movement, as well as the medications he takes for the chronic pain, which the Veteran indicated makes it unlawful for him to perform his duties as a commercial pilot. Based on the foregoing, the Board finds that a TDIU predicated on unemployability stemming from the Veteran’s service-connected disabilities is warranted for the entire period on appeal. 4. Entitlement to SMC at the housebound rate SMC at the housebound rate is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s). This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises, or if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.350(i). As previously mentioned, relevant to the period on appeal, the Veteran is in receipt of a temporary total rating for post-surgical convalescence for his left shoulder surgery between November 23, 2016 and December 31, 2017 and from March 20, 2018 to June 30, 2018. The Veteran is already in receipt of SMC at the housebound rate between June 30, 2017 to August 1, 2017, September 21, 2017 to November 1, 2017, and March 20, 2018 to July 1, 2018. However, the Board finds that the Veteran is entitled to SMC at the housebound rate for the entirety of the appellate period between November 23, 2016 and December 31, 2017 based on the temporary total rating for post-surgical convalescence for his left shoulder surgery and other service-connected disabilities being independently ratable as at least 60 percent disabling, including, but not limited to, his lumbar spine disability rated as 40 percent disabling from January 22, 2016 and his right hip disability rated as 30 percent disabling from January 1, 2016. (Continued on the next page) Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. M. Gill, 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.