Citation Nr: 21003214 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-06 323 DATE: January 19, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for right lower extremity radiculopathy is denied. Entitlement to a disability rating in excess of 20 percent for left lower extremity radiculopathy is denied. Entitlement to a disability rating in excess of 10 percent for a lumbar spine disorder is denied. REMANDED Entitlement to service connection for a bilateral hip disorder, to include as secondary to service-connected lumbar spine disorder, is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. At worst, right lower extremity radiculopathy does not manifest as moderate incomplete paralysis of the sciatic nerve. 2. At worst, left lower extremity radiculopathy does not manifest as moderately severe incomplete paralysis of the sciatic nerve. 3. At worst, lumbar spine disorder does not manifest as combined range of motion of the thoracolumbar spine not greater than 120 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. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code 8520 (2019). 2. The criteria for entitlement to a disability rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.124a, Diagnostic Code 8520 (2019). 3. The criteria for entitlement to a disability rating in excess of 10 percent for lumbar spine disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321. 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Code 5242 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Navy from December 1963 to January 1968. These matters are before the Board of Veterans’ Appeals (Board) on appeal from the April 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Since the Board’s remand of January 2020, the RO increased the disability rating assigned to left lower extremity radiculopathy to 20 percent. As this does not represent the maximum available benefit for left lower extremity radiculopathy, the claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that Veterans are presumed to seek the maximum available benefit for a disability). Competent Evidence Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). The Board may consider many factors when assessing the credibility and weight of lay evidence, including statements made during treatment, self-interest or bias, internal consistency, and consistency with other evidence. Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Bostain v. West, 11 Vet. App. 124, 127 (1998). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant, Increased Disability Ratings The Veteran contends that the respective disability ratings, as noted above, do not contemplate the severity of his respective symptomatology. Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will 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). Right lower extremity radiculopathy Left lower extremity radiculopathy The Veteran’s right lower extremity radiculopathy and left lower extremity radiculopathy has been evaluated according to 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Codes 8520-8730 address ratings for paralysis of the peripheral nerves affecting the lower extremities, neuritis, and neuralgia. 38 C.F.R. § 4.124a, Diagnostic Codes 8520-8730. Under Diagnostic Code 8520, 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. § 4.124a, Diagnostic Code 8520. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. Id. An 80 percent rating is warranted with complete paralysis of the sciatic nerve. Id. The term “incomplete paralysis,” with respect to peripheral nerve injuries, indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the lesion or to partial regeneration. Where the involvement is wholly sensory, the rating should be for mild, or at the most, moderate symptomatology. 38 C.F.R. § 4.124a. The words “mild,” “moderate” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. C.F.R. § 4.6 According to MERRIAM WEBSTER, “Mild” means “gentle in nature or behavior”. See www.merriam-webster.com/dictionary/mild (last accessed on January 7, 2021). “Moderate” means “tending toward the mean or average amount or dimension”. See www.merriam-webster.com/dictionary/moderate (last accessed on December 16, 2020). “Severe” means “very painful or harmful”. See www.merriam-webster.com/dictionary/severe (last accessed on December 16, 2020). “Incomplete” means “lacking a usually necessary part, element of step”. See www.merriam-webster.com/dictionary/incomplete (last accessed on December 16, 2020). In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Evidence and Analysis In February 2013, the Veteran was afforded a VA examination. A clinician reviewed the claims file; considered the Veteran’s accounts; and conducted an appropriate evaluation. The clinician findings included mild intermittent pain at the right lower extremity; mild intermittent pain at the left lower extremity; mild numbness at the right lower extremity and mild numbness at the left lower extremity. The clinician reported bilateral involvement of the L4/L5/S1/S2/S3 sciatic nerve roots. As to severity, the clinician opined that both right lower extremity and left lower extremity were mild. There was no evidence of other neurological abnormalities. As to functional impact, the clinician opined that bilateral lower extremity radiculopathy (as associated with lumbar spine disorder) allowed for sedentary employment with breaks from prolonged sitting. And, with chronic narcotic use, the operation of equipment would be prohibited. In a May 2015 VA telephone encounters, the Veteran reported that he experienced numbness and tingling in his feet (greater in the left than in the right), both when sitting or lying down. The Veteran noted that elevating his lower extremities provided some relief. A VA clinician mentioned the possibility of beginning a regimen of muscle relaxers; however, the Veteran did not entertain this as he believed that muscle relaxes would cause on-going sedation. In May 2018, a clinician noted that the Veteran reported that if he stands for a length of time, he must sit down because of left posterior hip pain. At this time. The Veteran also reported that he often falls because his leg gives way. A VA emergency room (ER) report of August 2018 shows that the Veteran sought treatment for tingling in his toes. At this time, an ER clinician noted that the Veteran could be developing neuropathy, At the August 2019 Board hearing, the Veteran testified that he experiences most pain in his left leg, exceeding that of his right leg. The Veteran also conveyed that he uses crutches and a cane when his pain worsens. Narcotics were taken in the past, but the Veteran now stated that he takes gabapentin and ibuprofen In August 2020, the Veteran was afforded another VA examination. A clinician reviewed the claims file; considered the Veteran’s accounts; and conducted an appropriate evaluation. Pertinent to the instant increased rating claims, the clinician provided diagnoses of right lower extremity radiculopathy and left lower extremity radiculopathy. As to right lower extremity radiculopathy, the clinician found mild paresthesias/dysesthesias and mild numbness. Upon assessment of severity, the clinician indicated that right lower extremity radiculopathy was mild. As to left lower extremity radiculopathy, the clinician found moderate constant pain; moderate paresthesias/dysesthesias; and moderate numbness. Upon assessment of severity, the clinician indicated that left lower extremity radiculopathy was moderate. There was no evidence of other neurological abnormalities. As to functional impact, the clinician opined that bilateral lower extremity radiculopathy (as associated with lumbar spine disorder), the clinician opined that the Veteran could only stand for 5-to-10 minutes at a time. In December 2020, the Veteran’s representative submitted an informal hearing presentation (IHP). In pertinent part, the representative contended that the evidence militates in favor of increased disability ratings for both right lower extremity radiculopathy and left lower extremity radiculopathy. As noted above, 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. § 4.124a, Diagnostic Code 8520. Therefore, to receive a disability rating in excess of 10 percent for right lower extremity radiculopathy, there would need to be a showing that right lower extremity manifests as moderate incomplete paralysis of the sciatic nerve. Such is not shown. At worst, according to the competent medical evidence of record, right lower extremity manifests in mild severity, notably, mild intermittent pain; mild numbness; and mild paresthesias/dysesthesias. Indeed, this symptomatology best approximates that of a 10 percent disability rating. Turning to left lower extremity radiculopathy, to receive a disability rating in excess of 20 percent, there would need to be a showing the left lower extremity radiculopathy manifests as moderately severe incomplete paralysis of the sciatic nerve. Such is not shown. At worst, according to the competent medical evidence of record (notably the August 2020 VA examination report), left lower extremity manifests in moderate severity, notably, moderate constant pain; moderate paresthesias/dysesthesias; and moderate numbness. This symptomatology best approximates that of a 20 percent disability rating. In selecting the appropriate qualitative level of disability, the Board considered the imposed loss of function and sensed discomfort. During the Board hearing, the Veteran testified that the pain and numbness on the right was less than on the left and not noticeable. Standing and walking endurance is limited and he did report use of a cane and shopping cart in stores for support, but he was able to drive and leave the home for shopping. As noted above, the Veteran is competent to report discernable symptoms. See Jandreau, supra. The Board finds that the Veteran’s hearing testimony and lay representations to clinicians are also credible, plausible and, in largest part, internally consistent. See Caluza, supra. However, as a lay person, neither the Veteran nor his representative, have the neurological training or clinical prowess to render a competent opinion as to the severity of either right lower extremity radiculopathy or left lower extremity radiculopathy. See Jandreau, Bostain, both supra. As such this portion of lay evidence warrants diminished probative weight when assessing the clinical severity of these two disabilities. The Board assigns significant probative weight to the VA examination reports, as discussed above. In each examination instance, a highly-trained clinical professional reviewed the claims file; considered the Veteran’s subjective accounts; and conducted an appropriate evaluation. Moreover, these professionals evaluated all of the required testing and assessment criteria necessary to ascertain the severity of both right lower extremity radiculopathy and left lower extremity radiculopathy. Therefore, the Board finds that the preponderance of evidence is against granting a disability rating in excess of 10 percent to right lower extremity radiculopathy and a disability rating in excess of 20 percent to left lower extremity radiculopathy. As such, there are no doubts to resolve. See 38 U.S.C. § 5107(b); Gilbert, supra. Lumbar spine disorder Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Deluca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. See DeLuca, supra. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable Diagnostic Code. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and numbness in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. See Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). Musculoskeletal VA examinations, to be adequate, must address particular issues when are where that are practicable and medically possible—to include active and passive motion; weight bearing and non-weight bearing; range of motion of an opposing joint; and findings as to loss of motion during flare-ups. See Correia v. McDonald, 28 Vet. App. (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board observes that the VA examiners who performed musculoskeletal joint examinations, after these cases, whether implicitly or explicitly, addressed these vectors in their examination reports. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The Veteran’s lumbar spine disorder has been evaluated according to the general formula provided in 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. The General Rating Formula for Diseases and Injuries of the Spine is as follows: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: Unfavorable ankylosis of the entire spine: 100 percent disabling. Unfavorable ankylosis of the entire thoracolumbar spine: 50 percent disabling. Forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine: 40 percent disabling. Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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: 20 percent disabling. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height: 10 percent disabling. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees and left and right lateral rotation are 0 to 30 degrees. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2017). Intervertebral disc syndrome (IVDS) is evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes warrants a maximum 60 percent rating when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. “Chronic orthopedic and neurological manifestations” means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Discussion Upon the February 2013 VA examination, the clinician provided diagnoses of L5-S1 spondylolisthesis, degenerative joint disease (DJD), and degenerative disc disease (DDD) of the lumbar spine. The Veteran’s initial and post-repetitive motion forward flexion was 70 degrees; and the combined range of motion was to 210 degrees. No guarding or muscle spasm was present. Muscle strength, reflexes, and sensation were normal at all indices. The clinician found evidence of neither atrophy nor IVDS. Likewise, there was no objective evidence of ankylosis. The clinician noted that the Veteran reported occasionally wearing a back brace—when he rides in cars for extended periods and when lifting objects. The Veteran did not endorse the occurrence of flare-ups. And, as already noted, the clinician opined that the Veteran’s lumbar spine disability (and associated bilateral lower extremity radiculopathy) allows for sedentary employment with breaks from prolonged sitting. Lastly, with chronic narcotic use, the operation of equipment would be prohibited. A review of the Veteran’s VA treatment records during the period under consideration discloses complaints of left thoracolumbar spine pain. The Veteran’s on-going problems list includes low back pain. Clinicians monitored the Veteran’s roster of medications, both to maximize efficacy and to avoid interactions. At the August 2019 Board hearing, the Veteran testified that his lumbar spine disorder pain has caused him to take days off from work when he was employed. Upon the August 2020 VA examination, the clinician continued the February 2013 clinician’s diagnoses. The Veteran’s initial and post-repetitive motion forward flexion was to 90 degrees; and the combined range of motion was to 185 degrees. No guarding or muscle spasm was present. With the exceptions of right-side hip flexion and knee extension which showed active movement against some resistance, muscle strength testing was normal. There was no presence of atrophy or IVDS. Reflex testing was normal at all indices. Sensory exam results were normal, with the exception of decreased findings as to bilateral thigh/knee; bilateral lower leg ankle; and bilateral foot/toes. There was no objective evidence of ankylosis The Veteran did not endorse the occurrence of flare-ups. And, as noted above, the clinician opined that functional impact (with bilateral lower extremity radiculopathy) consisted of the Veteran’s ability only to stand for 5-to-10 minutes at a time. In the December 2020 IHP, the Veteran’s representative reiterated his contention as to the lumbar spine disability. As noted above, to receive a higher disability rating there would need to be a showing of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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. At worst, according to the competent medical evidence of record discussed above, the Veteran’s lumbar spine disorder does not manifest in any of the ways articulated directly above. As such, a 10 percent disability rating best approximates the severity of the Veteran’s lumbar spine disorder. As but one example, the combined range of motion of the thoracolumbar spine was greater than 120 degrees but not greater than 235 degrees. As noted about, the combined range of motion was 210 degrees upon the February 2013 examination and 185 degrees upon the August 2020 examination. As noted above, the Veteran is competent to report discernable symptoms. See Jandreau, supra. The Board finds that the Veteran’s hearing testimony and lay representations to clinicians are also credible, plausible and, in largest part, internally consistent. See Caluza, supra. However, as a lay person, neither the Veteran nor his representative, have the orthopedic training or clinical prowess to render a competent opinion as to the severity of a lumbar spine disorder. See Jandreau, Bostain, both supra. As such this portion of lay evidence warrants diminished probative weight when assessing the clinical severity of the Veteran’s lumbar spine disorder. The Board assigns significant probative weight to the VA examination reports, as discussed above. In each examination instance, a clinical professional reviewed the claims file; considered the Veteran’s subjective accounts; and conducted an appropriate evaluation. Moreover, these professionals evaluated all of the required testing and assessment criteria necessary to ascertain the severity of a lumbar spine disorder. Therefore, the Board finds that the preponderance of evidence is against granting a disability rating in excess of 10 percent to the Veteran’s lumbar spine disorder. As such, there are no doubts to resolve. See 38 U.S.C. § 5107(b); Gilbert, supra. REASONS FOR REMAND Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Bilateral hip disorder In a January 2020 remand directive, the Board, with specificity, asked the that the VA clinician conducting a bilateral hip disorder examination “address the in-service notation of marked difference in leg length and whether this condition has any bearing on the Veteran’s claimed altered gait.” Upon review of the August 2020 VA hip and thigh conditions examination, the clinician did not address this identified in-service notation. Rather, the clinician noted that the results of the examination showed no current hip disabilities. The Board finds that the RO has not substantially complied with this January 2020 remand directive. Stegall v. West, 11 Vet. App. 268, 270-271 (1998). TDIU The issue of entitlement to a TDIU is inextricably intertwined with the issue on appeal. See Smith (Daniel) v. Gober, 236 F. 3d 1370, 1373 (Fed. Cir. 2001). Hence, a thorough consideration of the TDIU claim must be deferred pending the directed development and subsequent readjudication of the Veteran’s other bilateral hip disorder claim Therefore, additional development is in order The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records. 2. After obtaining the necessary authorization from the Veteran and his representative, obtain and associate with the claims file any additional identified and relevant private treatment records. All attempts to secure these records must be documented in the record. If any requested records are unavailable, the Veteran should be notified of such in accordance with 38 C.F.R. § 3.159(e). 3. Upon completion of the above, arrange for a VA addendum opinion with an appropriate clinician. The selected clinician must review the claims file and refer to specific medical and lay evidence when rendering opinions. The clinician must address the in-service notation of marked difference in the Veteran’s leg length and whether this difference has any bearing on the Veteran’s claimed altered gait. Upon consideration of the evidence of record, the clinician is asked to respond to the following: a. Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral hip disorder is etiologically related to his service? AND b. Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral hip disorder was proximately caused by, or aggravated beyond its natural progression by, the Veteran’s service-connected lumbar spine disorder? The Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran’s reports, she/he must provide an explanation for such rejection. Rationales must be provided for each conclusion reached. 4. Upon completion of the above-directed development, readjudicate the service connection issue on appeal; and then readjudicate entitlement to the inextricably intertwined issue of TDIU. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.