Citation Nr: 21062922 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 16-08 836 DATE: October 12, 2021 ORDER An increased rating of 40 percent for a lumbosacral spine disability is granted, effective September 10, 2020. An increased rating in excess of 20 percent for a lumbosacral spine disability before September 10, 2020 is denied. A compensable rating for a surgical scar of the lumbar spine is denied. An increased rating in excess of 10 percent for acne vulgaris of the back is denied. An increased rating of 40 percent for right lower extremity radiculopathy is granted, effective August 10, 2012. An increased rating in excess of 40 percent for right lower extremity radiculopathy is denied. An increased rating of 20 percent for left lower extremity radiculopathy is granted, effective August 10, 2012. An increased rating in excess of 20 percent for left lower extremity radiculopathy is denied. An increased rating in excess of 30 percent for onychomycosis of the bilateral toes is denied. Eligibility for payment or reimbursement for an automobile or other conveyance and adaptive equipment or adaptive equipment only is denied. REMANDED Entitlement to service connection for syncope is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. Entitlement to service connection for right lower extremity autonomic neuropathy is remanded. Entitlement to service connection for left lower extremity autonomic neuropathy is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. Since September 10, 2020, the Veteran's lumbosacral spine disability has been manifested by limitation of motion after repeated use over time most nearly approximating limitation of forward flexion of the thoracolumbar spine to thirty degrees or less. There is no evidence during this period of any ankylosis or intervertebral disc disease (IVDS) with incapacitating episodes having a total duration of at least six weeks in the past twelve months. See September 2020 VA Examination. 2. Before September 10, 2020, the Veteran's lumbosacral spine disability was manifested by no more than forward flexion limited to 50 degrees. There is no evidence during this period of more severe limitation of flexion or IVDS with incapacitating episodes having a total duration of at least four weeks in the past twelve months. See VA Examinations dated January 2012, December 2014. 3. There is no evidence throughout the claim period that the Veteran's lumbar spine surgical scar has been painful or unstable, associated with underlying soft tissue damage, or at least 144 square inches in size. See VA Examinations dated January 2012, March 2017, September 2020. 4. The Veteran's acne vulgaris of the back has been manifested by no more than deep acne of the back throughout the claim period. There is no evidence of scars that are unstable, painful, associated with underlying soft tissue damage, or at least 144 square inches in size, nor of any characteristics of disfigurement. See VA Examinations dated January 2012, January 2014, September 2020. 5. The Veteran's right lower extremity radiculopathy has been manifested by symptoms most nearly approximating moderately severe incomplete paralysis throughout the claim period, such as decreased strength, paresthesias and/or dysesthesias, pain, and severe numbness. There is no evidence of severe incomplete paralysis with marked muscular atrophy throughout the claim period. See VA Examinations dated June 2011, January 2012, January 2014, March 2017, September 2020. 6. The Veteran's left lower extremity radiculopathy has been manifested by symptoms most nearly approximating moderate incomplete paralysis throughout the claim period, such as decreased sensation, pain, and paresthesias and/or dysesthesias. There is no evidence of symptoms of moderately severe incomplete paralysis throughout the claim period. VA Examinations dated June 2011, January 2012, January 2014, March 2017, September 2020. 7. The Veteran's onychomycosis of the bilateral toes has been manifested by no more than skin disease requiring systemic therapy for a total duration of six weeks or more over the past twelve months. There is no evidence of constant or near constant systemic therapy or characteristic lesions involving more than forty percent of the entire body or of exposed areas affected. See VA Examinations dated January 2012, January 2014, September 2020. 8. The Veteran's service-connected disabilities do not result in loss or loss of use of a hand or foot, permanent impairment of both eyes, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of a knee or hip. See, e.g., VA Examinations dated June 2011, January 2012, January 2014, November 2015, March 2017, September 2020. CONCLUSIONS OF LAW 1. The criteria for an increased rating of 40 percent for a lumbosacral spine disability are met from September 10, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5241. 2. The criteria for an increased rating in excess of 20 percent for a lumbosacral spine disability before September 10, 2020 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5241. 3. The criteria for a compensable rating for a surgical scar of the lumbar spine are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7801. 4. The criteria for an increased rating in excess of 10 percent for acne vulgaris of the back are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7828. 5. The criteria for an increased rating of 40 percent for right lower extremity radiculopathy are met from August 10, 2012. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 6. The criteria for an increased rating in excess of 40 percent for right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 7. The criteria for an increased rating of 20 percent for left lower extremity radiculopathy are met from August 10, 2012. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 8. The criteria for an increased rating in excess of 20 percent for left lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 9. The criteria for an increased rating in excess of 30 percent for onychomycosis of the bilateral toes are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7813. 10. The criteria for eligibility for payment or reimbursement for an automobile or other conveyance and adaptive equipment or adaptive equipment only are not met. 38 U.S.C. §§ 3901, 3902, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.808. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 1988 to May 1988, from December 1990 to May 1991, from January 2002 to December 2002, and from February 2003 to February 2006. This case is before the Board of Veterans' Appeals (Board) on appeal from February 2014, December 2014, and December 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Increased Ratings 1. A Lumbosacral Spine Disability Since September 10, 2020 The Veteran's lumbosacral spine disability is currently rated as 20 percent disabling throughout the claim period, under the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a. Under the General Rating Formula, a rating in excess of 20 percent for a disability of the thoracolumbar spine requires forward flexion limited to 30 degrees or less, or ankylosis. A rating in excess of 20 percent may also be warranted for IVDS with incapacitating episodes having a total duration of at least four weeks in the past twelve months. There is no evidence throughout the claim period of forward flexion limited to less than 50 degrees or IVDS with any incapacitating episodes. See VA Examinations dated January 2012, January 2014, September 2020. However, at a September 2020 VA spine examination, the Veteran reported that with repetitive use over a period of time, his back pain worsens to the point of "inability to use." The examiner stated that this increased disability could not be described in terms of range of motion. Significantly, the Veteran reported that the inability to use his back results from pain. He did not report that he was actually unable to move his back, or that his range of motion was reduced to zero. Nevertheless, this evidence clearly indicates that the Veteran's disability is more severe than is reflected in the objective range of motion findings of the examination. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's lumbosacral spine disability has been manifested by symptoms most nearly approximating limitation of forward flexion to 30 degrees, since September 10, 2020. See 38 C.F.R. §§ 4.3, 4.7. Accordingly, an increased rating of 40 percent is warranted from that date. However, because there is no evidence throughout the claim period of ankylosis of the thoracolumbar spine, or of limitation of motion approximating ankylosis, or IVDS with any incapacitating episodes, a rating in excess of 40 percent is not warranted. Before September 10, 2020 There is no evidence before September 10, 2020 of limitation of forward flexion to 30 degrees or less, or any symptoms closely approximating such limitation. The Veteran was afforded VA spine examinations in January 2012 and January 2014. The January 2012 examination noted forward flexion limited to 50 degrees with no flare ups and no additional limitation of motion after three repetitions. The January 2014 VA examination noted forward flexion limited to 70 degrees with once monthly flare ups making it difficult to get out of bed and no additional limitation of motion after three repetitions. The Veteran did not report additional limitation of motion with flare ups or repetitive use over time at either examination. The findings of the January 2012 and January 2014 VA examinations are competent, credible, and entitled to significant weight. Moreover, there is no evidence to the contrary. Therefore, a rating in excess of 20 percent before September 10, 2020 is not warranted. 2. Surgical Scar of the Lumbar Spine The Veteran's surgical scar of the lumbar spine is currently rated as noncompensably disabling throughout the claim period, under Diagnostic Code (DC) 7801. A compensable rating for a scar, not of the head, face, or neck may be warranted for a scar with underlying soft tissue damage covering at least six square inches, a scar without underlying soft tissue damage covering at least 144 square inches, or a scar that is unstable or painful. 38 C.F.R. § 4.118, DCs 7801 7804. The Veteran has been afforded three VA examinations to evaluate the severity of his lumbar spine surgical scar throughout the claim period, in January 2012, March 2017, and September 2020. None of the examinations noted findings of any scars associated with underlying soft tissue damage, having an area of at least 144 square inches, or that were unstable or painful. The findings of the VA examinations are competent credible and entitled to significant weight. Moreover, there is no evidence to the contrary. Therefore, a compensable rating for a surgical scar of the lumbar spine is not warranted. 3. Acne Vulgaris of the Back The Veteran's acne vulgaris of the back is currently rated as 10 percent disabling throughout the claim period, under DC 7828. Under that code, a rating in excess of 10 percent requires deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck; disfigurement of the head, face, or neck; one or more scars with underlying soft tissue damage having an area of at least twelve square inches; or three or four unstable or painful scars. 38 C.F.R. § 4.118. The Veteran has been afforded four VA examinations evaluating his acne during the claim period, in January 2012, January 2014, March 2017, and September 2020. None of these examinations noted findings of deep acne affecting 40 percent or more of the face and neck, any disfigurement, or scars with underlying soft tissue damage, or that were unstable or painful. The findings of the VA examinations are competent credible and entitled to significant weight. Moreover, there is no evidence to the contrary. Therefore, a rating in excess of 10 percent for acne vulgaris of the back is not warranted. 4. Right and Left Lower Extremity Radiculopathy Right Lower Extremity The Veteran's right lower extremity radiculopathy is currently rated as 20 percent disabling throughout the claim period, under DC 8520. Under that code, a rating in excess of 20 percent requires moderately severe incomplete paralysis of the sciatic nerve. The Veteran has been afforded five VA examinations evaluating his radiculopathy throughout the claim period, in June 2011, January 2012, January 2014, March 2017, and September 2020. These examinations reveal a largely consistent disability picture throughout the claim period, with symptoms of moderate to severe numbness, decreased strength, decreased or absent sensation, pain, and dysesthesias. The Board notes that VA examiners in March 2017 and September 2020 made findings suggesting that the Veteran's radiculopathy had resolved. The March 2017 examiner noted evidence of a history of radiculopathy per an EMG study, but no evidence of ongoing axonal loss, or current neuropathy or radiculopathy. The September 2020 examiner agreed with the March 2017 examiner's findings. However, both examinations nevertheless reflected symptoms of radiculopathy, the same symptoms, in fact, which were reflected in earlier examination reports. Therefore, affording the Veteran the benefit of the doubt, the Board finds that these symptoms remained attributable to the Veteran's right lower extremity radiculopathy throughout the claim period. See 38 C.F.R. § 4.3. Moreover, the Board also notes that the Veteran's own reports have consistently painted a somewhat more severe picture of his radiculopathy throughout the claim period. For instance, at his January 2012 VA examination, the Veteran reported loss of positional sense of his right lower extremity, and at his January 2014 examination he reported constant pain and symptoms requiring the use of a wheelchair or cane and leg brace. The Veteran reported that his symptoms had worsened in March 2017. Although in September 2020 he reported they had improved somewhat, he nevertheless reported continuing right foot drop, decreased sensation, and intermittent pain and numbness. Considering the evidence as a whole, and affording weight to both the objective medical findings and the Veteran's competent lay reports as to his own symptoms, the Board finds that the Veteran's right lower extremity radiculopathy has been manifested by symptoms most nearly approximating moderately severe incomplete paralysis throughout the claim period. Accordingly, an increased rating of 40 percent is warranted for right lower extremity radiculopathy. A rating in excess of 40 percent under DC 8520 requires severe incomplete paralysis with marked muscular atrophy. There is no evidence of any muscular atrophy at any point throughout the claim period. Therefore, a rating in excess of 40 percent for right lower extremity radiculopathy is not warranted. Left Lower Extremity The Veteran's left lower extremity radiculopathy is currently rated as 10 percent disabling throughout the claim period, also under DC 8520. Under this code, a rating in excess of 10 percent requires moderate incomplete paralysis of the sciatic nerve. As with the right lower extremity, VA examinations reveal a largely consistent disability picture throughout the claim period, with symptoms slightly less severe than the right side. In particular, the examinations reflect findings of decreased sensation, numbness, mild constant or intermittent pain, reduced reflexes, and mild to moderate dysesthesias. See VA Examinations dated June 2011, January 2012, January 2014, March 2017, September 2020. (As with the right lower extremity, the Board affords the Veteran the benefit of the doubt regarding the attribution of symptoms noted on the March 2017 and September 2020 VA examinations and finds that his left lower extremity symptoms remained attributable to his radiculopathy throughout the claim period.) The Veteran's reports of his left lower extremity symptoms have also consistently reflected somewhat more severe impairment than contemporary examination findings. As noted above, the Veteran reported symptoms requiring the use of a wheelchair at a January 2014 VA examination and reported that his symptoms had worsened in March 2017. Although in September 2020 he reported that they had improved somewhat, he nevertheless reported continuing numbness and intermittent pain. Considering the evidence as a whole, and affording weight to both the objective medical findings and the Veteran's competent lay reports as to his own symptoms, the Board finds that the Veteran's left lower extremity radiculopathy has been manifested by symptoms most nearly approximating moderate incomplete paralysis throughout the claim period. Accordingly, an increased rating of 20 percent is warranted for left lower extremity radiculopathy. A rating in excess of 20 percent under DC 8520 requires moderately severe incomplete paralysis. There is no evidence throughout the claim period of symptoms indicating moderately severe incomplete paralysis, such as moderately severe pain, numbness, or paresthesias and/or dysesthesias. See VA Examinations dated June 2011, January 2012, January 2014, March 2017, September 2020. Therefore, a rating in excess of 20 percent for left lower extremity radiculopathy is not warranted. 5. Onychomycosis of the Bilateral Toes The Veteran's onychomycosis of the bilateral toes is currently rated as 30 percent disabling throughout the claim period, under the General Rating Formula for the Skin. Under the General Rating Formula, a rating in excess of 30 percent requires either characteristic lesions involving more than 40 percent of the entire body or of exposed areas affected, or constant or near-constant systemic therapy required over the past twelve months. The Veteran has been afforded three VA examinations evaluating his onychomycosis throughout the claim period, in January 2012, January 2014, and September 2020. None of these examinations noted findings of characteristic lesions involving more than 40 percent of the entire body or of exposed areas affected, or constant or near-constant systemic therapy required over the past twelve months. The findings of the VA examinations are competent credible and entitled to significant weight. Moreover, there is no evidence to the contrary. Therefore, a rating in excess of 30 percent for onychomycosis of the bilateral toes is not warranted. 6. Automobile Allowance Veterans or service members with certain service-connected disabilities may be found eligible to receive financial assistance in acquiring one automobile or other conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C. § 3901. Eligibility for assistance to purchase a vehicle and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 U.S.C. § 3901; 38 C.F.R. § 3.808. The Veteran is service connected for posttraumatic stress disorder, obstructive sleep apnea, migraine headaches, onychomycosis of the bilateral toes, type two diabetes mellitus, a lumbosacral spine disability, a surgical scar of the lumbar spine, radiculopathy of the right and left lower extremities, acne vulgaris of the back, and tinnitus. There is no evidence that any of these disabilities result in loss or permanent loss of use of one or both hands, permanent impairment of vision, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of one or both knees or hips. Therefore, the Board restricts its analysis to the question of whether the Veteran's service-connected disabilities result in loss or permanent loss of use of one or both feet. VA regulations provide that permanent loss of use of a hand or foot exists when "no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with the use of a suitable prosthetic appliance." See 38 C.F.R. §§ 3.350 (a)(2). At a June 2011 VA examination, the Veteran reported that his lower extremity radiculopathy was causing him to fall more, and that he wore a full leg brace. Similarly, at a September 2020 VA examination, the Veteran reported that a brace he wore for right drop foot did not fit him well and his right foot sometimes tripped him up and caused him to fall. A January 2012 VA examination also noted that the Veteran had no right leg positional sense. However, records from throughout the claim period consistently indicate that the Veteran can walk unassisted, albeit with difficulty or for limited distances. See VA Examinations dated June 2011, January 2014, September 2020. Because the Veteran has had sufficient use of both feet to be able to walk unassisted throughout the claim period, the Board finds that his service-connected disabilities do not result in the loss or permanent loss of use of one or both feet. Accordingly, eligibility for payment or reimbursement for an automobile or other conveyance and adaptive equipment or adaptive equipment only is not warranted. REASONS FOR REMAND 1. Entitlement to Service Connection for Syncope, Right and Left Lower Extremity Peripheral and Autonomic Neuropathy, and Right and Left Hip and Knee Disabilities The Board remanded the issues of entitlement to service connection for syncope, right and left lower extremity peripheral and autonomic neuropathy, and right and left hip and knee disabilities in December 2018 with directions to provide the Veteran new examinations and medical nexus opinions in support of these claims. A Board remand confers on the Veteran the right to compliance with the remand orders and imposes on VA a concomitant duty to ensure such compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition, when VA undertakes to provide an examination for a claim for service connection, even if not statutorily obliged to do so, it must provide an adequate one or, at minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). In order to be adequate, medical opinions must support their conclusions with an analysis or rationale the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds that the examinations and medical nexus opinions obtained in response to the Board's December 2018 remand are inadequate and in certain respects fail to comply with the Board's remand orders. Syncope and Right and Left Lower Extremity Peripheral and Autonomic Neuropathy The Veteran was afforded new VA examinations and medical nexus opinions on these claims in September 2020. Regarding the Veteran's claimed syncope, the examiner stated on the one hand that symptoms occurring after the Veteran's service were due to medication and unrelated to his in-service symptoms, and on the other hand that there was no current diagnosis of syncope, notwithstanding ongoing rare or occasional dizziness, which the examiner characterized as a "common minor symptom complaint." In the first place, the examiner provided no rationale as to why the Veteran's post-service symptoms were more likely due to medication than related to his in-service symptoms. Secondly, the examiner provided no explanation for his conclusion that rare or occasional symptoms indicate no syncope, rather than rare or occasional syncope. The examiner's opinions are not supported by rationales which the Board can evaluate, and the Board therefore finds that they are inadequate. Regarding the Veteran's claimed peripheral and autonomic neuropathy, the examiner concluded that the Veteran had no peripheral neuropathy of either lower extremity, and that any autonomic neuropathy "appear[s] mostly resolved" and was "in line with [common] symptoms complaints." The Board is unable to determine from this whether it is the examiner's opinion that the Veteran has never had autonomic neuropathy, or whether he had autonomic neuropathy at some point during the claim period which has now resolved. If the latter, the examiner was required to provide direct and secondary nexus opinions. The December 2018 Board remand directed that opinions be obtained both regarding whether the Veteran's claimed neuropathy was directly related to service and regarding whether it was secondary to his service-connected type two diabetes mellitus. The September 2020 VA examination contains neither a direct nor a secondary nexus opinion regarding the Veteran's claimed peripheral and autonomic neuropathy. Therefore, because the Board finds that the September 2020 VA examination opinions are inadequate, and because they fail to comply with the Board's December 2018 remand orders to provided direct and secondary opinions regarding the Veteran's claimed peripheral and autonomic neuropathy, a remand is necessary to provide new VA examinations and opinions in support of the Veteran's claims. Right and Left Hip and Knee Disabilities As for the Veteran's claimed right and left hip and knee disabilities, the September 2020 VA examiner noted degenerative changes per radiological findings during the claim period, as well as reports of aching pain in the hips and knees, but concluded that the Veteran has "no current diagnosis" or "no objective condition" of the hips or knees. Instead, the examiner characterized the Veteran's degenerative changes as "normal aging and normal variant changes." The examiner provided no rationale in support of his opinion that the Veteran's degenerative changes of the hips and knees are normal aging changes not related to service. Moreover, the examiner's opinion included no opinion as to whether the Veteran's hip and knee pain itself results in functional impairment, and if so, whether it is related to service. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) ("In the absence of a currently diagnosed condition, pain alone may still constitute a disability, so long as the pain results in functional impairment.). Therefore, the Board finds that the September 2020 VA examination is inadequate. Accordingly, a remand is necessary to provide the Veteran new VA examinations and medical nexus opinions in support of these claims. 2. TDIU The Veteran is currently in receipt of a TDIU from January 24, 2011. However, as discussed below, he is schedularly eligible for a TDIU from October 10, 2006, and the Board finds that a claim for a TDIU before January 24, 2011 is part of his claims for increased ratings discussed above. The Court of Appeals for Veterans' Claims (CAVC) has held that a claim for a TDIU is part of a claim for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Board finds that these criteria are met in this case. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either: a) one disability that is rated at least 60 percent disabling, or b) two or more disabilities that amount to a combined disability rating of at least 70 percent and one of which is rated at least 40 percent disabling. 38 C.F.R. § 4.16(a). Here, the Veteran has a combined rating of 80 percent with a single disability (obstructive sleep apnea) rated as 50 percent from October 10, 2006. Therefore, the schedular threshold is met from that date. The remaining issue is whether the Veteran's service-connected disabilities precluded him from securing and following a substantially gainful occupation during the period before January 24, 2011. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The central question is whether the Veteran's service-connected disabilities alone were of sufficient severity to produce unemployability, taking into consideration his education, training, and special work experience, but not his age or impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Here, there is evidence of record indicating that the Veteran was prevented from working from August 2010 by his syncope and autonomic neuropathy. See May 2011 VA Treatment Record; October 2011 TDIU Application. The Veteran is not currently service connected for syncope or autonomic neuropathy; however, entitlement to service connection for those disabilities is remanded herein. If service connection is granted on remand, the Veteran may be entitled to a TDIU for the period from August 2010 to his current entitlement, January 24, 2011. Accordingly, the Board finds that the issue of entitlement to a TDIU before January 24, 2011 is inextricably intertwined with the issues of entitlement to service connection for syncope and autonomic neuropathy, and must be remanded pending adjudication of those issues. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. After completing the development outlined in Item 1., schedule the Veteran for VA examinations and medical nexus opinions in support of his claims for service connection for syncope, right and left lower extremity peripheral and autonomic neuropathy, and right and left hip and knee disabilities. Upon thorough review of the claims file and physical examination of the Veteran, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran's syncope had its onset in or is otherwise related to his active duty service, to include reports of syncope and lightheadedness in June 2004? (b.) Is it at least as likely as not that the Veteran's syncope was either a) caused or b) aggravated by his autonomic neuropathy? Aggravation here means worsening beyond the normal progression (which need not be permanent) of the Veteran's syncope. If you determine that the Veteran's syncope was aggravated by his autonomic neuropathy, please estimate the degree of aggravation beyond the baseline level of the syncope that is caused by his autonomic neuropathy. (c.) Please note any diagnosis of peripheral neuropathy the Veteran has had during the claim period (from April 11, 2011 to present). For any noted diagnosis, is it at least as likely as not that the right or left lower extremity peripheral neuropathy had its onset in or is otherwise related to his active duty service? (d.) For any noted diagnosis, is it at least as likely as not that the right or left lower extremity peripheral neuropathy was either a) caused or b) aggravated by the Veteran's service-connected type two diabetes mellitus? Aggravation here means worsening beyond the normal progression (which need not be permanent) of the Veteran's right or left lower extremity peripheral neuropathy. If you determine that the Veteran's right or left lower extremity peripheral neuropathy was aggravated by his service-connected type two diabetes mellitus, please estimate the degree of aggravation beyond the baseline level of the right or left lower extremity peripheral neuropathy that is caused by his diabetes. (e.) Please note any diagnosis of autonomic neuropathy the Veteran has had during the claim period (from April 11, 2011 to present), including diagnoses which may have resolved during the appeal period. For any noted diagnosis, is it at least as likely as not that the right or left lower extremity autonomic neuropathy had its onset in or is otherwise related to his active duty service? (f.) For any noted diagnosis, is it at least as likely as not that the right or left lower extremity autonomic neuropathy was either a) caused or b) aggravated by the Veteran's service-connected type two diabetes mellitus? Aggravation here means worsening beyond the normal progression (which need not be permanent) of the Veteran's right or left lower extremity autonomic neuropathy. If you determine that the Veteran's right or left lower extremity autonomic neuropathy was aggravated by his service-connected type two diabetes mellitus, please estimate the degree of aggravation beyond the baseline level of the right or left lower extremity autonomic neuropathy that is caused by his diabetes. (g.) Please note any right or left hip diagnosis the Veteran has had during the claim period (from September 15, 2015 to the present). For every noted diagnosis, is it at least as likely as not that the right or left hip disability had its onset during or is otherwise related to the Veteran's active duty service, to include reports of pain and numbness in the hips in December 2004, April 2005, and June 2005? (h.) In the event that the criteria for a diagnosis of a hip disability are not met, the please specifically state whether there is any functional impairment associated with the Veteran's complaints of right and left hip pain. Please complete the "Functional Impact" section of the report of examination. If there is functional impairment, please offer an opinion as to whether this impairment is at least as likely as not associated with the Veteran's service, to include reports of pain and numbness in the hips in December 2004, April 2005, and June 2005. (i.) Please note any right or left knee diagnosis the Veteran has had during the claim period (from September 15, 2015 to the present). For every noted diagnosis, is it at least as likely as not that the right or left knee disability had its onset during or is otherwise related to the Veteran's active duty service, to include a September 1998 report of pain in both knees since service in the Persian Gulf? (j.) In the event that the criteria for a diagnosis of a knee disability are not met, the please specifically state whether there is any functional impairment associated with the Veteran's complaints of right and left knee pain. Please complete the "Functional Impact" section of the report of examination. (k.) If there is functional impairment, please offer an opinion as to whether this impairment is at least as likely as not associated with the Veteran's service, to include a September 1998 report of pain in both knees since service in the Persian Gulf. The examiner must provide a fully articulated medical rationale for each opinion, citing to peer-reviewed medical literature referenced in formulating it, if any. If the examiner finds that an opinion cannot be provided, this conclusion should also be clearly explained (e.g. lack of sufficient information/evidence in this case, or a lack of knowledge among the medical community at large, and not the insufficient knowledge of the individual examiner). S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Timmerman, 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.