Citation Nr: 21063172 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-04 445 DATE: October 13, 2021 ORDER Entitlement to service connection for left shoulder disability is denied. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability, is denied. Entitlement to an initial 40 percent rating, from October 21, 2015, for lumbosacral strain, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 40 percent for lumbosacral strain is denied. Entitlement to an initial 10 percent rating, from October 21, 2015 through December 16, 2018, and a 40 percent rating, from December 17, 2018, for right lower extremity radiculopathy of the sciatic nerve, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 10 percent, from October 21, 2015 through December 16, 2018, and a rating higher than 40 percent, from December 17, 2018, for right lower extremity radiculopathy of the sciatic nerve, is denied. Entitlement to an initial compensable rating, from October 21, 2015 through February 11, 2020, and a rating higher than 30 percent, from February 12, 2020, for right lower extremity radiculopathy of the femoral nerve, is denied. Entitlement to an initial 10 percent rating, from October 21, 2015 through December 16, 2018, and a 40 percent rating, from December 17, 2018, for left lower extremity radiculopathy of the sciatic nerve, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 10 percent, from October 21, 2015 through December 16, 2018, and a rating higher than 40 percent, from December 17, 2018, for left lower extremity radiculopathy of the sciatic nerve, is denied. Entitlement to an initial compensable rating, from October 21, 2015 through February 11, 2020, and a rating higher than 20 percent, from February 12, 2020, for left lower extremity radiculopathy of the femoral nerve, is denied. REMANDED Entitlement to service connection for bilateral foot disability (other than left foot plantar wart), to include as secondary to service-connected disability, is remanded. Entitlement to service connection for urinary disability, to include as secondary to service-connected disability, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, from October 21, 2015 through October 10, 2018, is remanded. REFERRED The issue of entitlement to an increased rating for posttraumatic stress disorder (PTSD) was raised in an August 2021 "Application for Disability Compensation and Related Compensation Benefits" form (VA Form 21-526EZ). This matter is referred to the agency of original jurisdiction (AOJ) for adjudication. 38 C.F.R. § 20.904(b) (2020) (continuing to provide for Board referral of unadjudicated claims). FINDINGS OF FACT 1. The Veteran's left shoulder disability did not have its onset in service and is not otherwise related to an in-service injury or disease. 2. The Veteran's erectile dysfunction did not have its onset in service, is not otherwise related to an in-service injury or disease, and is not caused or aggravated by service-connected disability. 3. Since the October 21, 2015 effective date of service connection, the Veteran's lumbosacral strain has been manifested by limitation of forward flexion of the thoracolumbar spine to between 30 degrees and 45 degrees, with additional limitation of motion during flare ups and with repeated use over time, and to the extent that medication has ameliorated these symptoms, such amelioration cannot be considered; there is no spinal ankylosis, functional equivalent of spinal ankylosis, or incapacitating episodes due to intervertebral disc syndrome having a total duration of at least 6 weeks during a 12-month period. 4. From October 21, 2015 through December 16, 2018, the Veteran's right lower extremity radiculopathy was manifested by at most mild incomplete paralysis. 5. Since December 17, 2018, the Veteran's right lower extremity radiculopathy has been manifested by at most moderately severe incomplete paralysis. 6. From October 21, 2015 through December 16, 2018, the Veteran's left lower extremity radiculopathy was manifested by at most mild incomplete paralysis. 7. Since December 17, 2018, the Veteran's left lower extremity radiculopathy has been manifested by at most moderately severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for left shoulder disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for erectile dysfunction, to include as secondary to service-connected disabilities, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for an initial 40 percent rating, but no higher, from October 21, 2015, for lumbosacral strain, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.71A, Diagnostic Codes (DC) 5237, 5243. 4. The criteria for an initial 10 percent rating, but no higher, from October 21, 2015 through December 16, 2018, and a 40 percent rating, but no higher, from December 17, 2018, for right lower extremity radiculopathy of the sciatic nerve are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8520. 5. The criteria for an initial compensable rating, from October 21, 2015 through February 11, 2020, and a rating higher than 30 percent, from February 12, 2020, for right lower extremity radiculopathy of the femoral nerve are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8526. 6. The criteria for an initial 10 percent rating, but no higher, from October 21, 2015 through December 16, 2018, and a 40 percent rating, but no higher, from December 17, 2018, for left lower extremity radiculopathy of the sciatic nerve are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8520. 7. The criteria for an initial compensable rating, from October 21, 2015 through February 11, 2020, and a rating higher than 30 percent, from February 12, 2020, for left lower extremity radiculopathy of the femoral nerve are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1982 to September 1984. These matters initially came before the Board of Veterans' Appeals (Board) from a September 2016 rating decision. In December 2016, a Decision Review Officer (DRO) awarded a 20 percent rating for lumbosacral strain, from October 21, 2015. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a December 2019 hearing and a transcript of the hearing has been associated with his claims file. In February 2020, the Board remanded these matters for further development. In March 2020, the AOJ made the following determinations: assigned a 40 percent rating for lumbosacral strain, from February 12, 2020; awarded service connection for right lower extremity radiculopathy of the sciatic nerve and assigned an initial noncompensable disability rating, from April 25, 2016 through February 11, 2020, and a 40 percent rating, from February 12, 2020; awarded service connection for right lower extremity radiculopathy of the femoral nerve and assigned an initial noncompensable disability rating, from April 25, 2016 through February 11, 2020, and a 30 percent rating, from February 12, 2020; awarded service connection for left lower extremity radiculopathy of the sciatic nerve and assigned an initial noncompensable disability rating, from April 25, 2016 through February 11, 2020, and a 40 percent rating, from February 12, 2020; and awarded service connection for left lower extremity radiculopathy of the femoral nerve and assigned an initial noncompensable disability rating, from April 25, 2016 through February 11, 2020, and a 20 percent rating, from February 12, 2020. As for characterization of the issues on appeal, the Board has included the separate issues of entitlement to higher initial ratings for left and right lower extremity radiculopathy of the sciatic and femoral nerves because these issues are being considered as part of the appeal for a higher initial rating for the service-connected back disability. See 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (providing that associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code). Chavis v. McDonough, 34 Vet. App. 1, 15-18 (2021) (radiculopathy need not be separately appealed to be considered part of a claim for a higher rating for the spine) Since the claim period for the back issue dates back to the October 21, 2015 effective date of service connection, the Board has characterized the radiculopathy issues as listed above. Moreover, the Board notes that, during the pendency of this appeal, the Veteran has also perfected an appeal with respect to the issues of entitlement to service connection for sleep apnea and prostate cancer, and these issues have been certified to the Board for appellate review. However, there is a pending request for a Board hearing as to these matters. Thus, the issues of entitlement to service connection for sleep apnea and prostate cancer will be the subject of a future Board decision. As a final preliminary matter, in the February 2020 remand, the Board instructed the AOJ to, among other things, ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records, obtain the Veteran's outstanding VA treatment records, afford the Veteran examinations to determine the nature of any current left shoulder disability and erectile dysfunction, obtain medical opinions as to whether any such disabilities are related to service and/or are caused or aggravated by service-connected disabilities, and readjudicate the service connection, back, and TDIU issues on appeal. Pursuant to the Board's remand, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of a March 2020 letter. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letter. Moreover, all available outstanding VA treatment records were obtained and associated with the claims file, the Veteran was afforded VA examinations in June 2020 to assess the nature of any current left shoulder disability and erectile dysfunction, medical opinions were obtained as to whether these claimed disabilities are related to service and/or are caused or aggravated by service-connected disabilities, and the AOJ readjudicated the service connection, back, and TDIU issues on appeal by way of an October 2020 supplemental statement of the case. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Although the supplemental statement of the case did not include the issue of a higher initial rating for the lumbosacral strain, that issue was adjudicated in the March 2020 rating decision and a remand for a supplemental statement of the case on that issue is therefore unnecessary. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability that is proximately due to, the result of, or aggravated by service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. 1. Entitlement to service connection for left shoulder disability The Veteran contends that he has current left shoulder disability which had its onset in service and is related to a shoulder injury in service. The question for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds, for the following reasons, that, while there is evidence that the Veteran has current left shoulder disability, the claimed disability is not shown to have had its onset in service or to be otherwise related to a disease or injury in service. The report of a VA shoulder examination dated in June 2020 reveals that the Veteran has been diagnosed as having a left shoulder strain. Thus, current left shoulder disability has been demonstrated. The Veteran contends that his claimed left shoulder disability had its onset in service and is related to a shoulder injury in service. Specifically, he has reported that he injured his shoulder while lifting a safe in service and that he has continued to experience left shoulder symptoms in the years since that time. He is competent to report the history of his claimed left shoulder disability (including a shoulder injury in service and a continuity of shoulder symptomatology in the years since service). However, his reports must be weighed against the other evidence of record and their credibility must be assessed. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). There is no evidence of any complaints of or treatment for left shoulder problems in the Veteran's service treatment records and his August 1984 separation examination was normal other than for pseudofolliculitis barbae, tinea pedis, knee problems, and scarring. The earliest evidence of left shoulder problems following service is a February 1986 "Veteran's Application for Compensation or Pension" form (VA Form 21-526) on which the Veteran reported left shoulder disability. The Board acknowledges that there is lay evidence of earlier left shoulder disability in that the Veteran has reported a continuity of left shoulder symptomatology in the years since service. As explained below, however, the Board finds that the Veteran's reports as to the history of his claimed left shoulder disability (to include his reports of a continuity of symptomatology in the years since service) are not credible. Moreover, the Veteran has provided information and statements which are inconsistent with his reports of a continuity of left shoulder symptomatology in the years since service. As explained above, he has reported that he injured his left shoulder while lifting a safe in service and that he has continued to experience shoulder symptoms in the years since that time. However, he reported on an August 1984 report of medical history form completed for purposes of separation from service that he was neither experiencing, nor had he ever experienced, any swollen or painful joints, arthritis/rheumatism/bursitis, or painful/"trick" shoulder. He reported during a March 2010 VA physical therapy consultation that he injured his left shoulder in mid-2009 when he caught himself falling down the stairs, that he had been experiencing shoulder pain since that time, and that before mid-2009 he was able to use his left arm without restrictions or symptoms. He reported during a March 2010 VA primary care evaluation that he had been experiencing "left shoulder pain for several months," and that he believed he injured his shoulder while at work moving trays. Also, the Veteran reported during a December 2015 VA physical therapy consultation that left shoulder pain had "been occurring for a couple of months" and that there was no inciting incident. In light of the fact that there is no evidence of any complaints of or treatment for left shoulder problems in the Veteran's service treatment records, the fact that his August 1984 separation examination was normal other than for pseudofolliculitis barbae, tinea pedis, knee problems, and scarring, and the information and statements provided by the Veteran that are inconsistent with his reports of a continuity of left shoulder symptomatology in the years since service, the Board concludes that his reports concerning the history of his claimed left shoulder disability (including any reports of a continuity of symptomatology in the years since service) are not credible. In addition, the only competent and probative opinion on whether there is a relationship between the Veteran's current left shoulder disability and service weighs against the claim. The physician who conducted the June 2020 VA shoulder examination opined that the Veteran's claimed left shoulder disability was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service, to include his reported left shoulder injury while lifting a heavy safe during service. She reasoned that the Veteran was diagnosed as having a left shoulder strain and that it was highly unlikely that a shoulder injury which occurred prior to 1985 would have persisted for greater than 25 years, would be seen as a strain, and would not have required more intensive therapy prior. Also, the Veteran's August 1984 separation examination did not reflect any shoulder symptoms or abnormalities at the time of his discharge from service. The June 2020 opinion does not explicitly acknowledge or discuss the Veteran's reports of a continuity of left shoulder symptomatology in the years since service. However, as explained above, any reports of a continuity of left shoulder symptomatology are not deemed to be credible and an opinion based on such an inaccurate history would be inadequate. Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2006) (it is appropriate for the Board to find a medical opinion inadequate when it relies on lay statements that the Board has found not credible). Moreover, the June 2020 opinion is based upon examination of the Veteran, a review of his claims file, and consideration of his reported history, and it is accompanied by a specific rationale that is consistent with the evidence of record. Therefore, the June 2020 opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Additionally, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive question presented in this case (i.e., whether any relationship exists between the Veteran's left shoulder disability and service) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). An opinion as to whether there is a link between the Veteran's claimed left shoulder disability and service (where there is no credible evidence of any left shoulder problems for years following service) is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a relationship between the Veteran's current left shoulder disability and service, and neither he nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's left shoulder disability had its onset during service or is otherwise related to service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and service connection for left shoulder disability is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability The Veteran contends that he has current erectile dysfunction and that this disability is caused by his service-connected back disability and its associated neurological impairments. The Board finds, for the following reasons, that, while there is evidence that the Veteran has current erectile dysfunction, the claimed disability is not shown to have had its onset in service, to be otherwise related to a disease or injury in service, or to be caused or aggravated by service-connected disability. Medical records, including the report of a VA male reproductive system conditions examination dated in June 2020, reveal that the Veteran has been diagnosed as having erectile dysfunction. Thus, current erectile dysfunction has been demonstrated. The Veteran does not contend, and the evidence does not otherwise reflect, that he has experienced a continuity of erectile dysfunction symptomatology in the years since service. In this regard, there is no evidence of any complaints of or treatment for erectile dysfunction in his service treatment records and his August 1984 separation examination was normal other than for pseudofolliculitis barbae, tinea pedis, knee problems, and scarring. The earliest evidence of erectile dysfunction following service are VA treatment records dated in August 2008 which reveal that the Veteran was diagnosed as having erectile dysfunction. The absence of any evidence of erectile dysfunction for over two decades after the Veteran's separation from active service in September 1984 is one factor weighing against a finding that his current erectile dysfunction was present in service or in the year or years immediately after service. See Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue)." In addition, the only competent, probative opinions on whether there is a relationship between the Veteran's current erectile dysfunction and service or service-connected disabilities weigh against the claim. The physician who conducted the June 2020 VA male reproductive system conditions examination opined that the Veteran's claimed erectile dysfunction was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. She reasoned that there was no evidence to support a finding that the Veteran had erectile dysfunction while in service. The erectile dysfunction began well after the Veteran left service and was most likely due to his hypertension and age. According to medical literature, age and hypertension are two well known risk factors for erectile dysfunction. Moreover, the June 2020 examiner opined that the Veteran's claimed erectile dysfunction was not likely ("less likely than not"/"less than 50 percent probability") proximately due to or the result of his service-connected lumbosacral strain or lumbar radiculopathy. She reasoned that the Veteran reported that his erectile dysfunction began around 2013, but that his back disability began in service, almost 30 years prior to when erectile dysfunction began. The well described risk factors for erectile dysfunction are advanced age and hypertension. The Veteran's age increased after leaving service and he was diagnosed as having hypertension after leaving service, but prior to being diagnosed as having erectile dysfunction. The erectile dysfunction would more likely than not have occurred independently of the Veteran's service-connected back related disabilities. Lastly, the June 2020 examiner opined that the Veteran's claimed erectile dysfunction was not likely (not "at least as likely as not") aggravated beyond its natural progression by his service-connected lumbosacral strain or lumbar radiculopathy. The rationale provided for this opinion was essentially the same as that which was provided for why the disability is not caused by the service-connected back disability and lumbar radiculopathy, but the examiner additionally noted that the Veteran's erectile dysfunction would more likely than not have occurred at the current level of dysfunction independently of the back conditions. The June 2020 opinions are based upon an examination of the Veteran, a review of medical literature and his claims file, and consideration of his reported history, and they are accompanied by specific rationales that are consistent with the evidence of record. Therefore, the June 2020 opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, although lay evidence may be competent on a variety of matters concerning the nature and cause of disability, the dispositive questions presented in this case (i.e., whether any relationship exists between the Veteran's erectile dysfunction and service or service-connected disability) are questions as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377, n. 4. An opinion as to whether there is a link between the Veteran's erectile dysfunction and service or service-connected disability (where there is no evidence of any erectile dysfunction for years following service) is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a relationship between the Veteran's current erectile dysfunction and service or any service-connected disability, and neither he nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's erectile dysfunction had its onset during service, that it is otherwise related to service, or that it is caused or aggravated by service-connected disability. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and service connection for erectile dysfunction is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. II. Higher Initial Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). If two ratings are potentially applicable, 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. § 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. Background The Veteran reported during a June 2016 VA back examination that as a result of his back disability, there were many days that he was unable to "get out," bend to tie his shoes, or get comfortable in bed. Flare ups of back symptoms occurred, during which he was unable to bend or lift anything, and experienced tingling, a burning sensation, and numbness down both legs. He was taking narcotics for pain. The Veteran was unable to perform spinal range of motion testing because he was experiencing a "bad day." There was evidence of pain with weight-bearing and moderate tenderness in the lower back. The Veteran was not being examined immediately after repetitive use over time or during a flare up and the examination was medically consistent with his statements describing functional loss with repetitive use over time and during flare ups. The examiner who conducted the June 2016 examination noted that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time or during flare ups. There was no localized tenderness, guarding, or muscle spasm of the thoracolumbar spine and there were no additional contributing factors of disability. Moreover, lower extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, and lower extremity deep tendon reflexes were all normal bilaterally. Straight leg raise testing was positive on the right and negative on the left. The Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine, the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's back disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having lumbosacral strain. This disability impacted his ability to work in that it limited his ability to perform heavy lifting and carrying. In an October 2016 statement (VA Form 21-4138), the Veteran reported that he was unable to perform range of motion testing during the June 2016 VA back examination because he had been told to stop using his pain medications due to scheduled surgery. As a result, he was "in a lot of pain" at the time of the October 2016 examination. He experienced an altered gait due to his back pain, and bilateral sciatic nerve radiculopathy caused sharp shooting pains down both legs to his feet. A December 2016 VA back examination report indicates that as a result of the Veteran's back disability, he was always in pain and occasionally was unable to get out of bed. He used a tens unit and multiple pain medications to treat his back symptoms, but he was still always in pain. Flare ups of back symptoms occurred and the Veteran sometimes had to roll out of bed onto his knees and crawl to the bathroom due to back symptoms. There was tingling and sharp shooting pain down both legs, the Veteran lacked feeling in his feet, he experienced problems with sitting and standing, and he would "lay down a lot." Examination revealed that the ranges of motion of the thoracolumbar spine were flexion to 50 degrees and extension, right and left lateral flexion, and right and left lateral rotation all to 15 degrees. The ranges of motion themselves contributed to functional loss in that the Veteran experienced problems with heavy lifting and carrying. There was pain associated with all ranges of spinal motion and the pain caused functional loss. There was moderate tenderness in the lower back, but no evidence of pain with weight-bearing. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. He was not being examined immediately after repetitive use over time or during a flare up and the examination was medically consistent with his statements describing functional loss with repetitive use over time and during flare ups. Pain, fatigue, weakness, and lack of endurance significantly limited functional ability with repeated use over time and during flare ups, and the examiner who conducted the December 2016 examination specified that the ranges of motion of the thoracolumbar spine with repeated use over time and during flare ups would be flexion to 45 degrees and extension, right and left lateral flexion, and right and left lateral rotation all to 10 degrees. There was localized tenderness and guarding which did not result in an abnormal gait or abnormal spinal contour, but there were no muscle spasms. There were no additional factors contributing to disability. Moreover, lower extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, lower extremity sensation was normal bilaterally, straight leg raise testing was negative bilaterally, and the Veteran did not experience any radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine, the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine, and he did not have intervertebral disc syndrome of the thoracolumbar spine. He did not use any assistive devices and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's back disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. A diagnosis of lumbosacral strain was provided. This disability impacted the Veteran's ability to work in that he was limited in his ability to perform heavy lifting and carrying. VA treatment records dated from March 2017 to January 2018, the report of a March 2018 VA back examination, and a July 2018 examination report from Concerto Health indicate that the Veteran experienced constant daily lumbar back pain and stiffness, with occasional short stabbing pain and numbness and tingling radiating from the back and down the back of the legs to the feet (2 to 3 times per week in the right leg and rarely in the left leg). The pain was exacerbated with bending over or performing certain twisting movements. He experienced difficulty reaching to don his socks and shoes and there was pain with back flexion and rotation. The Veteran took muscle relaxants to treat his symptoms and had some physical therapy in the past, but he had not undergone any back surgery or injections. There were no flare ups of back symptoms. There was functional loss/impairment in that there was low back pain with bending forward, lifting over 10 pounds, and standing for over half an hour. Examination revealed that the ranges of motion of the thoracolumbar spine were flexion to 30 degrees, extension to 10 degrees, and right and left lateral flexion and rotation all to 20 degrees. The ranges of motion themselves contributed to functional loss in that the Veteran experienced difficulty putting on his footwear. There was pain noted with all ranges of spinal motion and the pain resulted in functional loss. There was evidence of pain with weight-bearing, mild midline tenderness, and some lateral tenderness (worse on the right side). The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. The Veteran was not being examined immediately after repetitive use over time and the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time. There was guarding, but it did not result in an abnormal gait or abnormal spinal contour. There were no muscle spasms and there were no additional factors contributing to disability. Moreover, lower extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, lower extremity sensation was all normal bilaterally, and straight leg raise testing was negative bilaterally. Knee and ankle reflexes were hypoactive (1+) bilaterally. The Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis of the spine, there were no other neurologic abnormalities or findings related to the thoracolumbar spine, the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's back disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran was diagnosed as having lumbosacral strain. This disability impacted his ability to work in that he experienced difficulty with pain when standing or sitting for over half an hour with position change, there was pain while lifting from below knee level, and he was limited to lifting twenty pounds. Also, the examiner who conducted the March 2018 examination noted that there was objective evidence of pain on passive range of motion testing, but there was no evidence of pain on non weight-bearing. A VA primary care progress note dated on December 17, 2018 indicates that the Veteran's lower back pain and lumbar radiculopathy had recently worsened and that he sometimes used a back brace as needed. He was not interested in using any additional medications. The Veteran reported during the December 2019 Board hearing, a February 2020 VA back examination, and an October 2020 VA primary care evaluation that he experienced back pain which would shoot down his legs and bilateral foot numbness. His back was so painful on some days that he was unable to walk. He used a back brace and "a lot of pain medications." Flare ups of back pain occurred, during which it was difficult to move, get out of bed, and perform activities of daily living, and he would have to roll out of bed onto the floor and crawl to the bathroom. There was functional loss/impairment of the thoracolumbar spine in that the Veteran did not bowl or walk much anymore. Examination revealed that the ranges of motion of the thoracolumbar spine were flexion to 34 degrees, extension to 70 degrees, right lateral flexion to 10 degrees, left lateral flexion to 18 degrees, right lateral rotation to 26 degrees, and left lateral rotation to 37 degrees. The ranges of motion themselves contributed to a functional loss in that it was difficult for the Veteran to bend over far enough to tie his shoes. There was pain noted on rest/non-movement and evidence of pain with weight-bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions and there was additional loss of function or range of motion after three repetitions due to pain. Specifically, the ranges of spinal motion following repetitive use testing were flexion to 31 degrees, extension to 5 degrees, right lateral flexion to 9 degrees, left lateral flexion to 15 degrees, right lateral rotation to 19 degrees, and left lateral rotation to 18 degrees. The Veteran was not being examined immediately after repetitive use over time or during a flare up and the examination was medically consistent with his statements describing functional loss with repetitive use over time and during flare ups. Pain significantly limited functional ability with repeated use over time and the examiner who conducted the February 2020 examination specified that the ranges of spinal motion following repeated use over time would be flexion to 34 degrees, extension to 7 degrees, right lateral flexion to 10 degrees, left lateral flexion to 18 degrees, right lateral rotation to 26 degrees, and left lateral rotation to 37 degrees. The ranges of spinal motion during flare ups would be flexion to 31 degrees, extension to 5 degrees, right lateral flexion to 9 degrees, left lateral flexion to 15 degrees, right lateral rotation to 19 degrees, and left lateral rotation to 18 degrees. There were muscle spasms of the thoracolumbar spine during which the Veteran was hardly able to walk, and there was guarding which resulted in a slow and stiff gait. There were additional factors contributing to disability in terms of disturbance of locomotion, interference with sitting, and interference with standing. The Veteran's back pain was exacerbated with prolonged walking, sitting, and standing. Moreover, lower extremity muscle strength was all 4/5 bilaterally, but there was no muscle atrophy. Knee and ankle reflexes were absent (0) bilaterally and sensation was decreased at the left thigh/knee. Lower extremity sensation was otherwise normal. Straight leg raise testing was positive on the right and negative on the left. The Veteran experienced severe right lower extremity constant pain, moderate left lower extremity intermittent pain, moderate bilateral lower extremity paresthesias/dysesthesias, and severe bilateral lower extremity numbness. There were no other signs or symptoms of radiculopathy. Overall, there was bilateral lower extremity radiculopathy involving the sciatic and femoral nerves (severe on the right and moderate on the left). There was no ankylosis of the spine, there were no other neurologic abnormalities or findings related to the thoracolumbar spine, the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine, and he did not use any assistive devices. There was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's back disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. Diagnoses of lumbosacral strain and lumbar radiculopathy were provided. These disabilities impacted the Veteran's ability to work in that he had difficulty performing any tasks below waist level because he experienced difficulty bending over. He was unable to walk, sit, or stand for sustained periods because his pain would increase and he had to stop what he was doing to change his position and alleviate the pain. Also, the examiner who conducted the February 2020 examination noted that there was objective evidence of pain on non-weight bearing and that passive range of motion testing could not be performed or it was not medically appropriate. 2. Entitlement to a higher initial rating for lumbosacral strain, rated 20 percent disabling prior to February 12, 2020 and 40 percent disabling since that date The Veteran's service-connected back disability is rated under 38 C.F.R. § 4.71A, DC 5237 as a lumbosacral strain. A lumbosacral strain under DC 5237 is rated based on limitation of motion of the thoracolumbar spine under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula both prior to and since the regulatory change, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, if 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. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. The rating criteria provide that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Court has held that a veteran may be entitled to a rating higher than 40 percent under the General Rating Formula if he experiences the functional equivalent of ankylosis when considering the provisions of 38 C.F.R. §§ 4.40 and 4.45. Chavis v. McDonough, 34 Vet. App. 1, 23-24 (2021). Under DC 5243 both prior to and since the regulatory change, intervertebral disc syndrome (preoperatively or postoperatively) is rated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71A, DC 5243. Under the criteria for rating intervertebral disc syndrome, the following ratings apply: a 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating is warranted for 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 is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71A, DC 5243. For purposes of ratings under DC 5243, 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. 38 C.F.R. § 4.71a, DC 5243, Note (1). Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested thoracolumbar spine symptoms of the type and extent, frequency, and/or severity, as appropriate, to warrant a 40 percent rating, but no higher, during the entire claim period from the October 21, 2015 effective date of service connection, under the criteria in effect both prior to and since the regulatory change. The above evidence reflects that the Veteran was unable to perform spinal range of motion testing during the June 2016 VA back examination due to pain. Forward flexion of the thoracolumbar spine was to 50 degrees during the December 2016 examination, 30 degrees during the March 2018 examination, and 34 degrees during the February 2020 examination. The Veteran reported during the June 2016, December 2016, and February 2020 examinations that he experienced flare ups of back symptoms, during which he was unable to bend and stand up out of bed, and had to roll out of bed onto the floor and crawl due to pain. The examiner who conducted the December 2016 examination reported that flexion would be to 45 degrees during flare ups and following repeated use over time due to pain, fatigue, weakness, and lack of endurance. Also, the examiner who conducted the February 2020 examination indicated that flexion was to 31 degrees following repetitive use testing and would be to 34 degrees and 31 degrees following repeated use over time and during flare ups, respectively, due to pain. Although forward flexion of the spine was to 50 degrees during the December 2016 examination and the examiner reported that the Veteran would only lose an additional 5 degrees of flexion during flare ups and following repeated use over time, the Board points out that the Veteran reported during that examination that he was using multiple pain medications to treat his symptoms. At the time of the June 2016 examination, he was unable to perform any range of motion testing due to pain and he explained that he was experiencing such severe pain during that examination because he had been told to stop using his prescribed narcotic pain medication due to a scheduled surgery. The Board points out that it "may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria." Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). In other words, the Board cannot consider the ameliorative effects of medication unless medication is referenced in the applicable diagnostic code. That is precisely the situation in this case. The Veteran's medication has occasionally ameliorated the effects of his back disability. Since the Veteran was not taking any pain medications at the time of the June 2016 examination, the Board finds that this examination (during which he was unable to perform any range of motion testing due to pain) is reflective of the level of impairment due to the Veteran's back disability in the absence of medication use. Overall, in light of the range of motion measurements that were recorded during the examinations conducted during the claim period, the Veteran's reports of flare ups of back symptoms which significantly impair his ability to move and function, and not taking into account the ameliorative effects of the Veteran's medication, the Board finds that the symptoms of the Veteran's service-connected back disability have most closely approximated the criteria for a 40 percent rating under the General Rating Formula (which contemplates limitation of flexion of the thoracolumbar spine to 30 degrees or less) during the entire claim period since the October 21, 2015 effective date of service connection. The Board also finds that a rating higher than 40 percent is not warranted at any time during the claim period. Specifically, there has been no showing of any actual ankylosis at any time during the claim period. As for the functional equivalent of ankylosis, the Board acknowledges the Veteran's reports of functional impairment during flare ups and with repeated use over time, he is competent to report the symptoms associated with his service-connected back disability and the extent of his impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's back symptoms have most closely approximated the criteria for at most a 40 percent rating for limitation of spinal motion under the General Rating Formula during the entire claim period. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent rating at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's back symptoms have not shown to be so disabling to actually or effectively result in fixation of the entire thoracolumbar spine in flexion or extension with any of the additional symptoms or limitations listed in Note (5) of the General Rating Formula. Moreover, although the Veteran has reported a significant amount of time spent in bed due to his back symptoms, he has not experienced any symptoms of intervertebral disc syndrome of the thoracolumbar spine that required bed rest prescribed by a physician and treatment by a physician. Therefore, an initial rating higher than 40 percent is not warranted on the basis of ankylosis or intervertebral disc syndrome. In sum, an initial 40 percent rating, but no higher, from October 21, 2015, for lumbosacral strain is warranted. 3. Radiculopathy The Veteran's left and right lower extremity radiculopathy of the sciatic nerve is rated under 38 C.F.R. § 4.124A, DC 8520. Under DC 8520, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124A, DC 8520. The left and right lower extremity radiculopathy of the femoral nerve is rated under 38 C.F.R. § 4.124A, DC 8526. Under DC 8526, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 30 percent rating is warranted for severe incomplete paralysis; and a 40 percent rating is warranted for complete paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124A, DC 8526. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124A. A. Right and Left Lower Extremity Radiculopathy of the Sciatic and Femoral Nerves Prior to December 17, 2018 The Veteran's right and left lower extremity radiculopathy of the sciatic and femoral nerves are both currently rated noncompensable during the claim period prior to December 17, 2018. The above evidence reflects that during the claim period from the October 21, 2015 effective date of service connection for the Veteran's back disability through December 16, 2018, the Veteran experienced radiating pain, tingling, burning, and numbness from his back down both legs. Examinations conducted during this period revealed at most slightly diminished (1+) knee and ankle reflexes bilaterally, but lower extremity muscle strength and sensation were normal bilaterally and there was no muscle atrophy. In light of the Veteran's reported bilateral lower extremity neurological symptoms and resolving reasonable doubt in the Veteran's favor, the Board finds that the symptoms of his service-connected right and left lower extremity radiculopathy of the sciatic nerve more closely approximated the criteria for a 10 percent rating (i.e., mild incomplete paralysis) under DC 8520 for paralysis of the sciatic nerve during the entire period from October 21, 2015 through December 16, 2018. As for right and left lower extremity radiculopathy of the femoral nerve, there is no evidence of involvement of the femoral nerve during the claim period prior to December 17, 2018. Moreover, the Veteran's reported right and left lower extremity neurological symptoms prior to December 17, 2018 are all contemplated by the 10 percent ratings that are being awarded under DC 8520, and to separately compensate him for the same symptoms under DC 8526 during this period would constitute pyramiding. 38 C.F.R. § 4.14. Therefore, compensable ratings for right and left lower extremity radiculopathy of the femoral nerve during the claim period prior to December 17, 2018 are not warranted. Lastly, the Board finds that ratings higher than 10 percent for right and left lower extremity radiculopathy of the sciatic nerve during the period from October 21, 2015 through December 16, 2018 are not warranted. In particular, the Veteran only reported pain, tingling, burning, and numbness in his lower extremities, lower extremity reflexes were at most only slight diminished (1+), all other lower extremity neurological testing was normal bilaterally, and there was no muscle atrophy. Overall, the Veteran's right and left sciatic nerve radiculopathy were manifested by at most mild incomplete paralysis. In sum, initial 10 percent ratings, but no higher, are warranted for right and left lower extremity radiculopathy of the sciatic nerve, from October 21, 2015 through December 16, 2018. Initial compensable ratings for right and left lower extremity radiculopathy of the femoral nerve are not warranted during this period. B. Right and Left Lower Extremity Radiculopathy of the Sciatic and Femoral Nerves from December 17, 2018 The Veteran's right and left lower extremity radiculopathy of the sciatic and femoral nerves are both currently rated noncompensable during the period from December 17, 2018 through February 11, 2020. Since February 12, 2020, the right and left lower extremity radiculopathy of the sciatic nerve are both rated 40 percent disabling, the right lower extremity radiculopathy of the femoral nerve is rated 30 percent disabling, and the left lower extremity radiculopathy of the femoral nerve is rated 20 percent disabling The above evidence reflects that during the claim period from December 17, 2018, the Veteran has experienced back pain which radiates down both legs and bilateral foot numbness. Examinations conducted during this period have revealed slightly impaired (4/5) lower extremity muscle strength bilaterally, absent knee and ankle reflexes bilaterally, and decreased sensation at the left thigh/knee. Lower extremity sensation has otherwise been normal and there has been no muscle atrophy. In light of the Veteran's reported and observed bilateral lower extremity neurological symptoms and resolving reasonable doubt in his favor, the Board finds that the symptoms of his service-connected right and left lower extremity radiculopathy of the sciatic nerve have more closely approximated the criteria for a 40 percent rating (i.e., moderately severe incomplete paralysis) under DC 8520 for paralysis of the sciatic nerve during the entire period from December 17, 2018. Although it is unclear exactly when the Veteran's bilateral lower extremity neurological symptoms worsened following the March 2018 VA back examination, he reported during the VA primary care evaluation dated on December 17, 2018 that his lumbar radiculopathy had recently worsened. Therefore, December 17, 2018 is the earliest that it is factually ascertainable that the right and left lower extremity radiculopathy of the sciatic nerve met or approximated the criteria for a 40 percent rating under DC 8520. As for right and left lower extremity radiculopathy of the femoral nerve, there is no evidence of involvement of the femoral nerve during the claim period prior to the February 12, 2020 VA back examination. Moreover, the Veteran's reported and observed right and left lower extremity neurological symptoms during the period from December 17, 2018 through February 11, 2020 are all contemplated by the 40 percent ratings that are being awarded under DC 8520 and 40 percent is the maximum schedular rating for paralysis of the femoral nerve under DC 8526. Also, to separately compensate the Veteran for the same symptoms under DC 8526 during the period from December 17, 2018 through February 11, 2020 would constitute pyramiding. 38 C.F.R. § 4.14. Therefore, compensable ratings for right and left lower extremity radiculopathy of the femoral nerve during the claim period from December 17, 2018 through February 11, 2020 are not warranted. Lastly, the Board finds that ratings higher than 40 percent for right and left lower extremity radiculopathy of the sciatic nerve during the period from December 17, 2018, a rating higher than 30 percent for right lower extremity radiculopathy of the sciatic nerve during the period from February 12, 2020, and a rating higher than 20 percent for left lower extremity radiculopathy of the femoral nerve during the period from February 12, 2020 are not warranted. In particular, there has been no marked muscle atrophy associated with the Veteran's right or left lower extremity radiculopathy at any time during the claim period, and there has not been complete loss of right or left lower extremity motor function. Also, the Veteran's right and left lower extremity neurological symptoms during these periods are all contemplated by the 40 percent ratings under DC 8520 and to award any higher rating(s) under DC 8526 during the period from February 12, 2020 on the basis of the same symptoms that are already contemplated by the 40 percent ratings under DC 8520 would constitute pyramiding. 38 C.F.R. § 4.14. The Board acknowledges that the February 2020 examiner reported severe incomplete paralysis of the right sciatic and femoral nerves and at most moderate incomplete paralysis of the left sciatic and femoral nerves. However, an examiner's characterization of the level of severity of a disability is not binding on the Board. 38 C.F.R. § 3.100 (a) (2017) (delegating the Secretary's authority "to make findings and decisions... as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination... so that the current rating may accurately reflect the elements of disability present"). Overall, the Board finds that initial 40 percent ratings, but no higher, are warranted for right and left lower extremity radiculopathy of the sciatic nerve, from December 17, 2018. Initial compensable ratings, from December 17, 2018 through February 11, 2020 for right and left lower extremity radiculopathy of the femoral nerve, a rating higher than 30 percent from February 12, 2020 for right lower extremity radiculopathy of the femoral nerve, and a rating higher than 20 percent from February 12, 2020 for left lower extremity radiculopathy of the femoral nerve are not warranted. 4. Additional Considerations As a final point, the Board notes that in conjunction with the higher rating matters decided herein, other than the issue of entitlement to a TDIU prior to October 11, 2018 which is addressed below, no other related issues have been raised by the Veteran or his representative, and no other such issues have 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). REASONS FOR REMAND 1. Entitlement to service connection for bilateral foot disability (other than left foot plantar wart), to include as secondary to service-connected disability, is remanded. The Veteran contends that he has current bilateral foot disability other than left foot plantar wart that is related to service. His VA treatment records reflect that he has been diagnosed as having various foot disabilities other than left foot plantar wart (including, but not limited to, plantar fasciitis, hammertoes, and pes planus) and he contends that his foot disabilities were caused by prolonged marching and running in service. In the alternative, he contends that his foot disability is caused by an abnormal gait associated with his service-connected back disability and lower extremity radiculopathy. In the February 2020 remand, the Board instructed the AOJ to obtain an addendum medical opinion regarding whether any foot disability other than left foot plantar wart is related to service (to include the foot problems documented in the Veteran's service treatment records and his prolonged marching and running in service) or is caused or aggravated by the service-connected left foot plantar wart, lumbosacral strain, and/or lumbar radiculopathy of the lower extremities (to include any abnormal gait caused by these disabilities. Pursuant to the Board's remand, the Veteran was afforded a VA foot examination in June 2020 and was diagnosed as having bilateral pes planus and bilateral hammertoes. The physician who conducted the examination opined that the Veteran's claimed bilateral foot disability was not likely incurred in or caused by service or proximately due to, the result of, or aggravated by his service-connected disabilities. These opinions are inadequate because the only rationale for the opinion that the claimed disability is not related to service is that pes planus and hammertoes were not present at the time of the Veteran's separation examination, and there is no explanation provided for why the currently diagnosed foot disabilities are not related to the Veteran's other foot problems and physical activities in service. Moreover, with regard to the secondary service connection opinions, the physician did not address whether any impaired gait associated with the Veteran's service-connected disabilities contributed to his claimed foot disabilities, and the rationale that accompanies the aggravation opinion only addresses pes planus. Lastly, the June 2020 opinions do not address the plantar fasciitis that was diagnosed during the claim period (see the report of a June 2016 VA foot examination). In light of the above inadequacies of the June 2020 opinions, a remand is necessary to obtain new opinions as to whether the Veteran's claimed bilateral foot disability is related to service or is caused or aggravated by service-connected disability. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Salisbury Vista electronic records system (dated to September 2020), the VA Puget Sound Health Care System (dated to August 2021), and the VA Portland Health Care System (dated to January 2020). Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for urinary disability, to include as secondary to service-connected disability, is remanded. The Veteran contends that he has current urinary disability that is caused by his service-connected back disability and its associated neurological impairments. In the February 2020 remand, the Board instructed the AOJ to afford the Veteran an examination to determine the nature of any current urinary disability and to obtain a medical opinion as to whether any such disability is related to service or is caused or aggravated by the service-connected lumbosacral strain and/or lumbar radiculopathy of the lower extremities. Pursuant to the Board's remand, the Veteran was afforded a VA urinary tract conditions examination in June 2020 and was diagnosed as having voiding dysfunction secondary to prostate cancer. The physician who conducted the examination opined that the Veteran's claimed urinary disability was not likely incurred in or caused by service or proximately due to, the result of, or aggravated by his service-connected disabilities. These opinions are inadequate because the examiner did not acknowledge or discuss the potential significance of the Veteran's treatment for a possible urinary tract infection in service in March 1984. Moreover, the rationale that accompanies the aggravation opinion only addresses why the Veteran's urinary disability is not caused by his service-connected back and neurological disabilities. In light of the above inadequacies of the June 2020 opinions, a remand is necessary to obtain new opinions as to whether the Veteran's claimed urinary disability is related to service or is caused or aggravated by service-connected disability. Also, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to a TDIU due to service-connected disabilities, from October 21, 2015 through October 10, 2018, is remanded. The Veteran submitted a Veteran's Application for Increased Compensation Based on Unemployability form (VA Form 21-8940) in November 2018, on which he reported that he stopped working in July 2009, at which time he worked in retail. However, there is evidence in the claims file that suggests he subsequently had additional full time employment with VA, employment as a social worker, and potential employment in the mortgage industry (see e.g., a VA psychiatry note and a VA homeless program note (both dated in February 2010) and the Veteran's Social Security Administration (SSA) disability records). Therefore, the Veteran should be asked to clarify his employment history throughout the entire claim period from October 2015 through October 2018. Also, the AOJ should contact the SSA and request the Veteran's earning statements during this period. Also, all outstanding VA treatment records should be secured upon remand. Finally, because a decision on the remanded service connection issues could significantly impact a decision on the issue of entitlement to a TDIU prior to October 11, 2018, the issues are inextricably intertwined. A remand of the claim for a TDIU is thus warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-8940 and to report his education and complete employment history and earnings, especially for the period from October 21, 2015 through October 10, 2018. 2. The AOJ should contact the SSA and request the Veteran's earning statements for the period from 2015 through 2018. If the SSA informs the AOJ that it cannot provide earnings statements to VA without the Veteran's approval, the AOJ should undertake to obtain any documentation needed from the Veteran to enable the AOJ to obtain his SSA earning statements. 3. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for foot disability and urinary disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for foot disability and urinary disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran's outstanding VA treatment records from the Salisbury Vista electronic records system for the period since September 2020; the VA Puget Sound Health Care System for the period since August 2021; the VA Portland Health Care System for the period since January 2020; and all such relevant records from any other sufficiently identified VA facility. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any foot disability other than left foot plantar wart experienced by the Veteran since approximately April 2016 (including, but not limited to, pes planus, hammertoes, and plantar fasciitis) at least as likely as not (1) began during service; (2) is related to an in-service injury or disease, including the foot problems documented in his service treatment records and his prolonged marching and running in service; (3) is caused by service-connected left foot plantar wart, lumbosacral strain, and/or lumbar radiculopathy of the lower extremities (to include any abnormal gait caused by these disabilities); OR (4) is aggravated by service-connected left foot plantar wart, lumbosacral strain, and/or lumbar radiculopathy of the lower extremities (to include any abnormal gait caused by these disabilities). The clinician must also indicate whether any pes planus experienced by the Veteran since approximately April 2016 is a congenital condition or an acquired condition (see 38 C.F.R. § 4.57 for guidance as to what constitutes congenital versus acquired pes planus). The clinician must provide reasons for each opinion given. In this regard, the clinician should acknowledge and discuss the Veteran's currently diagnosed pes planus, hammertoes, and plantar fasciitis, the foot problems documented in his service treatment records, his contention that his current foot disabilities are related to his prolonged running and marching in service, and his contention that his current foot disabilities are associated with an impaired gait caused by his service-connected back disability and bilateral lower extremity radiculopathy. 6. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any urinary disability experienced by the Veteran since approximately April 2016 at least as likely as not (1) began during service; (2) is related to an in-service injury or disease, including his possible urinary tract infection in March 1984; (3) is caused by service-connected lumbosacral strain and/or lumbar radiculopathy of the lower extremities; OR (4) is aggravated by service-connected lumbosacral strain and/or lumbar radiculopathy of the lower extremities. The clinician must provide reasons for each opinion given. In this regard, the clinician should acknowledge and discuss the Veteran's possible urinary tract infection documented in his service treatment records in March 1984. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.