Citation Nr: 21065837 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 15-45 386 DATE: October 27, 2021 ORDER For the entire period on appeal, a rating in excess of 70 percent for PTSD is denied. An initial rating in excess of 20 percent for a low back disability is denied. For the entire period on appeal, an initial rating of 20 percent, but no higher, for right lower extremity radiculopathy, secondary to the service-connected low back disability, is granted. For the period on appeal from January 30, 2007 to May 26, 2011, a separate rating of 20 percent, but no higher, for left lower extremity radiculopathy, secondary to the service-connected low back disability, is granted. Beginning May 26, 2011, a separate rating of 20 percent, but no higher, for left lower extremity radiculopathy, secondary to the service-connected low back disability, is granted. For the period on appeal prior to December 1, 2020, an initial rating of 10 percent, but no higher, for irritable bowel syndrome (IBS) is granted. Beginning December 1, 2020, a rating in excess of 30 percent for IBS is denied. For the entire period on appeal, a rating in excess of 10 percent for a right hip disability is denied. For the entire period on appeal, a rating in excess of 10 percent for a left hip disability is denied. For the entire period on appeal, beginning January 30, 2007, a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for bilateral carpal tunnel syndrome is remanded. Entitlement to an initial rating in excess of 20 percent for right upper extremity radiculopathy is remanded. Entitlement to an initial rating in excess of 20 percent for left upper extremity radiculopathy is remanded. Entitlement to a compensable rating for residuals of a pelvic fracture is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's PTSD symptoms did not more nearly approximate total occupational and social impairment. 2. For the entire period on appeal, the Veteran's low back disability has not been primarily productive of forward flexion of 30 degrees or less, or ankylosis of the entire thoracolumbar spine or entire spine, and he has not had IVDS resulting in incapacitating episodes that required bed rest prescribed by a physician and treatment by a physician. 3. For the entire period on appeal, beginning January 30, 2007, the Veteran's right and left lower extremity radiculopathy most nearly approximated no more than moderate incomplete paralysis of the sciatic nerve. 4. For the period on appeal prior to December 1, 2020, the Veteran's IBS most nearly approximated moderate symptoms, with frequent episodes of bowel disturbance with abdominal distress, but not severe symptoms, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. The Veteran is in receipt of the maximum schedular rating for IBS. 5. Beginning December 1, 2020, the Veteran is in receipt of the maximum schedular rating for IBS. 6. For the entire period on appeal, the Veteran's right hip disability has not manifested in flexion limited to 30 degrees or less or limitation of abduction of the thigh with motion lost beyond 10 degrees; extension was not limited to 5 degrees, and there was no flail joint, ankylosis, or impairment of the femur. 7. For the entire period on appeal, the Veteran's left hip disability has not manifested in flexion limited to 30 degrees or less or limitation of abduction of the thigh with motion lost beyond 10 degrees; extension was not limited to 5 degrees, and there was no flail joint, ankylosis, or impairment of the femur. 8. For the entire period on appeal, beginning January 30, 2007, the Veteran's service-connected disabilities render her unable to obtain and maintain substantially gainful employment consistent with her educational and occupational background. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2020). 2. For the entire period on appeal, the criteria for an initial rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.59, 4.71a, DC 5243 (2020). 3. For the entire period on appeal, the criteria for a rating of 20 percent, but no higher, for right lower extremity radiculopathy, secondary to the service-connected low back disability, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124a, DC 8520 (2020). 4. For the period on appeal from January 30, 2007 to May 25, 2011, the criteria for a separate rating of 20 percent, but no higher, for left lower extremity radiculopathy, secondary to the service-connected low back disability, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124a, DC 8520 (2020). 5. Beginning May 25, 2011, the criteria for a rating of 20 percent, but no higher, for left lower extremity radiculopathy, secondary to the service-connected low back disability, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.123, 4.124a, DC 8520 (2020). 6. For the period on appeal prior to December 1, 2020, the criteria for an initial rating of 10 percent, but no higher, for IBS have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, DC 7319 (2020). 7. Beginning December 1, 2020, the criteria for a rating in excess of 30 percent for IBS have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, DC 7319 (2020). 8. For the entire period on appeal, the criteria for a rating in excess of 10 percent for a right hip disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.59, 4.71a, DCs 5010-5252 (2020). 9. For the entire period on appeal, the criteria for a rating in excess of 10 percent for a left hip disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.59, 4.71a, DCs 5010-5252 (2020). 10. For the entire period on appeal, beginning January 30, 2007, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from November 1983 to August 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2010 and January 2013 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In the September 30, 2010 rating decision, the RO, in pertinent part, granted service connection for a low back disability and assigned an initial 20 percent disability rating, effective December 30, 2007. In addition, the RO granted service connection for radiculopathy of the right lower extremity and assigned a 10 percent rating, effective January 30, 2007. In December 2010, the Veteran submitted a notice of disagreement as to this rating decision. While no statement of the case has been issued as to the issue of entitlement to an increased initial rating for radiculopathy of the right lower extremity, the Board finds that it is part of the present appeal as it is a part of the increased rating claim for low back disability. In the January 2013 rating decision, the RO, in pertinent part, denied the Veteran's application to reopen the previously denied claim of service connection for bilateral carpal tunnel syndrome. The RO also granted service connection for IBS and assigned a noncompensable initial rating, effective September 14, 2011. Finally, the RO denied entitlement to increased ratings for a low back disability, residuals of a pelvis fracture, PTSD, and bilateral hip disabilities. Regardless of any RO determinations on the applications to reopen, the Board has a jurisdictional responsibility to consider whether it is proper for the claims to be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). In March 2019, the Board remanded this matter for additional development. In a December 2020 rating decision, during the pendency of this appeal, the RO, in pertinent part, increased the rating for IBS from 0 to 30 percent, effective December 1, 2020. The RO also granted service connection for right and left upper extremity radiculopathy and assigned an initial rating of 20 percent, effective July 5, 2011. Because less than the maximum available benefit for schedular ratings were awarded and because the increased and separate compensable ratings were not awarded for the entirety of the claims period, the claims remain before the Board. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993). In a September 2021 rating decision, the RO granted an earlier effective date of December 30, 2007 for the award of service connection for a low back disability and assigned an initial rating of 20 percent. The Board notes that, in consideration of the awards granted herein, the Veteran is currently in receipt of a 100 percent combined schedular rating from January 30, 2007. However, receipt of a 100 percent schedular disability evaluation for a service-connected disability or disabilities does not necessarily moot the issue of entitlement to a TDIU. Bradley v. Peake, 22 Vet. App. 280, 293-294 (2008). As such, the issue of entitlement to a TDIU remains on appeal. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). Where an increase in an existing disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 42 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Where a veteran is diagnosed with multiple disabilities of the same body part/system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to a rating in excess of 70 percent for PTSD. The Veteran is in receipt of a 70 percent disability rating for PTSD under 38 C.F.R. § 4.130, DC 9411. He seeks a higher rating. The Veteran's PTSD is rated under the general rating formula for rating mental disorders pursuant to 38 C.F.R. § 4.130, DC 9434. Under such formula, a 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). Here, the RO certified the Veteran's appeal to the Board after August 4, 2014; therefore, the bipolar disorder claim is governed by DSM 5 and the GAF scores are not relevant for consideration. See Golden v. Shulkin, 29 Vet. App. 221, 225-26 (2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where DSM-5 applies). When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran's symptoms affecting his or her level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. On review, the Board finds that a rating higher than 70 percent is not warranted because the evidence does not reflect that the Veteran's PTSD has caused total occupational and social impairment. There is no evidence of disorientation to time or place, persistent delusions or hallucinations, persistent danger of hurting self or others, grossly inappropriate behavior, gross impairment in thought processes or communication, intermittent inability to perform activities of daily living, or memory loss for close relatives, own occupation, or own name. Throughout the period on appeal, the Veteran has maintained a relationship with her family and some friends, though the relationships were strained at times, and has worked for extended periods, even if only part-time. See March 2010 VA treatment record (noting that the Veteran wanted to move back to the area where she grew up to be near her family, despite tension with her mother, and that she kept in touch with some high school friends);January 2012 VA treatment note (noting good relationships with a cousin and friends from high school, and recently rekindling old friendships); July 2012 VA mental health treatment record (reported turning down offers to groom dogs (her business) and citing problems with committing to a specific appointment, feeling like she may not be able to handle the stress of doing what needs to be done); December 2012, January 2014, March 2016, and January 2017 VA treatment records (indicating Veteran owned a mobile pet grooming business, but only worked part time because of back pain); June 2016 VA treatment note (indicating the recent death of a friend); September 2020 (reflecting employment from July 2016 to December 2017 as a bus driver and for nearly three years in supply, ending in 1999); January 2016 private vocational assessment (indicating that the Veteran worked at least part time as a self-employed dog groomer since 1999); December 2020 VA PTSD examination report (noting difficulty in establishing and maintaining effective work and social relationships, but not inability to do so). While the Veteran has at times indicated that she has poor memory, the evidence does not indicate that she has memory impairment that rises to the levels of disorientation to time or place, gross impairment in thought processes, or memory loss for names of close relatives, own occupation, or own name, as is required for a 100 percent rating. See June 2012 VA treatment record (noting racing thoughts with poor memory); December 2013 VA treatment record (indicating that recent and remote memory and attention/concentration were intact); December 2012 VA PTSD examination report (indicating that the Veteran was sleep deprived and concentration could be impacted, but describing the memory loss as mild, such as forgetting names, directions, or recent events). The Board notes further that a higher rating of 100 percent based on total occupational and social impairment generally requires symptoms severe enough to severely distort the individual's perception of reality, which is not shown by the record. For these reasons, total occupational and social impairment is not demonstrated by the record, and a 100 percent rating for the Veteran's PTSD is not warranted. Finally, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 2. Entitlement to an initial rating in excess of 20 percent for a low back disability. The Veteran is in receipt of an initial disability rating of 20 percent for his low back disability. She asserts that a higher rating is warranted. The Veteran's low back disability is currently rated under 38 C.F.R. § 4.71a, DC 5243, applicable to intervertebral disc syndrome (IVDS). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a. Intervertebral disc disease can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). Under the IVDS Formula, a rating of 20 percent is warranted for incapacitating episodes with a total duration of at least two weeks but less than four weeks during the past 12 months. A rating of 40 percent is warranted for incapacitating episodes with a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, IVDS Formula. For these purposes, an incapacitating episode is defined as 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. Note (1). On February 7, 2021, amendments to the schedule for rating disabilities of the musculoskeletal system, including DC 5242 for degenerative arthritis and DC 5243 for IVDS, went into effect. See 85 Fed. Reg. 76460 (November 30, 2020). The amendment to DC 5242 clarifies that the rating criteria is to be applied for other than IVDS. The amendment to DC 5243 for IVDS specifies that it is to be applied only when there is disc herniation with compression and/or irritation of the adjacent nerve root. Id. Turning to the evidence, a January 1995 Medical Board Evaluation Proceeding form indicated that the Veteran had chronic mechanical low back pain. An August 1996 lumbar spine x-ray report showed evidence of mild lumbar rotoscoliosis. A May 2002 MRI report diagnosed lumbosacral degenerative disc disease. A May 2003 private treatment record indicated that the Veteran had intermittent back pain, which limited her ability to complete housework and job activities. She did not have any loss of bowel or bladder function. Flexion was 90 degrees, and extension was to 0 degrees. She had tenderness in the lower lumbar area, more on the left than the right. An October 2003 medical treatment record indicated that the Veteran had back pain, which she described as stabbing, burning, cruel, and throbbing. She stated that the pain was 7/10 in intensity and always present with variable intensity. The back pain was worse with standing, walking, and bad weather. A September 2005 medical treatment record indicated that the Veteran was having symptoms of low back pain. In a February 2009 letter, the Veteran's treating physician stated that her low back disability had been treated with numerous steroid injections. In August 2008, the Veteran underwent a permanent implantation of a spinal cord stimulator for management of her severe and intractable low back pain. The physician opined that the Veteran's back pain will significantly limit her ability to engage in physical activity and to work full-time. In July 2010, the Veteran was afforded a VA spine examination. Muscle spasm was noted. Pain was 9/10 most days with current pain management reaching the level of narcotic pain control through progression of therapies to intrathecal pump deliver pump device placed in August 2009. Patient was now manageably controlled, though never pain free. There was no evidence of bladder dysfunction or bowel dysfunction that is separate from the separately service-connected IBS. Severe flare-ups were reported, occurring every 3 to 4 months and lasting 3 to 7 days. The flare-ups were precipitated by overuse and walking too long. The Veteran did not have incapacitating episodes. She used several devices/aids, including corrective shoes, orthotic insert, a cane, and a brace. Her gait was abnormal, characterized by shuffling and hyperextension of the neck. Abnormal spinal curvature (list and lumbar flattening) was noted. On detailed motor examination, decreased muscle strength (4/5) was noted with bilateral hip flexion and extension, bilateral knee flexion and extension, bilateral ankle dorsiflexion and plantar flexion, and left great toe extension. Additional decreased muscle strength (3/5) was noted with right great toe extension. A limitation on testing of the lower extremities was noted, due to apprehension with pain induced on extent of movement, right greater than left side, lower extremity. Decreased muscle jerk (1+) was noted for bilateral knee jerk and right ankle jerk. On examination, flexion was 0 to 37 degrees, extension was 0 to 13 degrees, left lateral flexion was 0 to 17 degrees, right lateral flexion was 15 degrees, and bilateral lateral rotation was 20 degrees. There was objective evidence of pain on active range of motion and following repetitive motion. There were no additional limitations after three repetitions of range of motion. The examiner noted slow response times, though all motion active and passive were completed, and ratcheting on going from sitting to standing with sharp pain elicited in the low lumbar region. The Veteran was noted to be unemployed, but not retired, due to her spinal disability. The examiner noted that there were effects on the Veteran's usual daily activities, with severe effects on chores, shopping, traveling, bathing, and dressing, and prevention of exercise, recreation, and sports. Effects on toileting were mild and effects on grooming were moderate. The Veteran was noted to have difficult with any tasking requiring lifting and carrying or bending due to extent of spinal debility. She monitored and limited activities to reduce strain on back. She had difficulty with long standing and ambulation. The VA examiner opined that the Veteran was not employable, as her level of debility and accompanying pain with narcotic pain management precludes labor. In September 2011, the Veteran was afforded a VA spine examination. She did not report having flare-ups impact the function of the thoracolumbar spine. On examination, forward flexion was 70 degrees, extension was 20 degrees, right lateral flexion as 20 degrees, left lateral flexion was 15 degrees, and right and left lateral rotation were both 15 degrees, all with pain beginning at that point. After three repetitions, there was no additional loss of range of motion or functional impairment/loss. There was no localized tenderness, pain to palpation, guarding, or muscle spasm. Muscle strength testing was normal bilaterally, and there was no muscle atrophy. Reflex and sensory testing were also normal bilaterally. No bowel or bladder impairments were noted. The VA examiner opined that the Veteran did not have IVDS. No assistive devices were used. The VA examiner opined that the Veteran's low back disability did not impact her ability to work. In April 2012, the Veteran was afforded a VA spine examination. The Veteran reported having frequent flare-ups impacting the function of her low back, due to over activity. She reported having to go to part time work as a dog groomer due to her chronic back pain and flares. She stated that sexual activity is also extremely painful due to her back and hip pain. On examination flexion was 70 degrees, with pain beginning at 60 degrees; extension is 20 degrees, with pain beginning at that point; and right and left lateral flexion and lateral rotation were 25 degrees, with pain beginning at that point. There was no additional loss of range of motion after 3 repetitions, but there was less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. Localized tenderness or pain to palpation of the lumbar spine was noted. The Veteran had guarding or muscle spasm of the thoracolumbar spine severe enough to result in an abnormal gait. Muscle strength testing was normal bilaterally, and there was no muscle atrophy. Reflex testing was normal for the bilateral knees and left ankle, but hypoactive (1+) in the right ankle. Sensation to light touch was decreased in the right thigh/knee, right lower leg/ankle and right foot/toes, but otherwise normal bilaterally. The Veteran did not have IVDS of the thoracolumbar spine. She reported occasionally using a cane due to her chronic low back pain. The VA examiner opined that the Veteran's low back disability impacts her ability to work, such that she is best suited for sedentary or near-sedentary type job tasks. The Veteran stated that she could only stand for about 15-20 minutes before she has to sit. She stated that she could only walk about 100 yards before she has to stop and sit to rest due to pain. An October 2014 private operative report indicated that the Veteran had lumbar spine surgery. The surgeon noted that the Veteran's symptoms in the left are worse standing and walking, and improved when she sits and lays down. Some guarding was noted on examination and caused limitations of flexion/extension. She had difficulty with right leg single leg stance. Muscle strength was normal, but she had decreased to light touch of the right thigh. A January 2015 private medical treatment record indicated that her back pain had been worse since the October 2014 surgery. In December 2020, the Veteran was afforded a VA spine examination. Her current symptoms included dull, aching, sharp, unbearable pain in the low back. She stated that the back pain and lower back tightness and numbness were constant, and she needed support to stoop or stand. She reported flare-ups occurred constantly with standing using lower back, muscle spasms in the lower back, and reoccurring pain and numbness. The back flare-ups occurred daily, and started when she got up and started moving around. The back flare-ups were precipitated by anything, bending, stooping, standing for a period of time, walking, vacuuming, and cleaning. On examination, forward flexion was 75 degrees, extension was 30 degrees, right lateral flexion was 30 degrees, left lateral flexion was 20 degrees, right lateral rotation was 25 degrees, and left lateral rotation was 30 degrees. Pain was noted on examination and caused functional loss. Pain was noted with left lateral flexion, and right and left lateral rotation. There was evidence of pain with weight bearing. There was objective evidence of moderate localized tenderness or pain to palpation of the thoracic and lumbar spinals. The Veteran was not able to perform repetitive use testing and the examination was not conducted during a flare-up. The examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during a flare-up. Pain significantly limited functional ability with repeated use over a period of time and during a flare-up, such that forward flexion was 65 degrees, extension was 20 degrees, right lateral flexion was 30 degrees, left lateral flexion was 20 degrees, right lateral rotation was 25 degrees, and left lateral rotation was 30 degrees. There was no guarding or muscle spasm of the thoracolumbar spine, or additional factors contributing to disability. Muscle strength testing was normal bilaterally, and there was no muscle atrophy. Reflex and sensory testing were normal bilaterally. The Veteran had IVDS, but had not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. There was objective evidence of pain on passive range of motion testing and on weight-bearing testing. New diagnoses of thoracic and lumbosacral strain were noted, and described as a progression of the previously diagnosed lumbar degenerative disc disease and degenerative joint disease. Based on review of the evidence, both lay and medical, the Board finds that an initial rating in excess of 20 percent is not warranted at any point during period on appeal. Throughout the period on appeal, the evidence reflects forward flexion of at least 37 degrees, and more frequently at least 60 degrees, which is greater than the 30 degrees that is required for a higher rating under the General Rating Formula. See May 2003 private treatment record, and July 2010, September 2011, April 2012, and December 2020 VA examination reports. The Veteran has consistently had some range of motion of her thoracolumbar spine, and the evidence does not reflect that her functional impairments or limitations were analogous to favorable or unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. Additionally, there is evidence of disc herniation, and as such, the threshold requirement for application of DC 5243 under the 2021 amended rating criteria is satisfied; however, the objective medical evidence shows that the Veteran has not had incapacitating episodes of IVDS that required bed rest prescribed by a physician during the pendency of the appeal. See September 2011, April 2012, and December 2020 VA examination reports. Thus, the Board finds that a rating in excess of 20 percent is not warranted at any point during the period on appeal, under both the amended and former rating criteria for rating IVDS under DC 5243. The Board has considered the Veteran's reported impairment of lumbar spine function, including pain, difficulty walking, standing, bending, stooping, lifting, and sitting, muscle tenderness and spasm, abnormal gait, and guarding, as well as additional limitations of motion and functional impairments due to pain, repeated use over time, and flare-ups. Even considering additional limitation of motion or function of the thoracolumbar spine due to pain or other symptoms such as tenderness, muscle spasm, or pain (see 38 C.F.R. §§ 4.40, 4.45, 4.59), the evidence does not show that the lumbar spine disability more nearly approximates the criteria for a higher rating during the pendency of the appeal. The Board finds that any functional impairment the Veteran experiences on account of her back disability is contemplated by the 20 percent rating currently assigned and is not of such severity that it could be characterized as ankylosis or flexion of 30 degrees or less, as is required for the next-higher rating. Indeed, the Veteran was able to flex her back to at least 37 degrees on examination, throughout the period on appeal. As such, a higher rating based on pain and functional loss is not warranted for the entire period on appeal. The medical evidence consistently indicated that the Veteran does not have any bowel or bladder impairment related to the lumbar spine disability and separate from the already service-connected IBS, and the Veteran has not reported any such neurological manifestations. In addition, the Veteran is already in receipt of separate compensable ratings for bilateral lower extremity radiculopathy as a neurological manifestation of the low back disability, and the Board addresses herein whether higher ratings are warranted for bilateral lower extremity radiculopathy. Neither the Veteran nor her attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 3. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy, secondary to the service-connected low back disability. 4. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy, secondary to the service-connected low back disability. 5. Entitlement to a separate compensable rating for left lower extremity radiculopathy, secondary to the service-connected low back disability, for the period on appeal from January 30, 2007 to May 25, 2011. The Veteran is currently in receipt of a 10 percent initial rating, effective January 30, 2007, for right lower extremity radiculopathy, secondary to the service-connected low back disability. He is also in receipt of a 10 percent initial rating, effective May 26, 2011, for left lower extremity radiculopathy, secondary to the service-connected low back disability. He contends higher ratings are warranted. As explained above, as part of any increased rating claim for a low back disability, the Board must consider whether separate compensable ratings are warranted for bilateral lower extremity radiculopathy. During the pendency of this appeal, the Veteran was awarded separate compensable ratings for right and left lower extremity radiculopathy; however, the 10 percent rating for left lower extremity radiculopathy was only awarded for part of the initial rating period on appeal, beginning May 26, 2011. Therefore, the Board must consider whether a separate compensable rating is warranted for left lower extremity radiculopathy for the period on appeal from January 30, 2007, the effective date of the award of service connection for a low back disability, to May 25, 2011. As an initial matter, the Board notes that the Veteran is also in receipt of a separate 30 percent rating under DC 5270 for a right ankle disability, which appears to account for any pain and limitation of function related to the right ankle. She is also in receipt of separate 10 percent ratings for right and left hip disabilities under DCs 5010-5252, which appear to account for any pain and limitation of function related to the right and left hips. Therefore, such symptomatology cannot be considered in rating the radiculopathy of the right and left lower extremities. See 38 C.F.R. § 4.14. The Veteran's right and left lower extremity radiculopathy are both rated under 38 C.F.R. § 4.124a, DC 8520, applicable to paralysis of the sciatic nerve. Under DC 8520, an 80 percent disability rating is assigned for complete paralysis of the sciatic nerve, demonstrated by foot drop, no active movement possible of the muscles below the knee, and knee flexion that is weakened or (very rarely) lost. Lower disability ratings are provided for incomplete paralysis, defined by the Rating Schedule as "a degree of lost or impaired function substantially less than the type picture for complete paralysis given." A 60 percent disability rating is assigned for severe, incomplete paralysis, with marked muscular atrophy. A 40 percent disability rating is assigned for moderately severe, incomplete paralysis. A 20 percent disability rating is assigned for moderate, incomplete paralysis. A 10 percent disability rating is assigned for mild, incomplete paralysis. 38 C.F.R. § 4.124a, DC 8520. The regulation further provides that 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. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." Sellers v. Wilkie, 30 Vet. App. 157 (2018) ("DC 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms"). It should also be noted that use of terminology such as "mild" and "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Turning to the evidence, a February 2002 EMG interpretation report indicated that there was no evidence of lumbosacral radiculopathy. A May 2002 radiologic examination report indicated that the Veteran had pain in her lower back that radiated down the right leg. A September 2003 private treatment record indicated that the Veteran had low back pain that radiated to her bilateral lower extremities. She complained of pain in her right thigh and pain and numbness down the left thigh and calf area. An October 2003 private treatment record indicated that the Veteran's low back pain radiated to her bilateral lower extremities. A March 2004 private treatment record indicated that the Veteran's low back pain radiated down her left leg. The pain was a 5/10 in severity. She reported numbness in the left leg. A September 2005 treatment record indicated that the Veteran had symptoms of low back pain and left leg numbness. A July 2006 private treatment note indicated that the Veteran had low back pain and some numbness in the buttocks and both legs. A January 2007 treatment record indicated that the Veteran had left buttock pain radiating to the back of the leg. A July 2010 VA spine examination report indicated that the Veteran had radicular pain in the bilateral legs, with numbness and tingling. She also had symptoms of paresthesias, leg or foot weakness, and unsteadiness, but no falls. Decreased muscle jerk (1+) was noted for bilateral knee jerk and right ankle jerk. On detailed motor examination, decreased muscle strength (4/5) was noted with bilateral hip flexion and extension, bilateral knee flexion and extension, bilateral ankle dorsiflexion and plantar flexion, and left great toe extension. A September 2011 VA back conditions examination report indicated sensory testing was normal bilaterally. The VA examiner opined that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. An April 2012 VA back conditions examination report indicated that muscle strength testing was normal bilaterally and there was no muscle atrophy. Right ankle reflexes were hypoactive, but all other reflexes were normal bilaterally. Sensory examination revealed decreased sensation in the right thigh/knee, lower leg/ankle, and foot toes, but otherwise normal sensation. The VA examiner opined that the decreased sensation of the right leg was likely secondary to both the right sciatica and service-connected right ankle disability. A December 2020 VA back conditions examination report indicated that when the Veteran's back condition began, she had symptoms of sharp pain and dull tingling on left and left legs, and numbness in the right and left thighs. The current symptoms included numbness and tingling in the right leg. Muscle strength testing was normal bilaterally, and there was no muscle atrophy. Reflex and sensory testing were normal bilaterally. She had symptoms of right lower extremity radiculopathy, including mild intermittent pain, paresthesias and/or dysesthesias, and numbness. The VA examiner opined that the Veteran had moderate bilateral radiculopathy. A January 2021 VA treatment record indicated that, since October 2020, the Veteran reported having consistent right thigh pain that started in the lower back and radiated into the thigh. She had constant numbness, and the skin of the right thigh was cooler than the left thigh. Based on review of the evidence, both lay and medical, the Board finds that the Veteran's radiculopathy of the right and left lower extremities has manifested in moderate incomplete paralysis for the entire initial rating period on appeal. This is based on evidence of symptoms of mild to moderate pain, paresthesias, and numbness, as well as intermittent reports of decreased sensation, reflexes, and muscle strength. However, the record does not indicate that these symptoms were ever more than moderate in severity. The Board notes that the December 2020 VA examiner indicated that the Veteran's radicular symptoms were moderate in severity. Furthermore, the Board notes that while the Veteran had numerous intermittent symptoms, her constant radicular symptoms of pain and numbness were wholly sensory. For these reasons, the Board finds that the Veteran's right and left lower extremity radicular symptoms more nearly approximate no more than a moderate level of radiculopathy, warranting a rating of 20 percent, but no higher, for the entire initial rating period on appeal, beginning January 30, 2007. Finally, the Board notes that neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 6. Entitlement to an initial compensable rating for IBS. The Veteran is currently in receipt of a noncompensable (0 percent) initial disability rating for IBS prior to December 1, 2020, and a 30 percent rating thereafter. She asserts that a higher rating is warranted for the entire period on appeal. The Veteran's IBS is rated under DC 7319, applicable to irritable colon syndrome. See 38 C.F.R. § 4.114. Under DC 7319, a 0 percent rating is assigned for mild impairment; disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate impairment; frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is assigned for severe impairment; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Descriptive words such as "slight," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. With regard to coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. Id. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board also notes that, with regard to the schedule of ratings for the digestive system, section 4.114 expressly prohibits, in pertinent part, the combination of ratings under DCs 7301 to 7329, inclusive, which include the schedular criteria for irritable colon syndrome (DC 7319). Turning to the evidence, a September 2005 treatment record indicated that the Veteran was having symptoms of constipation. A June 2011 VA treatment record indicated that the Veteran had chronic constipation from her pain medications. In September 2012, the Veteran was afforded a VA examination. She reported having had constipation with occasional diarrhea since service. Continuous medication was required for control of the Veteran's condition. She had alternating diarrhea and constipation, including 4 days without a bowel movement. She had abdominal distention, including cramping. However, she did not have episodes of bowel disturbance with abdominal distress. The Board notes this VA examination report contained inconsistent evidence about the Veteran's symptoms, as the report of "alternating diarrhea and constipation" is not consistent with "constipation with occasional diarrhea" and the report of "abdominal distention with cramping" is not consistent with the finding that she did not have "episodes of bowel disturbance with abdominal distress." As such, this examination report has limited probative value. An October 2012 VA treatment record indicated that the Veteran complained of increased constipation and not emptying. She reported using medications as prescribed. She had diarrhea one time in two months, otherwise usually has a bowel movement every 1-2 days. An April 2019 VA treatment record indicated that the Veteran had a history of chronic constipation related to opiate use. She had one bowel movement daily. She denied having abdominal pain. In December 2020, the Veteran was afforded a VA examination. She reported that when the condition began, her symptoms were having a constant hard stool, not being able to push out without helping somewhat with hand, and then going to the bathroom because of loose bowel, cramps, and having to wear diapers. Her current symptoms included having constant hard stool for days if she did not take a stool softener, cramps, and bloating. She reported having intermittent diarrhea, and occasional episodes of bowel disturbance with abdominal distress. After a review of all the relevant evidence, both lay and medical, the Board finds that an initial rating of 10 percent, but no higher, is warranted for the period on appeal prior to December 1, 2020. The weight of the evidence prior to December 1, 2020 reflects that the Veteran had chronic constipation and abdominal distress (cramping). However, the evidence indicates that she had only occasional diarrhea (1 time in two months), which is insufficient to meet the criteria for a rating in excess of 10 percent. See October 2012 VA treatment record. Thus, the criteria for a rating of 10 percent, but no higher, for IBS have been met for the period on appeal prior to December 1, 2020. For the period on appeal from December 1, 2020, forward, the Veteran is currently in receipt of a 30 percent rating, which is the maximum rating available for IBS under DC 7319. Thus, the Board concludes that the Veteran is not entitled to any higher rating for the IBS under DC 7319 for the period on appeal from December 1, 2020, forward. Moreover, the evidence does not support higher ratings at any point during the period on appeal based upon any other diagnostic code pertaining to abdominal disabilities. As discussed above, the predominant manifestations of the IBS are frequent constipation with abdominal distress during the period on appeal prior to December 1, 2020, and alternating diarrhea and constipation, with more or less constant abdominal distress, during the period on appeal from December 1, 2020, forward. A rating of 30 percent is authorized under DC 7346 for hernia with symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The maximum rating of 60 percent under DC 7346 is authorized for hernia with symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Here, while symptoms of pain and anemia are noted, there has been no evidence of dysphagia, pyrosis, regurgitation, hematemesis or melena with moderate anemia, weight loss, vomiting, or other symptom combinations productive of either considerable or severe impairment of health. There also is no showing of ulcerative colitis as evaluated under DC 7323, and in any event, the next-higher rating under DC 7323 contemplates numerous yearly attacks of colitis, which has not been shown here. While the Veteran's constipation and abdominal distress occur more or less constantly according to her statements and reports to the VA examiner, there is no showing of malnutrition, marked or otherwise. Moreover, indicia of general debility, or any serious health complication, are lacking. DC 7332 provides for higher ratings only if there is evidence of complete loss of anal sphincter control or extensive bowel leakage and occasional or fairly frequent involuntary bowel movements; this is neither alleged nor shown here. Therefore, the other Diagnostic Codes regarding abdominal conditions do not afford a basis for the assignment of a higher initial rating at any point during the period on appeal in the absence of a showing of the symptoms or findings discussed. See 38 C.F.R. § 4.114, DCs 7301, 7304 - 7307, 7332. Accordingly, the Board finds that DC 7319 is the appropriate diagnostic code for evaluating the Veteran's IBS as the rating criteria expressly takes into account the Veteran's symptomatology. None of the other diagnostic codes for evaluating the digestive system are more appropriate in this case and they do not provide for higher disability ratings for the Veteran's IBS-related symptoms. Finally, the Board notes that neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 7. Entitlement to a rating in excess of 10 percent for a right hip disability. 8. Entitlement to a rating in excess of 10 percent for a left hip disability. The Veteran is currently in receipt of separate 10 percent ratings for her right and left hip disabilities. She asserts that higher ratings are warranted for the entire period on appeal. The Veteran's right and left hip disabilities are rated under DC 5010-5252, applicable to arthritis due to trauma and limitation of flexion of the thighs. See 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the hip joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to DCs 5003 and 5010 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, DC 5010, instructed the rater to rate traumatic arthritis as degenerative arthritis under DC 5003. Under the revised criteria, DC 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under both the earlier and revised rating criteria, degenerative arthritis is rated under DC 5003. Under this code, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the hip is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the hip are Diagnostic Codes 5251 (limitation of extension), 5252 (limitation of flexion), and 5253 (impairment, including limitation of abduction, adduction, and rotation). The Veteran is already in receipt of a 10 percent rating under DC 5252 based on limitation of motion. As this is the maximum rating available under DC 5003, further discussion of entitlement to a higher rating under DC 5003 is not warranted. DC 5251 provides a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. DC 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. Id. Under Diagnostic Code 5253, impairment of the thigh may be rated based on limitation of abduction, limitation of adduction, or limitation of rotation. A 10 percent rating will be assigned for limitation of rotation where the individual cannot toe-out more than 15 degrees on the affected leg, or for limitation of adduction where the individual cannot cross the legs. A 20 percent rating will be assigned for limitation of abduction where there is motion lost beyond 10 degrees. Id. Normal ranges of motion of the hip are hip flexion from 0 degrees to 125 degrees and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Turning to the evidence, in April 2012, the Veteran was afforded a VA hip and thigh examination. She reported having chronic hip pain, and that her hips were very stiff in the mornings when she woke up. She stated that stooping, extending walking, or using stairs causes the most pain. She stated that it may take the entire day for the pain to return to baseline level. She reported having flare-ups that impacted the function of the hips. The flare-ups could occur for no specific reason, and getting off her feet helped the most. On examination, right hip flexion was 110 degrees, with pain beginning at 80 degrees, and right hip extension was greater than 5 degrees, with painful motion at that point. Right hip abduction was not lost beyond 10 degrees, adduction was not limited such that she could not cross legs, and rotation was not limited such that she could not toe-out more than 15 degrees. Left hip flexion ended at 110 degrees, with pain beginning at 90 degrees, and left hip extension was greater than 5 degrees, with painful motion at that point. Left hip abduction was not lost beyond 10 degrees, adduction was not limited such that she could not cross legs, and rotation was not limited such that she could not toe-out more than 15 degrees. There was no additional loss of range of motion of either hip following repetitive use testing; however, the Veteran had less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing, bilaterally. There was no localized tenderness or pain to palpation. Muscle strength testing was normal, bilaterally. There was no ankylosis of either hip joint. There was no malunion or nonunion of femur, flail hip joint, or leg length discrepancy, bilaterally. The Veteran occasionally used a cane and electric scooter due to her bilateral hip pain. The VA examiner opined that the functional impact of the Veteran's bilateral hip disability was such that she was best suited for sedentary or near sedentary-type job tasks. During the November 2017 Board hearing, the Veteran testified that she her hips bother her with sitting, standing, and movement. She said she has hip pain pretty much all the time. She described her left hip as feeling like it is going to pop out of the joint. She said her hips were about the same in severity. She testified that she got a raised toilet because it is difficult for her to get up and down with the toilet. She also got a ramp for the house because it is painful for her to go up and down stairs. In December 2020, the Veteran was afforded a VA hip and thigh conditions examination. She reported current symptoms of tightness, popping of joint, and aching. She had difficulty sitting for long periods of time. She reported having right hip flare-ups characterized by constant numbness in the right thigh, lasting until she used ice or a heating pad. The right hip flare-ups were precipitated by going shopping, vacuuming, and yardwork. She also reported having moderate to severe left hip flare-ups occurring 2-3 times weekly and lasting for days at times. The left hip flare-ups were precipitated by sitting, standing, twisting, walking, and giving out, and alleviated by stretching and ice. She reported having functional loss or impairment of the hips during sexual intercourse and when going to the bathroom. On examination, right hip flexion was 80 degrees, extension was 20 degrees, abduction was 45 degrees, adduction was 15 degrees, external rotation was 25 degrees, and internal rotation was 30 degrees. Right hip adduction was not limited such that the Veteran could not cross her legs. Pain was noted on examination with all ranges of motion for the right hip and caused functional loss. There was evidence of pain with weight bearing, but no evidence of localized tenderness or crepitus. Left hip flexion was 80 degrees, extension was 20 degrees, abduction was 45 degrees, adduction was 25 degrees, external rotation was 30 degrees, and internal rotation was 30 degrees. Left hip adduction was not limited such that the Veteran could not cross her legs. Pain was noted on examination with all ranges of motion for the left hip and caused functional loss. There was evidence of pain with weight bearing, but no evidence of localized tenderness or crepitus. Repetitive use testing was not performed, because the Veteran reported having a flare-up. The VA examiner indicated that the Veteran was not examined immediate after repetitive use over time or during a flare-up, and the examiner opined that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during flare-up. Pain significantly limited functional ability in both hips with repeated use over a period of time and during flare-up. The VA examiner described this limitation in terms of range of motion, indicating that right hip flexion was 70 degrees, extension was 20 degrees, abduction was 40 degrees, adduction was 15 degrees, external rotation was 25 degrees, and internal rotation was 30 degrees. Left hip flexion was 70 degrees, extension was 20 degrees, abduction was 45 degrees, adduction was 25 degrees, external rotation as 30 degrees, and internal rotation was 30 degrees. Post-test adduction of both hips was not limited such that the Veteran could not cross legs. There were no other additional factors contributing to disability. Muscle strength testing was normal bilaterally, and there was no muscle atrophy. There was no ankylosis of either hip. The Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. There was objective evidence of pain on passive range of motion of both hips, but no objective evidence of pain on non-weight bearing testing of the hips. Upon review, the Board initially notes that the Veteran has never manifested ankylosis of either hip and no evidence of record throughout the claims period has demonstrated a flail joint or impairment of the femur (to include fractures or malunion). Thus, Diagnostic Codes 5250, 5254, and 5255 are not for application in this case. In order to receive a compensable rating under DC 5251, extension limited to 5 degrees must be shown. Here, the April 2012 and December 2020 VA examination reports both indicated that the Veteran's limitation of the extension of both the right and left thighs was greater than 5 degrees. Further, repetitive-use testing did not additionally limit extension of either hip. Therefore, a compensable rating under DC 5251 is not warranted. In addition, a rating in excess of 10 percent under DC 5252 for limitation of flexion is not warranted for either hip for the entire period on appeal. A higher rating under DC 5252 requires limitation of flexion of the hip to 30 degrees or less. Here, the evidence reflects that the Veteran had at least 70 degrees of right and left hip flexion throughout the period on appeal. Therefore, the criteria for a rating in excess of 10 percent for limitation of flexion of the right and left hips under DC 5252 have not been met for the entire period on appeal. As to whether a compensable rating is warranted for the Veteran's hip and thigh disabilities under DC 5253, the evidence does not show that the Veteran had rotation limited to 15 degrees, limitation of adduction such that he could not cross his legs, or abduction limited beyond 10 degrees. To the contrary, the April 2012 and December 2020 VA examination report indicated, even during flare-ups and with repeated use over time, that external rotation was at least 25 degrees for the right hip and 30 degrees for the left hip, internal rotation was at least 30 degrees bilaterally, abduction was at least 40 degrees for the right hip and 45 degrees for the left hip, adduction was at least 15 degrees for the right hip and 25 degrees for the left hip, and the Veteran was able to cross her legs. Therefore, a compensable rating under DC 5253 is not warranted for the entire period on appeal. The Board has specifically considered the Court's holdings in DeLuca and Mitchell; however, the evidence fails to show that the Veteran's symptoms resulted in or approximated functional loss of flexion of 30 degrees or less, or functional loss of extension, rotation, adduction, or abduction to such a degree as to warrant a compensable rating. To the extent that the Veteran has reported experiencing significant pain and stiffness of the hips and thighs, including during flare-ups and with repetitive use, this symptom is already contemplated by the currently assigned 10 percent rating under DC 5252 and any further consideration of such pain under a separate diagnostic code would violate the pyramiding prohibition of 38 C.F.R. § 4.14. For these reasons, the Veteran is not entitled to a higher rating for either hip based on functional impairment or flare-ups. Finally, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 9. Entitlement to a TDIU. It is the established policy of VA that all veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. Controlling laws provide that a TDIU may be assigned when a veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. The Veteran in this case has met the schedular percentage requirements for TDIU under 38 C.F.R. § 4.16(a) since January 30, 2007, which is also the date of the claim that gave rise to the present appeal. During the period on appeal, she has been in receipt of service connection for PTSD (rated 50 percent disabling from January 30, 2007 and 70 percent disabling from May 26, 2011); a right ankle disability (rated 30 percent from January 30, 2007); a cervical from March 29, 2011, and 30 percent disabling from July 1, 2011); IBS (rated 10 percent disabling from September 14, 2011 and 30 percent disabling from December 1, 2020); a low back disability (rated 20 percent disabling from January 30, 2007), right upper extremity radiculopathy (rated 20 percent disabling from July 5, 2011); left upper extremity radiculopathy (rated 20 percent disabling from July 5, 2011); left lower extremity radiculopathy (rated 20 percent disabling from January 30, 2007); right lower extremity radiculopathy (rated 20 percent disabling from January 30, 2007); a right shoulder disability (rated 10 percent disabling from November 30, 2004); a right hip disability (rated 10 percent disabling from January 30, 2007); a left hip disability (rated 10 percent disabling from January 30, 2007); residuals, left ribs fracture, 7-9 (rated 0 percent disabling from August 18, 1995); residuals, removal right eye pterygium (rated 0 percent disabling from August 18, 1995); residuals, pelvis fracture (rated 0 percent disabling from August 18, 1995, 10 percent disabling from November 30, 2007, and 0 percent disabling from January 30, 2007); neck surgical scars (rated 0 percent disabling from March 29, 2011); and low back scars (rated 0 percent disabling from December 1, 2020). Her combined disability rating is 90 percent from January 30, 2007 and 100 percent from May 29, 2011. The remaining question is whether these service-connected disabilities preclude the Veteran from securing and following a substantially gainful occupation. See 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his or her disability makes it difficult for him or her to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he or she is incapable "of performing the physical and mental acts required" to be employed. Id. at 363. Thus, the central question is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran's education, training, and special work experience, but not to his or her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013), the Federal Circuit held that, when a veteran is claiming TDIU based upon the combined effects of multiple service-connected disabilities, VA's duty to assist "does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities." See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner's opinion. Geib, 733 F.3d at 1354; see also 38 C.F.R. § 4.16(a). The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). There is no regulatory definition of "substantially gainful employment." 38 C.F.R. § 4.16(a) provides guidance in that it states: "Marginal employment shall not be considered gainful employment." It also says definitively that marginal employment exists when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Even if the income exceeds the poverty threshold, marginal employment may still exist on a facts-found basis. One example given is employment in a protected environment like a family business or a sheltered workshop. 38 C.F.R. § 4.16(a). VA must consider the nature of employment. Id. Notably, in Ray v. Wilkie, the Court of Appeals for Veterans Claims defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Here, the Veteran's DD-214 indicates that she served on active duty for nearly 12 years. Her military occupational specialty was automated logistical specialist. The March 2007 VA PTSD examination report indicated that she continued to be self-employed on a part-time basis with a mobile dog grooming business, but that there were several days per month when she was emotionally unable to perform her duties and she would cancel appointments. In February 2009, the Veteran's treating physician opined that the Veteran's service-connected low back and neck disability pain will significantly limit her ability to engage in physical activity and to work full-time. A March 2010 VA mental health treatment record indicated that the Veteran liked her work as a dog groomer, but frequently felt too depressed to keep appointments. She noted that her clients frequently asked about her marital status and history, and she became quite upset. On self-report psychological inventories, the Veteran endorsed severe distress related to re-experiencing, efforts at avoidance, emotional numbing and hyperarousal. Her responses also indicated extremely depressed mood with occasional passive suicidal ideation. The July 2010 VA spine examination report indicated that the Veteran was unable to work. The pain medication made her responses slow and effortful. Her pain was 9/10 most days. The VA examiner opined that the Veteran's level of debility and accompanying pain with narcotic pain management precluded labor. The Veteran had difficulty with any tasking requiring lifting and carrying or bending due to the extent of her spinal debility. She monitored and limited her activities to reduce the strain on her back. She had difficulty with long standing and ambulation. In a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, which was received by VA in May 2011, the Veteran reported that she became too disabled to work in 1993, that her disability affected full-time employment in October 2001, and that she last worked full-time in 2001. From December 2001 to October 2008, she was self-employed as a mobile pet groomer, working 15 hours a week, and earning no more than $925 per month. She stated that she had no earned income for the past 12 months. In June 2011, VA received another copy of VA Form 21-8940. The Veteran reported that she became too disabled to work in 2006, that her disability affected full-time employment in 2007, and that she last worked full-time in 1993 in the military. She reported being self-employed as a mobile dog groomer from January 2000 to August 2008, working 15 hours a week, and earning no more than $800 per month. An August 2011 private physical therapy treatment note indicated that the Veteran worked 5 half days as a dog groomer. Her back pain was aggravated by standing for more than 20 minutes, work, and constant movement of the upper extremities. The Veteran demonstrated poor sitting posture, increased thoracic kyphosis, poor postural awareness, strength, and endurance. A May 2012 VA physical therapy treatment note indicated that the Veteran was tolerating her daily activities and her dog grooming business, but that she still had to limit the amount of time she worked due to pain. A July 2012 VA treatment record indicated that the Veteran reported turning down offers to groom dogs, citing problems with committing to a specific appointment/date/time, feeling like she may not be able to handle the stress of doing what needs to get done. The August 2012 VA examination report indicated that the Veteran had a part-time dog grooming business, but had recently missed work, which she attributed to her back "giving way," as well as sometimes waking up and just not wanting to work. A January 2016 private vocational assessment indicated that the Veteran obtained training as a pet groomer in 1999 and subsequently became employed in this field in a self-employed basis. Prior to her cervical surgery in 2011, she worked on a part-time basis according to her functional limitations resulting from her orthopedic conditions and waxing and waning of her psychiatric symptoms. She resumed her business following recuperation from her surgery in July 2011, but reportedly is only able to work with small dogs, being unable to lift larger heavy dogs, and only works approximately 6 hours per week. She reportedly only earns approximately $100 per week for her efforts. The vocational rehabilitation consultant opined that the Veteran's psychiatric treatment records were reflective of an inability to perform any substantial gainful occupation on a consistent basis. The consultant also noted that the June 2010 VA examination indicated that the Veteran experiences chronic cervical and lumbar pain, walks with a shuffling gait, has a pelvic tilt to the right and hyperextension of the neck, intermittent right lower extremity radicular symptoms, and uses orthotic shoe inserts, a back brace, and a cane. Her pain and symptoms were exacerbated by overuse, prolonged standing and walking, lifting and carrying. She reportedly experiences severe flare-ups of pain every 3-4 months that last 3-7 days. The consultant opined that, given what appears to be the permanency of the Veteran's service-connected psychiatric, emotional, and behavioral symptoms and functional difficulties resultant of her PTSD, combined with her chronic pain and functional limitations of her cervical and lumbar spine disabilities, the Veteran has been unable to perform any significant gainful occupation within the general labor market since January 2007. In June 2016, a registered nurse reviewed the record and opined that the Veteran's ongoing need for narcotic pain medications for pain relief of her service-connected lumbar and cervical spine conditions prevent her from being able to obtain employment, as her pain medication regiment caused lightheadedness, drowsiness, and impaired focus/concentration. The nurse noted that attention to detail and the ability to focus are paramount in work environments, in both physically demanding roles and sedentary jobs. Furthermore, the nurse opined that the Veteran's social isolation, depressive states with decreased motivation, coupled with long periods of sleeping, intermittent suicidal ideation, periods of nightmares with recurrent thoughts, lethargy, and apathy affect her ability to maintain employment. The nurse opined that the Veteran's service-connected PTSD is psychiatrically disabling, and her service-connected low back and neck conditions are medically disabling. As such, the nurse opined that the Veteran has been unable to maintain substantial gainful employment due to her service-connected low back and neck disabilities and treatment, her service-connected PTSD and treatment, and resultant physical, psychological, and occupational limitations as early as June 30, 2007. A December 2017 VA mental health treatment note indicated that the Veteran reported easy tearfulness and worsening irritability. She was doing some part-time work as a driver, which had been difficult. Both her mother and a coworker had commented on her irritability. She noted more anxiety with driving over bridges. In September 2020, the Veteran submitted a copy of her Social Security Administration (SSA) earnings record, indicating that she had earned less than $8,000 per year each year since 2007. In a September 2020 VA Form 21-8940, the Veteran reported working as a bus driver for 10-15 hours per week from July 2016 to December 2017, and missing four days per month due to illness. She also worked in supply from 1996 to 1999 and had a forklift operation certification at that time. She stated that it had been over 20 years since she had been able to work full-time. The December 2020 VA PTSD examination report indicated that the Veteran graduated from high school and completed some college. She worked as a dog groomer. She reported lack of motivation to work and could miss work or be late. She was also sleep deprived, and her concentration and memory could be impacted. The VA examiner noted that interpersonal issues could result from irritability and lack of patience. The December 2020 VA examiner opined that the Veteran's low back and bilateral hip disabilities caused difficulty with prolonged sitting and standing, bending, squatting, and lifting heavy items. The same VA examiner also opined that the Veteran's neck disability caused her to have difficulty with overhead activities and repetitive motion. After a review of all the evidence of record, lay and medical, the Board finds that the Veteran has been unable to secure or maintain substantially gainful employment due to her service-connected disabilities since January 30, 2007. The evidence reflects that the Veteran experiences significant pain and mobility limitations due to her orthopedic disabilities. See February 2009 statement from the Veteran's treating physician. She has significant difficulty with prolonged sitting and standing, bending, squatting, and lifting heavy items. See July 2010 and December 2020 VA examination reports; August 2011 private physical therapy treatment note. In addition, the Veteran's regimen of medications to treat her orthopedic pain cause her to have difficulty focusing and concentrating, which are necessary skills for any employment. See July 2010 VA examination report; June 2016 opinion from a registered nurse. Furthermore, the Veteran's PTSD causes her to have anxiety, irritability, depression, and difficulty handling stressful situations, which result in significant occupational impairment. See March 2010 VA mental health treatment record; July 2012 VA treatment record; December 2017 VA treatment note; December 2020 VA PTSD examination report. In making these findings, the Board found the January 2016 and June 2016 private medical and vocational opinions to be highly probative, as they were based on detailed review of the record and included thorough rationales. In addition, the Board notes that the Veteran's employment history is limited. While the evidence reflects that the Veteran has worked as a dog groomer during the period on appeal, such employment appears to have been marginal. See May 2011, June 2011 and September VA Forms 21-8940; September 2020 SSA earnings record. Furthermore, as the Veteran was self-employed and appears to have managed her work hours to accommodate the functional impairments resulting from her service-connected PTSD and neck and low back disabilities, such employment was sheltered. Therefore, the Veteran's self-employment as a dog groomer did not constitute substantially gainful employment at any point during the period on appeal. For these reasons, the combined functional impact of the Veteran's service-connected orthopedic and psychiatric disabilities has rendered her unable to obtain and maintain substantially gainful employment for the entire period on appeal. Indeed, given the significant impact of her service-connected disabilities on the Veteran's ability to work and perform routine tasks that would likely be required for employment, the weight of the evidence supports a finding that her service-connected disabilities precluded her from obtaining and maintaining substantially gainful employment for the entire period on appeal. For these reasons, and resolving all reasonable doubt in the Veteran's favor, the Board grants a TDIU beginning January 30, 2007, the date the Veteran submitted the claim for service connection for the low back disability that gave rise to the present claim for a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). REASONS FOR REMAND 1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for bilateral carpal tunnel syndrome is remanded. The Board must defer consideration of the issue of whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for bilateral carpal tunnel syndrome, as it is inextricably intertwined with the issue of entitlement to initial ratings in excess of 20 percent for bilateral upper extremity radiculopathies, secondary to the service-connected cervical spine disability, being remanded herein. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001). 2. Entitlement to initial ratings in excess of 20 percent for right and left upper extremity radiculopathy is remanded. As the Board noted in its March 2019 remand, the Veteran has been diagnosed with numerous bilateral upper extremity nerve conditions. See February 2003 private treatment record (diagnosing mild left carpal tunnel); February 2009 VA treatment record (diagnosing meralgia paresthetica); March 2011 private treatment record (diagnosing cervical spine radiculopathy); and February 2013 VA treatment record (diagnosing possible cervical radiculopathy, right ulnar neuropathy of the cubital tunnel, and mild left carpal tunnel). The Board found that it is unclear from the record the extent to which the Veteran's bilateral upper extremity symptoms are related to or caused by each diagnosis. The Board's remand directives specifically instructed the VA examiner to provide an opinion as to what extent are the Veteran's symptoms of bilateral upper extremity radiculopathy distinguishable from the symptoms of any diagnosed carpal tunnel syndrome, cubital tunnel syndrome, and meralgia paresthetica. The Veteran has a right to compliance with the Board's remand orders. See Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). While the Veteran was afforded a VA cervical spine examination in December 2020 and the VA examiner opined that the Veteran had a current diagnosis of bilateral upper extremity radiculopathy, the examiner did not provide the requested opinion as to what extent are the Veteran's symptoms of bilateral upper extremity radiculopathy distinguishable from the symptoms of any diagnosed carpal tunnel syndrome, cubital tunnel syndrome, and meralgia paresthetica. As such, the Board finds that the December 2020 VA examination did not comply with the Board's March 2019 remand directives, and remand is required to obtain the requested medical opinion. See Stegall, supra. 3. Entitlement to a compensable rating for residuals of a pelvic fracture is remanded. The provisions of 38 C.F.R. § 4.67 provide that the variability of residuals following pelvic bone fractures necessitate rating on specific residuals, faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifest by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion. Upon review of the record, the Board finds that additional information is necessary to fully assess the extent of the Veteran's residuals of a pelvic fracture. Specifically, the Board notes that the Veteran has repeatedly reported experiencing pelvic pain during intercourse, and her service treatment records indicate that she was diagnosed with chronic dyspareunia as a residual of the pelvic fracture. In consideration of this diagnosis, her reported symptoms, and the provisions of 38 C.F.R. § 4.67, the Board finds that the Veteran should be afforded VA gynecological and muscle injury examinations to fully assess her residuals of a pelvic fracture. In addition, the Board in its March 2019 remand found that the issue of entitlement to an increased rating for residuals of a pelvic fracture is inextricably intertwined with the issues of entitlement to increased ratings for right and left hip disabilities remanded herein. Therefore, the Board must defer consideration of this issue. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from the VA examiner that conducted the December 2020 VA cervical spine examination, or a suitable substitute. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. After review of the claims file, the examiner should provide an opinion as to what extent are the Veteran's symptoms of the service-connected bilateral upper extremity radiculopathy distinguishable from the symptoms of any diagnosed carpal tunnel syndrome, cubital tunnel syndrome, and meralgia paresthetica. A thorough explanation must be provided for the opinion rendered. If the above requested opinion cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. 2. Schedule the Veteran for VA gynecological and muscle injury examinations to determine the nature and severity of her residuals of a pelvic fracture. The claims folder must be made available to the examiner in conjunction with the examination. Any testing deemed necessary should be performed. After review of the record and examination of the Veteran, the VA examiner(s) should comment on whether the Veteran has any muscle injuries and/or gynecological disabilities that are residuals of the pelvic fracture, and the extent of any such residuals. **The VA examiner(s) should specifically address the Veteran's reports of experiencing pain during intercourse, and her service treatment records indicate that she was diagnosed with chronic dyspareunia as a residual of the pelvic fracture. 3. Then, readjudicate the remanded issues on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thomas, 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.