Citation Nr: 21068208 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-13 478 DATE: November 9, 2021 ORDER Entitlement to a disability rating in excess of 10 percent prior to August 1, 2019, and in excess of 40 percent thereafter for residuals of a compression fracture of L3 (hereinafter referred to as a "low back disability") is denied. As of October 22, 2014, entitlement to an initial rating in excess of 20 percent for right lower extremity (RLE) radiculopathy is denied. As of October 22, 2014, entitlement to an initial rating in excess of 20 percent for left lower extremity (LLE) radiculopathy is denied. REMANDED Entitlement to a separate rating for a bowel and/or bladder disorder associated with the service-connected low back disability is remanded. FINDINGS OF FACT 1. Prior to August 1, 2019, the Veteran's low back disability was manifested by forward flexion to 65 degrees, extension ranging from 0 to 15 degrees, right and left lateral flexion ranging from 25 to 30 degrees, right lateral rotation ranging from 10 to 20 degrees, and left lateral rotation to 20 degrees with pain and guarding that did not result in abnormal gait or spinal contour; he did not have ankylosis or intervertebral disc syndrome (IVDS) with incapacitating episodes. 2. As of August 1, 2019, the Veteran's low back disability has been manifested, at its worst, by forward flexion to 10 degrees with no ankylosis, guarding that resulted in abnormal gait or abnormal spinal contour, and IVDS that did not require bed rest and treatment by a physician in the past 12 months. 3. As of November 19, 2015, the Veteran's RLE radiculopathy has been manifested by symptoms that, at its worst, approximates moderate incomplete paralysis. 4. As of November 19, 2015, the Veteran's LLE radiculopathy has been manifested by symptoms that, at its worst, approximates moderate incomplete paralysis. CONCLUSIONS OF LAW 1. Prior to August 1, 2019, the criteria for a disability rating in excess of 10 percent for a low back disability were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5242. 2. As of August 1, 2019, the criteria for a disability rating in excess of 40 percent for a low back disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5242. 3. As of October 22, 2014, the criteria for an initial rating in excess of 20 percent for RLE radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8526. 4. As of October 22, 2014, the criteria for an initial rating in excess of 20 percent for LLE radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1980 to September 1983. This case originally came before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was last before the Board in January 2019. By way of procedural history, the RO granted service connection for a low back disability in an August 1999 rating decision, granting a 10 percent initial rating, effective December 3, 1998. Subsequently, the Veteran filed an informal claim in October 2014, followed by a formal increased rating claim for the low back disability in June 2015. The RO denied an increased rating in an August 2015 rating decision, which was then appealed. The Board notes that the Veteran disagreed with the effective date for the 10 percent rating before contending that a rating in excess of 10 percent was warranted. See September 2015 NOD. An NOD must be submitted no later than one year following notification of the decision being appealed. The Veteran was granted service connection for a low back disability and assigned a 10 percent rating in an August 1999 rating decision. He did not submit an NOD regarding the effective date regarding the award of service connection within one year from the date of the rating decision. The September 2015 NOD that appealed the current claim was in response to the August 2015 rating decision, which continued the 10 percent rating for a low back disability. The Veteran cannot bring a freestanding claim for an earlier effective date. Leonard v. Nicholson, 405 F.3d 1333 (Fed. Cir. 2005); Rudd v. Nicholson, 20 Vet. App. 296 (Fed. Cir. 2006). In January 2019, the Board remanded the increased rating claim, as well as service connection claims for radiculopathy of the bilateral lower extremities (BLE) and for an acquired psychiatric disorder. At that time, the Board also denied service connection for numbness of the face. Service connection for RLE and LLE radiculopathy was granted in a March 2020 rating decision, which assigned 20 percent initial ratings, effective October 22, 2014. The effective dates are based on when the RO determined the claims to have been received. The issues of RLE and LLE radiculopathy are part and parcel of the underlying service-connected low back disability claim. The increased rating claim for a low back disability was received on October 22, 2014. Therefore, the awards are for the entire period on appeal, specifically as of October 22, 2014. Accordingly, the Board only addresses the initial ratings for RLE and LLE radiculopathy herein, and not the effective dates assigned. In a December 2020 rating decision, the RO granted service connection for an acquired psychiatric disorder, specifically posttraumatic stress disorder. As this issue was resolved by a full grant of benefits and the Veteran has not submitted any documents indicating that he is not satisfied with the decision, the Board finds that this issue is no longer part of the current appeal. See 38 C.F.R. § 19.26(d). The Board notes that service connection claims for right and left knee disorders were remanded by the Board in April 2020 and are currently pending on appeal. Additionally, the Veteran submitted a claim for a total disability rating for individual unemployability due to service-connected disabilities in April 2020 and a service connection claim for a lung disorder in September 2020. All of these claims are currently before the RO and not ready to be adjudicated at this time. Therefore, they are not addressed herein and will be adjudicated in a separate decision. The Board also acknowledges that the Veteran initially requested a Decision Review Officer (DRO) hearing in October 2015. However, he subsequently requested to reschedule the DRO hearing in February 2016 and December 2016, withdrew his request for a DRO hearing in January 2017, and failed to report to a January 2017 DRO hearing. The Veteran declined a Board hearing in his March 2017 VA Form 9. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Higher Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion (ROM) testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). 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. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to disability ratings in excess of 10 percent prior to August 1, 2019, and 40 percent thereafter for a low back disability The Veteran contends that higher ratings are warranted for his low back disability. In May 2020, the Veteran requested both an increased rating as well as an earlier effective date for the increased evaluation. He continued to assert that his condition was more severe than the rating demonstrated. His doctor recommended that he not lift more than five to 10 pounds in June 2017. Additionally, he was prescribed gabapentin in 2016 for muscle spasms, used a walker to get around, had some bowel incontinency, had no extension and limited flexion due to pain, had reduced muscle strength in the lower extremities, and had moderate to moderately severe central and lateral canal stenosis. Law The Veteran's low back disability is currently evaluated as 10 percent disabling prior to August 1, 2019; and then a 40 percent rating thereafter under 38 C.F.R. § 4.71a, DC 5242. His low back disability is rated under the General Rating Formula, which encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasms, and tenderness. See 38 C.F.R. § 4.71a, DCs 5235-5243. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including DC 5242, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021, the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, degenerative arthritis of the spine under DC 5242 was rated under the General Rating Formula for Diseases and Injuries of the Spine with an instruction to also see DC 5003. DC 5003 for degenerative arthritis (hypertrophic or osteoarthritis) states that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when 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, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In this case, the low back disability warrants a compensable rating for the entire appeal period. As a result, DC 5003 is not applied in rating the low back disability. As of February 7, 2021, DC 5242 states to consider DC 5003 or 5010 for degenerative arthritis and degenerative disc disease (DDD) other than IVDS. DC 5003 is not changed. However, DC 5010 for post-traumatic arthritis instructs to rate as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating shall be combined in accordance with § 4.25. The General Rating Formula provides for a 10 percent rating where there is forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; combined ROM of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; a combined ROM 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 rating is warranted where there is forward flexion of the thoracolumbar spine at 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is available for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is available for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined ROM refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined ROM of the thoracolumbar spine is 240 degrees. The normal ROMs for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined ROM. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (2); see also Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, DCs 5235-5243, Note (5). IVDS (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5243. As of February 7, 2021, DC 5243 clarifies that this diagnostic code is only to be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. DC 5242 will be assigned for all other disc diagnoses. Under the IVDS Formula, a 10 percent rating requires incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating requires incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating requires incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, and a 60 percent rating requires incapacitating episodes having a total duration of at least six weeks during the past 12 months. An "incapacitating episode" is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). Evidence Turning to the evidence in this case, the Board notes that an April 2015 private magnetic resonance imaging (MRI) of the lumbar spine revealed chronic 60 percent compression fracture deformity of the L3 vertebral body with residual fracture cleft within the posterior aspect of the L3 vertebral body, marked central spinal stenosis at L2-L3 with moderate to marked compression and flattening of the thecal sac, marked central spinal stenosis at the L3 vertebral body level secondary to retropulsion of the vertebral body, moderate central spinal stenosis at L3-L4, moderate to marked right L3-L4 neural foraminal stenosis that could result in right L3 radiculopathy, moderate L5-S1 facet osteoarthritis greatest on the right side, and moderate L3-L4 and mild to moderate L2-L3 disc degeneration. An April 2015 letter reflects that the Veteran was being treated for back pain and a previous back injury. He was told that he should not lift over 10 pounds, kneel, work in cramped environments, walk more than 200 feet at a time, crawl, stoop, climb, or sit more than an hour at a time without being able to get up and walk around. A May 2015 private treatment record reflects a complaint of low back pain radiating to the BLE. He described the pain as aching, numb-like stabbing, nagging, sharp, and gnawing. The pain was better with not doing any work above his head and not bending his back backwards, and worsened with any lumbar extension-type movement. When he walked with the shopping cart, he leaned forward on the cart to improve his pain. He also noted that the pain could be worse at night. He was assessed with severe central canal spinal stenosis at L3, lumbar spine degeneration, chronic L3 compression fracture, neuralgia, and bilateral L5 radiculopathy. An August 2015 VA examination report reflects review of only service treatment records (STRs) and VA treatment records and diagnoses of spondylosis of the thoracic and lumbar spine and vertebral fracture of the L3 in 1980. Over the past couple of years, his pain had been increasing. He reported flare-ups, which required him to rest a couple of days, and functional loss or functional impairment of the thoracolumbar spine. Specifically, he had to work while pushing a shopping cart because he could not walk too far. ROM testing revealed forward flexion to 65 degrees, extension to 15 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 20 degrees. He was not able to bend, stoop, or walk long distances. Pain was noted on examination with extension and caused functional loss. There was no evidence of pain with weight-bearing and no objective evidence of localized tenderness or pain on palpation. There was no additional loss of function or ROM after three repetitions. The Veteran was being examined immediately after repetitive use over time and had significantly limited functional ability due to pain and lack of endurance, although the examiner could not describe such in terms of ROM as the Veteran had not been observed over hours of time. The examination was not being conducted during a flare-up, but the examiner stated that the examination was medically consistent with the Veteran's statements describing functional loss during flare-ups. Pain and lack of endurance significantly limited functional ability with flare-ups, although such functional loss could not be described in terms of ROM as the Veteran had not been observed over a period of hours. He did not have any guarding or muscle spasms. Additionally, he had less movement than normal, disturbance of locomotion, and interference with standing. The examiner found that the Veteran did not have radicular pain or any other symptoms due to radiculopathy. He had no ankylosis, no other neurologic abnormalities or findings, and no IVDS of the thoracolumbar spine. The examiner noted that the Veteran complained that she made him do ROM testing that caused pain in his back. She explained that ROM was a required part of the examination and that she would not ask him to do anything that would cause injury to his back. She contacted the Veteran and offered to repeat the examination, but he said he had no complaints. She tried to contact his representative five times, but they did not return her calls. She noted that the Veteran reported a phobia about medical personnel and did not like to be in their presence. X-rays documented arthritis and revealed five lumbar-type vertebral bodies with subtle levoscoliosis in the mid-lumbar region, a moderately severe old compression fracture at L3 with nearly 50 percent loss of vertebral body height at the centrum, associated severe DDD laterally on the right as well as evidence of spondylosis throughout the lower thoracic and lumbar levels, and degenerative changes of the facet joints at L5-S1. Central stenosis could not be excluded due to some rotation of the Veteran on the lateral view. In his September 2015 Notice of Disagreement (NOD), the Veteran specifically disagreed with the VA examination which reported that the Veteran had no muscle spasms. A November 2015 VA treatment record reflects that his spinal stenosis had worsened over the past two years with pain in the low back that wrapped around anteriorly and down the legs. He was assessed with chronic back pain. A February 2016 VA treatment record reflects chronic low back pain in the midline lumbar spine with radiation down his anterior and posterior legs to his feet. He started to fall more frequently and reported more weakness in his legs. An August 2015 electromyograph (EMG) was normal. He had tenderness to palpation over the midline lumbar spine at about L4-5 and limited ROM in all planes due to pain and guarding. He had pain with extension and rotation bilaterally and flexion. A December 2016 VA treatment record reflects a complaint of low back pain in the midline lower back that radiated to the front of the thighs and then to the side of the legs, calves, and toes. He had no extension in the lumbosacral spine and limited flexion due to pain. He was assessed with low back pain that was greater than bilateral leg pain, lumbar DDD, lumbar spondylosis at all levels, lumbar stenosis at L2-3 and L3-4, an old L3 vertebral body fracture, possible thoracic spine DDD, and radiculitis. In February 2017, the Veteran reported that he was usually awoken by back pain. He drove 50 hours every two weeks, and had to stop every hour to get out of the car with his walker to get the stiffness out of his back and the numbness out of his legs as best as possible. If he did not do this, he became entirely constipated. An April 2017 VA examination report reflects review of the Veteran's claims file and diagnoses of vertebral fracture at L3 and spinal stenosis at L2-3 and L3-4. The Veteran reported symptoms that were continually getting slightly worse. In the last year, he experienced an increase in pain level to the lumbar area, associated with alternating sciatic into the BLE. He described the pain as aching, numb, stabbing, nagging, sharp, and gnawing. The pain was worse when he got in and out of his car, saw clients, pushed shopping carts, and worked over his head. He reported flare-ups every time he had to turn to exit his vehicle, for which he did not take pain medication but rather went to sleep at the end of the day. He reported functional loss or impairment, specifically pain-limiting features in all distal muscles, although there was no objective evidence for pain. ROM testing revealed forward flexion to 65 degrees, extension to 15 degrees, right and left lateral flexion to 30 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 20 degrees. Pain was noted on examination and caused functional loss with flexion, right lateral rotation, and left lateral rotation. There was evidence of pain with weight-bearing and localized tenderness or pain on palpation. The examiner noted that the Veteran complained of great pain, although there was no increased pulse rate, elevated blood pressure, dilated pupil size, or heavy perspiration. There was no pain on passive ROM testing or with nonweight-bearing. There was no additional loss of function or ROM after three repetitions. The Veteran was being examined immediately after repetitive use over time, but the examiner was unable to say without resorting to mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time as the test was not performed over a prolonged period of time. The examination was not being conducted during a flare-up, and the examiner stated that the examination was medically inconsistent with the Veteran's statements describing functional loss during flare-ups. The examiner found that pain, weakness, fatigability, and incoordination did not significantly limit the functional ability with flare-ups. The Veteran had guarding that did not result in abnormal gait or abnormal spinal contour due to a rare myofascitic node in the paraspinal area of the sacral area. He had symptoms due to radiculopathy. The Veteran did not have any ankylosis or IVDS of the thoracolumbar spine. X-rays documented arthritis. The Veteran had a thoracic vertebral fracture with a loss of 50 percent or more of height. An MRI of the lumbar spine in February 2017 revealed persistent moderately severe central and lateral canal stenosis at L2-3 and L3-4 and an old compression fracture at L3. The examiner found that the Veteran's problem was a mechanical issue and would not likely make much improvement without surgical intervention since no known therapies, injections, or medications would be able to change the bony abnormalities in his spinal cord. A July 2017 private MRI of the lumbar spine revealed stable appearance of the probable old burst fracture deformity of the L3 with posterior retropulsion of the posterior aspect of the vertebral body resulting in central spinal stenosis unchanged from 2012, broad-based right lateral disc osteophyte complex at L3-4 resulting in marked right lateral recess and neural foraminal stenosis, moderate left neural foraminal stenosis at L2-3 from disc bulge, and milder degenerative changes in the lower lumbar spine. A November 2018 VA MRI of the lumbar spine revealed an old, healed compression fracture of L3 with retropulsion causing severe central canal stenosis, unchanged; annular bulging and facet arthropathy of L2-3 causing severe central stenosis, unchanged; and prominent right disc osteophyte at L3-4 causing moderate narrowing of the right lateral recess and severe narrowing of the right neural foramen, unchanged. In December 2018, the Veteran complained of lower back pain and leg pain. There were no new symptoms or weakness. He had no extension in the lumbosacral spine and limited flexion due to pain. He was assessed with low back pain greater than bilateral leg pain, lumbar DDD, lumbar spondylosis at all levels, lumbar stenosis at L2-3 and L3-4, old L3 vertebral body fracture, status post medial branch block with no help, thoracic spine facet arthropathy in lower levels, and peripheral polyneuropathy confirmed by EMG. An August 1, 2019, VA examination report reflects review of the Veteran's claims file and diagnoses of degenerative arthritis of the spine, spondylosis, spinal stenosis and lumbar DDD status post compression fracture of the L3. He also had diagnoses of lumbar radiculopathy of the BLE and sensory peripheral neuropathy. The examiner noted that the new diagnosis of lumbar radiculopathy of the BLE, spondylosis, and spinal stenosis were directly due to or related to the service-connected diagnosis. The spondylosis and spinal stenosis and lumbar DDD status post L3 compression fracture diagnoses encompass the degenerative changes of the bony spine and disc, which were directly related to the traumatic injury that caused the compression fracture of L3. He reported constant low back pain located in the center of the back and radiating across the hip bones, anterior thighs, and inside of his knees. He had intermittent increased pain occurring four to five times a month, lasting two to three days. The Veteran reported flare-ups where he could only be in a chair, which occurred four to five times a month and lasted two to three days. ROM testing revealed forward flexion to 45 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 30 degrees. As a result, he was unable to bend forward and touch his knees. Pain was noted on examination with forward flexion and caused functional loss. Passive ROM was not performed as it was not feasible to do so in a safe and reasonable manner. However, the examiner then noted that with passive ROM, pain was felt at 10 degrees of flexion and 5 degrees with extension with no report of pain with lateral flexion or rotation. He had pain with weight-bearing, and no localized tenderness or pain on palpation. Nonweight-bearing assessment was not applicable as there was no objective evidence of pain when the spine was in a nonweight-bearing position at rest. After three repetitions, he had forward flexion to 40 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 30 degrees. Pain and lack of endurance caused this functional loss. He was not being examined immediately after repetitive use over time, and the examiner found that the examiner was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner stated that he was not able to describe such functional loss in terms of ROM as he had no basis to offer additional losses of function or motion with repeated use over time after review of the record. The examination was not being conducted during a flare-up, and the examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-up. Pain and lack of endurance significantly limited functional ability with flare-ups with forward flexion to 20 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees, and right and left lateral rotation to 15 degrees. He had guarding that resulted in abnormal gait or abnormal spine contour. The Veteran had radiculopathy involving the femoral nerve that was moderate in severity bilaterally. He did not have ankylosis of the spine, or other neurologic abnormalities or findings. He had IVDS of the thoracolumbar spine but did not require bed rest prescribed by a physician and treatment by a physician in the past 12 months. X-rays documented arthritis, and no thoracic vertebral fracture with loss of 50 percent or more of height. Analysis Prior to August 1, 2019 During this time, the evidence does not demonstrate that a disability rating in excess of 10 percent is warranted. Specifically, the Veteran had guarding that did not result in abnormal gait or spinal contour. See April 2017 VA examination report. Additionally, he had a vertebral body fracture with a loss of 50 percent or more of the height. See 4/27/15 private MRI; August 2015 VA examination report; April 2017 VA examination report. Additionally, ROM testing revealed forward flexion of the thoracolumbar spine to 65 degrees. Although both the August 2017 and April 2017 VA examiners found extension limited to 15 degrees, December 2016 and December 2018 VA treatment records reflect no extension due to pain. Regardless, even if the Veteran was unable to extend his back due to pain, the combined ROM, assuming all other ROM measurements remained the same, was still greater than 120 degrees although not greater than 235 degrees, which warrants a 10 percent rating. The Board notes that the August 2015 VA examiner noted pain on examination with extension that caused functional loss, and that the April 2017 VA examiner found pain with flexion and right and left lateral rotation that caused functional loss. Any additional functional loss impacts the combined ROM. Unfortunately, neither examiner determined at which point pain began in any direction. However, the evidence, including the medical evidence and the Veteran's lay statements, does not demonstrate that flexion was so affected that it was limited to 30 to 60 degrees or that combined ROM was limited to less than 120 degrees at any point during the appeal period. As the evidence does not demonstrate any guarding or muscle spasm of the thoracolumbar spine that caused abnormal gait or spinal contour, flexion so limited that it was limited to 30 to 60 degrees, ROM so limited that the combined ROM was less than 120 degrees, or any ankylosis of the thoracolumbar spine, a 10 percent rating is appropriate. The Board acknowledges that the Veteran's service-connected low back disability causes pain. The presence of pain, as described by the Veteran, is certainly a component of his disability and is contemplated in the rating criteria. The Board finds that the rating assigned adequately portrays any functional impairment, pain, fatigue, weakness, and any flare-ups that the Veteran experienced as a consequence of his low back disability based on the current evidence. Accordingly, a 10 percent rating prior to August 1, 2019, is appropriate as it already encompasses the provisions of 38 C.F.R. §§ 4.40, 4.45, and the DeLuca considerations. Additionally, both VA examiners found that the Veteran did not have IVDS. Therefore, a rating in excess of 10 percent based on the Formula for Rating IVDS is not warranted. The Board acknowledges the Veteran's disagreement with the VA examiner's finding that the Veteran had no muscle spasms. However, based on the General Rating Formula, muscle spasms alone only result in a 10 percent rating. A 20 percent rating would require muscle spasms that were severe enough to result in an abnormal gait or abnormal spinal contour. There is no evidence of such in this case. Accordingly, the evidence does not demonstrate that a rating in excess of 10 percent is warranted prior to August 1, 2019. As of August 1, 2019 Based on a careful review of all of the evidence of record, the Board finds that a disability rating in excess of 40 percent as of August 1, 2019, for the Veteran's low back disability is not warranted. The evidence reflects forward flexion to 10 degrees with passive ROM after considering pain. The Board acknowledges that the August 2019 VA examiner found pain with forward flexion that caused functional loss. However, the examiner did not state at which point pain began. Regardless, a 40 percent rating is the highest rating possible based on limitation of flexion. Therefore, based on forward flexion of the thoracolumbar spine being 30 degrees or less, the Board finds that the 40 percent rating is proper. The Board acknowledges that impairment severe enough to warrant a 40 percent rating may not have occurred exactly on August 1, 2019. However, this is the first evidence indicating this level of severity. Therefore, a 40 percent rating is warranted as of August 1, 2019. In order to warrant a higher rating, the evidence must demonstrate unfavorable ankylosis of the entire thoracolumbar spine. However, there is no evidence that the Veteran has ankylosis, either favorable or unfavorable, of the thoracolumbar spine. In fact, the August 2019 VA examiner found that the Veteran did not have any type of ankylosis of the spine. Additionally, the evidence does not suggest the immobility of any joint as the Veteran could move to some degree in almost all directions, albeit in a limited manner. Additionally, the Board notes that the Veteran had IVDS of the thoracolumbar spine. Pursuant to the new version of the regulations, it does not appear that there was disc herniation with compression and/or irritation of the adjacent nerve root as needed under the new regulations. Therefore, application of DC 5242 appears to be appropriate, which ultimately would rate the Veteran's low back disability based on limitation of motion. However, the Board considers both the old and new versions to determine which would be more beneficial for the Veteran and thus also considers the Formula for Rating IVDS as well. However, the examiner found that the Veteran's IVDS did not require bed rest prescribed by a physician or treatment by a physician in the past 12 months for his IVDS. Therefore, a rating in excess of 40 percent based on the Formula for Rating IVDS is not warranted under the old version of the regulations. The Board acknowledges that the Veteran's service-connected low back disability causes pain. The presence of pain, as described by the Veteran, is certainly a component of his disability and is contemplated in the rating criteria. The Board finds that the rating assigned adequately portrays any functional impairment, pain, fatigue, weakness, and any flare-ups that the Veteran experienced as a consequence of his low back disability based on the current evidence. Accordingly, a 40 percent rating as of August 1, 2019, is appropriate as it already encompasses the provisions of 38 C.F.R. §§ 4.40, 4.45, and the DeLuca considerations. Based on a careful review of all of the evidence, the Board finds that the evidence does not demonstrate unfavorable ankylosis of the thoracolumbar spine or IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. Therefore, a disability rating in excess of 40 percent as of August 1, 2019, is not warranted for his low back disability. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. Other Considerations In addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The evidence reflects radiculopathy of the BLE, which is separately addressed below. The evidence also notes bowel and bladder disturbance, which is remanded below. The Veteran does not have any other neurologic impairment associated with his low back disability. Neither the Veteran nor his 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, 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). 2-3: Entitlement to initial ratings in excess of 20 percent for RLE radiculopathy and LLE radiculopathy As stated above, in addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Law In this case, the RO granted service connection for RLE radiculopathy and LLE radiculopathy and assigned 20 percent ratings under 38 C.F.R. § 4.124a, DC 8526 as of October 22, 2014, the date of receipt of the underlying low back disability claim. Under DC 8526 for disability of the anterior crural (femoral) nerve, for mild incomplete paralysis, a 10 percent rating is assigned. For moderate incomplete paralysis, a 20 percent rating is assigned. For severe incomplete paralysis, a 30 percent rating is assigned. Complete paralysis of the femoral nerve with paralysis of the quadriceps extensor muscles is rated as 40 percent disabling. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild or, at most, the moderate degree. Id. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." Sellers v. Wilkie, 30 Vet. App. 157 (2018) ("DC 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms"). 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. 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. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Evidence An April 2015 private MRI of the lumbar spine revealed, in part, moderate to marked right L3-L4 neural foraminal stenosis that could result in right L3 radiculopathy. A May 2015 private treatment record reflects a complaint of low back pain radiating to the BLE. He noted numbness into both of his feet and some weakness into his feet. He had weakness and decreased sensation in the bilateral feet. He had decreased sensation over the dorsum of the bilateral feet but otherwise intact sensation to light touch. He had +3 reflexes in the bilateral patella and +2 in the bilateral ankles. He was assessed with severe central canal spinal stenosis at L3, lumbar spine degeneration, chronic L3 compression fracture, neuralgia, and bilateral L5 radiculopathy. An August 2015 VA spine examination report reflects review of only STRs and VA treatment records and diagnoses of spondylosis of the thoracic and lumbar spine and vertebral fracture of the L3 in 1980. He had normal muscle strength with hip flexion and knee extension bilaterally and active movement against some resistance with ankle plantar flexion, ankle dorsiflexion, and great toe extension bilaterally. He did not have muscle atrophy. Deep tendon reflexes were normal at the knees and ankles. Sensation to light touch testing results were normal. Straight leg raising test results were negative bilaterally. The examiner found that the Veteran did not have radicular pain or any other symptoms due to radiculopathy. An August 2015 VA peripheral nerves examination report reflects review of the Veteran's STRs and VA treatment records. The examiner found that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. Deep tendon reflexes were normal bilaterally, sensation testing for light touch results were normal bilaterally, and all lower extremity nerves were normal bilaterally. An EMG study was normal for the BLE. An August 2015 VA treatment record notes that a recent EMG showed no radiculopathy. In his September 2015 NOD, the Veteran noted that his private treatment records reflect a history and examination consistent with BLE radiculopathy. He also reported radicular pain resulting from his back condition at the examination. A November 2015 VA treatment record reflects that his spinal stenosis had worsened over the past two years with pain in the low back that wrapped around anteriorly and down the legs. He had bilateral numbness and tingling of the legs and weakness. He fell about twice a week. He was assessed with chronic back pain. A February 2016 VA treatment record reflects chronic low back pain in the midline lumbar spine with radiation down his anterior and posterior legs to his feet. He started to fall more frequently and reported more weakness in his legs. An August 2015 EMG was normal. He had decreased sensory to light touch from the thighs distally. In May 2016, the Veteran reported low back and left leg pain with numbness and weakness in the right leg. The Veteran had to stop three times on the way to his appointment due to pain and had to get up and walk around to relieve the pain. He also reported that he fell recently when he stepped and his left knee gave out. In December 2016, the Veteran complained of low back pain in the midline lower back that radiated to the front of the thighs and then to the side of the legs, calves, and toes. He also complained of numbness in the entire leg with weakness. He had reduced strength throughout the lower extremities and impaired sensibility in the entire BLE compared to the upper extremities. He was assessed with low back pain that was greater than bilateral leg pain, lumbar DDD, lumbar spondylosis at all levels, lumbar stenosis at L2-3 and L3-4, and an old L3 vertebral body fractur., possible thoracic spine DDD, and radiculitis. In February 2017, the Veteran reported that he was usually awaken by back pain. He drove 50 hours every two weeks and had to stop every hour to get out of the car with his walker to get the stiffness out of his back and the numbness out of his legs as best as possible. An April 2017 VA back examination report reflects review of the Veteran's claims file and diagnoses of vertebral fracture at L3 and spinal stenosis at L2-3 and L3-4. The Veteran reported symptoms that were continually getting slightly worse. In the last year, he experienced an increase in pain level to the lumbar area, associated with alternating sciatic into the BLE. He described the pain as aching, numb, stabbing, nagging, sharp, and gnawing. The pain was worse when he got in and out of his car, saw clients, pushed shopping carts, and worked over his head. He also had an increase in the numbness in his feet and weakness. He also reported that he fell once or twice a week. The lack of sensation did not follow the physiological dermatome pathways. Sensation to the lower extremity decreased over the dorsum of the right foot but was intact on the sole on the right. On the left, absent sharp sensation circumferentially to the distal thigh dermatomes and L2-S2 dermatomes bilaterally. He had normal muscle strength bilaterally with no muscle atrophy. He had normal deep tendon reflexes in the left knee and right ankle, but reflexes that were hyperactive without clonus in the right knee and hypoactive in the left ankle. Sensation to light touch testing results were normal in the upper anterior thigh and thigh/knee bilaterally, but decreased in the lower leg/ankle and foot/toes bilaterally. However, the examiner noted that the decreased sensation of dermatomes was not consistent with anatomical dermatomes. Straight leg raising test results were negative bilaterally. He had symptoms due to radiculopathy, specifically mild intermittent pain bilaterally and mild numbness bilaterally. The examiner stated that the symptoms involved other nerves, specifically non-anatomical findings and that the right and left sides were not affected. An April 2017 VA peripheral nerves examination report reflects review of the Veteran's claims file and a diagnosis of bilateral lower limb sensory peripheral neuropathy. He reported constant pain in his midline lumbar spine with radiation down his anterior and posterior legs to his feet. The pain was worse with prolonged standing, walking, long car rides, and overactivity. It improved with leaning forward on a shopping cart and sitting. He reported that he started to fall more frequently and reported more weakness in his legs, as well as chronic abdominal wall pain. Symptoms attributable to any peripheral nerve condition included mild constant pain bilaterally, no intermittent pain bilaterally, moderate paresthesias and/or dysesthesias bilaterally, moderate numbness bilaterally. He had normal muscle strength bilaterally with no muscle atrophy. Deep tendon reflex examination results were normal in the left knee and right ankle, but was hyperactive without clonus in the right knee and hypoactive in the left ankle. Sensory examination results were normal in the upper anterior thigh and thigh/knee bilaterally, but decreased at the lower leg/ankle and foot/toes bilaterally. The examiner noted that decreased sensation of dermatomes was not consistent with anatomical dermatomes. Lower extremity nerves were all normal. An EMG study was abnormal for the BLE, indicating evidence of bilateral lower limb sensory peripheral neuropathy but no electrical evidence of left lumbar radiculopathy. A December 2018 VA treatment record reflects a complaint of lower back pain and leg pain, specifically constant dull pain radiating down to the thighs and knees with numbness and tingling in the lower legs. There were no new symptoms or new weakness. The EMG was abnormal indicating evidence of bilateral lower limb sensory peripheral neuropathy and no electrical evidence of left lumbar radiculopathy. He was assessed with low back pain greater than bilateral leg pain, lumbar DDD, lumbar spondylosis at all levels, lumbar stenosis at L2-3 and L3-4, old L3 vertebral body fracture, status post medial branch block with no help, thoracic spine facet arthropathy in lower levels, and peripheral polyneuropathy confirmed by EMG. An August 2019 VA back examination report reflects review of the Veteran's claims file and diagnoses of degenerative arthritis of the spine, spondylosis, spinal stenosis and lumbar DDD status post compression fracture of the L3. He also had diagnoses of lumbar radiculopathy of the BLE and sensory peripheral neuropathy. The examiner noted that the new diagnosis of lumbar radiculopathy of the BLE, spondylosis, and spinal stenosis were directly due to or related to the service-connected diagnosis. He was experiencing sensory symptoms, such as pain and numbness, radiating from the lower back into his anterior thighs and lower legs, which was considered lumbar radiculopathy and peripheral neuropathy. Both were directly related to his service-connected diagnosis of residuals of a compression fracture of L3. The spondylosis and spinal stenosis and lumbar DDD status post L3 compression fracture diagnoses encompass the degenerative changes of the bony spine and disc, which were directly related to the traumatic injury that caused the compression fracture of L3. He reported constant low back pain located in the center of the back and radiating across the hip bones, anterior thighs, and inside of his knees. He had intermittent increased pain occurring four to five times a month, lasting two to three days. He had active movement against some resistance with hip flexion, knee extension, ankle plantar flexion, and ankle dorsiflexion bilaterally and normal strength with great toe extension bilaterally with no muscle atrophy. He had hypoactive reflexes bilaterally at the knee and ankle. Sensation to light touch testing results were normal bilaterally except that it was decreased at the right foot/toes. Straight leg raising test results were negative bilaterally. The Veteran had symptoms due to radiculopathy including moderate constant pain bilaterally, mild paresthesias and/or dysesthesias bilaterally, and mild numbness bilaterally. The examiner stated that it involved the femoral nerve and was moderate in severity bilaterally. An August 2019 VA peripheral neuropathy examination report reflects review of the Veteran's claims file. The examiner stated that the Veteran had never been diagnosed with diabetic peripheral neuropathy, but reported pain in his anterior thighs and numbness below his knees, which began four years ago. The pain began in his lower back and radiated around to his anterior hips and then down the anterior thighs. He reported difficulty lifting things due to the increase in pain in his anterior thighs. Symptoms attributable to peripheral neuropathy included mild constant pain bilaterally, mild paresthesias and/or dysesthesias, and mild numbness bilaterally. He had less than normal strength bilateral with knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. He had decreased deep tendon reflexes bilaterally. Light touch/monofilament testing results were normal bilaterally except the right ankle/lower leg was decreased. He had normal position sense bilaterally. Vibration sensation and cold sensation were not tested. He did not have muscle atrophy or trophic changes. An April 2017 EMG study was abnormal bilaterally, demonstrating bilateral lower limb sensory peripheral neuropathy and no electrical evidence of left lumbar radiculopathy. The examiner explained that the Veteran did not have diabetic peripheral neuropathy but rather had two separate neurological conditions in his lower extremities. He had low back pain radiating into his anterior hips and thighs, which was considered lumbar radiculopathy. He also had sensory disruption as noted on the April 2017 EMG, which was considered a sensory peripheral neuropathy. Both the lumbar radiculopathy and sensory peripheral neuropathy were directly related to his service-connected spondylosis, spinal stenosis, and DDD status post compression fracture of the L3. Analysis As an initial matter, the Board notes that the claims for RLE and LLE radiculopathy were awarded service connection as of October 22, 2014. The effective dates appear to be based on the date of an informal claim received. As stated above, the effective dates are not addressed herein, but only the initial ratings will be discussed. As of October 22, 2014, the Board finds that the evidence demonstrates that the severity of the Veteran's RLE and LLE radiculopathy does not warrant initial ratings in excess of 20 percent. The Board notes that the evidence is conflicting as to whether the Veteran initially had any kind of radiculopathy or neuropathy. Although the August 2015 VA examiners found that the Veteran did not have radicular pain or any other symptoms due to radiculopathy, a peripheral nerve condition, or peripheral neuropathy; the evidence repeatedly refers to sensory involvement, described as weakness, numbness, tingling, and decreased sensation in the legs and/or feet. See 5/27/15 private treatment record; 11/25/15 VA treatment record; 12/23/16 VA treatment record. The April 2017 VA back examiner found symptoms due to radiculopathy, specifically mild intermittent pain and mild numbness bilaterally. However, the examiner then stated that the symptoms involved other nerves, and specifically referred to non-anatomical findings. The April 2017 VA peripheral nerves examiner finally noted a diagnosis of BLE sensory peripheral neuropathy with mild constant pain, moderate paresthesias and/or dysesthesias, and moderate numbness bilaterally. The August 2019 VA back examination report reflects diagnoses of lumbar radiculopathy of the BLE and sensory peripheral neuropathy, for which he was experiencing sensory symptoms, such as pain and numbness, radiating from the lower back to his anterior thighs and lower legs. His symptoms included moderate constant pain, mild paresthesias and/or dysesthesias, and mild numbness bilaterally. The examiner stated that the radiculopathy involved the femoral nerve and was moderate in severity bilaterally. Additionally, the Veteran had hyperactive reflexes without clonus in the right knee and hypoactive reflexes in the left ankle in April 2017, and hypoactive reflexes bilaterally at the knee and ankle in August 2019. In April 2017, sensation to light touch testing results were normal in the upper anterior thigh and thigh/knee bilaterally, but decreased in the lower leg/ankle and foot/toes bilaterally, although the decreased sensation of dermatomes was not consistent with anatomical dermatomes. In August 2019, sensation to light touch testing results were normal bilaterally except at the right foot/toes. Moreover, he had reduced muscle strength with hip flexion, knee extension, ankle plantar flexion, and ankle dorsiflexion bilaterally. After considering the totality of the evidence, the Board finds that the RLE and LLE radiculopathy, at its worst, most closely approximates moderate incomplete paralysis for the entire appeal period, which warrants a 20 percent rating. The evidence does not demonstrate that the severity of the RLE and/or LLE radiculopathy more closely approximates severe incomplete paralysis of the femoral nerve. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. REASONS FOR REMAND 1. Entitlement to a separate rating for a bowel and/or bladder disorder associated with the service-connected low back disability is remanded. As stated above, in addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Such neurological abnormalities include bowel and bladder disturbances. Evidence, specifically as to treatment for the Veteran's low back disability, include discussion of constipation, bladder infections, and urinary incontinence. See 5/27/15 private treatment record; 11/25/15 VA treatment record; 12/23/16 VA treatment record; 1/23/20 private treatment record. Unfortunately, none of the examiners addressed whether such bowel and bladder issues are related to the Veteran's service-connected low back disability. As such, this claim is remanded in order to obtain a VA addendum opinion to more completely and adequately address the manifestations of his service-connected low back disability, specifically any bowel and/or bladder disorders. The matter is REMANDED for the following actions: 1. Obtain an addendum by a VA examiner to address the nature and etiology of the Veteran's bowel and/or bladder disorder. If the designated examiner determines that an additional examination is necessary, one should be provided to the Veteran. After reviewing the claims file in its entirety, the examiner is asked to address the following with complete rationale: a) Identify any and all diagnoses involving the bowel and bladder and, if possible, the onset of such. *The examiner should address treatment records that refer to constipation, bladder infections, and urinary incontinence.* b) For each diagnosis, provide an opinion as to whether it at least as likely as not (50 percent or greater probability) is an objective neurological abnormality CAUSED by or PROXIMATELY RELATED to the Veteran's service-connected low back disability. c) For each diagnosis, provide an opinion as to whether it at least as likely as not (50 percent or greater probability) is an objective neurological abnormality AGGRAVATED by the Veteran's service-connected low back disability. Aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. The VA examiner must provide separate findings and rationales relating to causation and aggravation. A complete rationale should be provided for any opinion provided. 2. Thereafter, readjudicate the remanded claim on appeal. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Lee, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.