Citation Nr: 21073505 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 17-67 388 DATE: December 8, 2021 ORDER An initial disability rating in excess of 30 percent for right ulnar nerve neuropathy is denied. An initial disability rating in excess of 20 percent for left ulnar nerve neuropathy is denied. An initial disability rating in excess of 20 percent for degenerative joint disease (DJD) with intervertebral disc disease syndrome (IVDS) is denied. A disability rating of 20 percent for DJD with IVDS, effective from March 9, 2016, is granted. A disability rating for radiculopathy of the right femoral nerve in excess of 20 percent, beginning December 27, 2012, is denied. A disability rating for radiculopathy of the right femoral nerve of 20 percent, beginning December 27, 2012, until May 23, 2021, is granted. A disability rating for radiculopathy of the right femoral nerve in excess of 10 percent, beginning May 23, 2021, is denied. A disability rating for radiculopathy of the left femoral nerve in excess of 20 percent, beginning December 27, 2012, is denied. A disability rating of 20 percent for radiculopathy of the left femoral nerve, beginning December 27, 2012, until May 23, 2021, is granted. A disability rating in excess of 10 percent for radiculopathy of the left femoral nerve, beginning May 23, 2021, is denied. A compensable disability rating for sciatic nerve pain right lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom, is denied. A compensable disability rating for sciatic nerve pain left lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom, is denied. REMANDED Whether the severance of service connection for Lyme disease was proper. Service connection for unspecified arthritis as secondary to Lyme disease. Service connection for headaches. Service connection for a neck condition. Service connection for right shoulder arthritis. Service connection for left shoulder arthritis. Service connection for a right hand thumb/finger condition. Service connection for a left hand thumb/finger condition. Service connection for right hand arthritis. Service connection for left hand arthritis. Service connection for a right hip condition. Service connection for right knee arthritis. Service connection for left knee arthritis and meniscal tear. Service connection for right shin splints. Service connection for left shin splints. Service connection for a right ankle condition. Service connection for a left ankle condition. A disability rating in excess of 30 percent for folliculitis. A compensable disability rating for hypertension. A total disability rating based on individual unemployability due to service-connected disability (TDIU). An effective date prior to October 24, 2014, for the award of service connection for major depressive disorder (MDD) with anxious distress. An increased initial disability rating in excess of 50 percent for MDD with anxious distress. FINDINGS OF FACT 1. The Veteran's right ulnar nerve neuropathy and left ulnar nerve neuropathy has been manifested by no more than have moderate incomplete paralysis. 2. Throughout the appeal period, the Veteran's DJD with IVDS was manifested by no more than 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. 3. Radiculopathy of the right and left femoral nerve beginning March 9, 2016, was manifested by a moderate disability picture, but not higher, and was not manifested by more than a mild disability from May 23, 2021. 4. The Veteran's sciatic nerve pain left and right lower extremities prior to April 9, 2019, was manifested by negative findings, and no more than mild findings therefrom. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for right ulnar nerve neuropathy is denied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8514. 2. The criteria for a disability rating in excess of 20 percent for left ulnar nerve neuropathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8514. 3. The criteria for a disability rating in excess of 20 percent for DJD with IVDS are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, DC 5243. 4. The criteria for a disability rating of 20 percent for DJD with IVDS, beginning March 9, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, DC 5243. 5. The criteria for a disability rating for radiculopathy of the right femoral nerve in excess of 20 percent, beginning December 27, 2012, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8526. 6. The criteria for a disability rating of 20 percent for radiculopathy of the right femoral nerve, beginning March 9, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8514. 7. The criteria for a disability rating in excess of 10 percent for radiculopathy of the right femoral nerve, from May 23, 2021, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8514. 8. The criteria for a disability rating for radiculopathy of the left femoral nerve in excess of 20 percent, beginning December 27, 2012, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8526. 9. The criteria for a disability rating of 20 percent for radiculopathy of the left femoral nerve, beginning March 9, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8514. 10. The criteria for a disability rating in excess of 10 percent for radiculopathy of the left femoral nerve, beginning May 23, 2021, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8514. 11. The criteria for a compensable disability rating for sciatic nerve pain lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8520. 12. The criteria for a compensable disability rating for sciatic nerve pain lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1999 to October 2002. The case is on appeal from rating decisions issued in April 2015, May 2016, December 2017, and June 2021. The issues involving radiculopathy were previously characterized as service connection issues, including in the December 2017 statement of the case (SOC) from which the Veteran perfected his appeal of these issues. A December 2017 rating decision, however, had granted service connection for radiculopathy of the femoral nerves. A June 2021 rating decision then granted service connection for sciatic nerve pain of the right and left lower extremities. The Board takes jurisdiction of the increased rating issues as part and parcel of the increased rating claim for the lumbar spine. See 38 C.F.R. § 4.71(a), General Rating Formula for Disease and Injuries of the Spine, Note (1). See also Chavis v. McDonough, 34 Vet. App. 1, 17 (2021). The rating decision was issued in June 2021, which granted staged ratings for radiculopathies of the lower extremities secondary to the service-connected lumbar spine disability. This award did not resolve those issues. See AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Murphy v. Shinseki, 26 Vet. App. 510, 514 (2014). This includes the implied issues involving a compensable rating for sciatic nerve pain left and right lower extremity prior to April 9, 2019. In May 2019, the Veteran withdrew his request for a Board hearing. In July 2021, the Veteran's representative waived initial RO consideration of additional evidence received since the issues were last adjudicated by the agency of original jurisdiction (AOJ). See 38 C.F.R. § 20.1305(c). 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). Although the Board is remanding other claims for additional development, remand is not necessary for the decided issues, as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 1. A disability rating in excess of 30 percent for right ulnar nerve neuropathy is denied. 2. A disability rating in excess of 20 percent for left ulnar nerve neuropathy is denied. The Veteran is seeking a higher initial rating for right and left ulnar nerve neuropathy. The appeal period now before the Board begins on October 24, 2014, which is when service connection went into effect for the disabilities. See Fenderson v. West, 12 Vet. App. 119 (1999). The right arm has been assigned a 30 percent rating throughout the entire appeal period. The left arm has been assigned a 20 percent rating throughout the appeal period. A. Rating schedule The Veteran's disability has been assigned a disability rating under DC 8514 of 38 C.F.R. § 4.124a. The applicable rating schedule is set forth as follows: 8514 The musculospiral nerve (radial nerve) Paralysis of: Rating Major Minor 5200 Scapulohumeral articulation, ankylosis of: Complete; drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; can not extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity 70 60 Incomplete: Severe 50 40 Moderate 30 20 Mild 20 20 In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120; see also 38 C.F.R. § 4.123, 124. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Introductory Note. Combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. See 38 C.F.R. § 4.124, DC 8719, Note. B. Discussion The evidence, most recently a December 2017 VA examination, shows that the Veteran is right handed. Thus, the service-connected right arm is considered the dominant hand. The service-connected left arm is considered the nondominant hand. 38 C.F.R. § 4.69. Regarding impairment of motor functions, his strength was 5/5 at VA examinations in March 2015, March 2016, and at VA Neurology evaluations in August 2016. He complained to his VA primary care provider in October 2014 of weak grip in the left hand. His strength in the right hand was 4/5 at VA Neurology in December 2016. His strength was 5/5 at a September 2017 VA examination, except for grip, which was 4/5. Regarding sensory disturbance, the Veteran reported a tingling feel on the left hand in October 2014, plus decreased sensation. At the March 2015 VA examination, his sensation was absent in both upper extremities, except vibratory, which was normal. Sensation was decreased in the hands and fingers at the March 2016 and September 2017 VA examinations, a March 2016 electromyogram (EMG) test, and at VA Neurology in August 2016, December 2016, and February 2017. Regarding loss of reflexes, the March 2015 VA examination showed reflexes of 1+. In March 2016, reflexes in the right upper extremity were 0+ and in the left upper extremity 1+. At the September 2017 VA examination, they were again 1+. Regarding pain, the Veteran consistently reported pain beginning from the October 2014 VA primary care visit. The March 2015 VA examination assessed moderate constant pain. The March 2016 VA examination assessed mild constant pain and moderate intermittent pain in the left upper extremity. The September 2017 VA examination assessed moderate intermittent pain. The Veteran has also reported flares, such as at the March 2016 VA EMG and in an October 2017 testimonial statement, wherein he wrote that the pain increased sharply when using the hands when writing, holding a cup, using the telephone, driving, or trying to hold tools. Regarding muscle atrophy, a January 2017 VA evaluation found abductor digiti minimi atrophy on the left. Otherwise, the VA examinations and outpatient treatment consultations found no muscle atrophy. There were no trophic changes or complete paralysis, as demonstrated at these VA examinations and outpatient treatment visits. Overall, the March 2015 VA examination found him to have moderate incomplete paralysis. The March 2016 VA examination found mild incomplete paralysis. The September 2017 VA examination found moderate incomplete paralysis on the right and left. Based on the above, the Board finds that the disability was primarily manifested by impairment of motor functions, sensory disturbance, loss of reflexes, pain, and minimal muscle atrophy. The Board finds that this level of impairment is most analogous to a moderate incomplete paralysis involving symptoms described by the Veteran and medically graded as significantly disabling; combinations of significant sensory changes and reflex or motor changes of a lower degree; and motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. (The evidence, such as the March 2016 and September 2017 VA examinations, show symptoms in the median nerve, which is not service connected. Except where the symptomatology is expressly distinguished, the Board has considered all symptoms as attributable to the service-connected ulnar nerve.) In a January 2018 brief, the Veteran's representative argued that a September 2017 VA examination failed to accurately capture the severity of the condition. The representative noted, by way of example, that the Veteran had constant tingling and numbness in his digits made worse by basic activity such as bending the arm at the elbow or holding small objects. The representative argued that the examiner's conclusions were contradicted by a different examination done the same day. The Board finds that this VA examination is adequate. The examination captured the Veteran's complaints, including difficulty holding and working with tools. The examiner performed a complete clinical evaluation of the condition. To the extent the examiner's opinion was contradicted by a different examiner that same day, the opinion regarded the service connection question, not the severity of the disability. Moreover, the VA examiner's findings are in line with the other evaluations conducted in relative proximity to the examination, such as a February 2017 VA Neurology consultation. The Board finds no basis to discount the September 2017 VA examiner's findings or remand for a new examination. There are some symptoms not expressly contemplated by the rating schedule. For example, in October 2013, he complained of itching at night. On several occasions, such as in January 2015, he reported a tremor. The severity of the symptoms associated with this condition as set forth in the rating schedule, are contemplated along a broad and non-exclusive continuum beginning from a mild to severe degree of severity with a noncompensable rating moving toward more severe symptoms, expressed with generally terms such as "mild" or "severe" and other requisite criteria for a compensable schedular rating. See Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018). Therefore, the rating schedule was purposely designed to compensate for all symptoms of his disability, and the complete and comprehensive signs and symptoms of the Veteran's condition are contemplated by the rating schedule. Because DC 8514 lacks any objective criteria, any evidence indicating severity of the disability, including its functional effects, is necessarily relevant to the schedular rating level. Id. at 218-19. Thus, the Veteran's complaints and functional effects of his disability are reasonably, even if not expressly, contemplated by his current rating. He has not otherwise indicated any interference with employment beyond the considerable loss of working time already contemplated by his 30 and 20 percent ratings, or frequent periods of hospitalization. In conclusion, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Accordingly, higher ratings are not warranted. 3. An initial disability rating in excess of 20 percent for DJD with IVDS prior to March 9, 2016, and in excess of 10 percent therefrom. The Veteran is seeking a higher initial rating for his service-connected degenerative joint disease with intervertebral disc disease syndrome (herein after "lumbar spine disability"). The appeal period now before the Board begins on December 27, 2012, which is when service connection went into effect for this condition. See Fenderson, 12 Vet. App. at 119. This disability has been assigned staged ratings as follows: 20 percent from December 27, 2012, and 10 percent rating beginning from March 9, 2016. In a January 2018 brief, the Veteran's representative argued that the Veteran was seeking restoration of the 20 percent rating from March 9, 2016, because a December 2017 rating decision improperly reduced the rating retroactively to 10 percent as of March 9, 2016. The representative argued that the reduction was improper as the notice for the proposed action was not followed, and the evidence did not show an improvement under the ordinary conditions of life and work. The representative pointed to a September 2017 VA examination showing pain causing functional loss. The representative also argued that an extraschedular rating is warranted as the back pain resulted in severe functional limitations and was the primary hindrance to gainful employment for a decade. The Board finds that the reduction issue is not on appeal. The Veteran did not file a notice of disagreement (NOD) with the December 2017 rating decision reducing the rating to 10 percent. The Board will nonetheless address whether a rating higher than 10 percent is warranted since that time. A. Applicable Law The Veteran's spine disability has been assigned a disability rating under DC 5242 of 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The applicable rating schedule is as follows: The Spine Rating General Rating Formula for Diseases and Injuries of the Spine (For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes): With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine 100 Unfavorable ankylosis of the entire thoracolumbar spine 50 Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine 40 Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis 20 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 10 Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) 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 range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Disabilities of the spine involving IVDS are assigned under DC 5243, which provides that the disability is to be rated either under the General Rating Formula or alternatively under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in a higher evaluation. See 38 C.F.R. § 4.71a, Note. For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See id. at Note (1). Effective February 7, 2021, the DCs pertaining to the lumbar spine were amended. For purposes of this decision, the applicable rating criteria for those DCs did not materially change. See 85 Fed. Reg. 76453 (Nov. 30, 2020, as corrected). 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); 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). B. Discussion 20 percent rating from December 27, 2012 The Board acknowledges the Veteran's lay reports of symptoms and functional loss. For example, at a VA Orthopedics evaluation in January 2012, he reported discomfort and tightness in the back. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. At a January 2012 VA Orthopedics consultation, the Veteran had flexion with pain starting at 60 degrees. At a March 2015 VA examination, he had limitation of flexion to 40 degrees. There was no ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. However, the Veteran did not have prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. The VA medical records do not reflect any prescribed bed rest, and the March 2015 VA examination found this to be absent. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability (apart from the radiculopathies already service-connected). The March 2015 VA examination marked this as absent, and the VA medical records do not indicate such symptomatology. Based on the foregoing, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent from December 27, 2012, to March 9, 2016. 10 percent rating beginning from March 9, 2016 The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss. In an October 2017 statement, he reported worsening pain over the years. He hurt every day. He had more problems with flexibility and lifting. His back would lock up if he sat too long, and he could not straighten it out when he stood up. The changing seasons very often caused flare-ups, or too much physical activity or being on his feet too much. He could only sit for 10 to 15 minutes, and he would lie down as much as he could. The least painful position was standing and leaning on something, but only for about 10 minutes until he needed to sit back down. He could walk about 10 minutes. At a March 2016 VA examination, he had flexion to 90 degrees and a combined range of motion of 225 degrees. He had guarding and muscle spasm, but not resulting in abnormal gait or abnormal spinal contour. A September 2017 VA examination found flexion to 70 degrees and a combined range of motion of 210 degrees. An October 2019 VA examination found flexion to 60 degrees and a combined range of motion of 110 degrees. A December 2020 VA examination found flexion at worst to 40 degrees and a combined range of motion of 115 degrees. A May 2021 VA examination found flexion at worst to 40 degrees with a combined range of motion of 90 degrees. The examiner found muscle spasm resulting in abnormal gait or abnormal spine contour. At VA Rheumatology consultations from January 2018 through January 2021, he was found to have full range of motion. This evidence presents some conflicting information as to the degree of limited motion. The VA examinations in March 2016 and September 2017, plus the VA Rheumatology consultations did not indicate a 20 percent disability level. The October 2019, December 2020, and May 2021 VA examinations, by comparison, did indicate a 20 percent disability level. By extending him the benefit of the doubt, the Board finds that the 20 percent disability level has been more nearly approximated. The next higher, 40 percent disability level, is not more nearly approximated as this evidence shows that his forward flexion of the thoracolumbar spine was greater than 30 degrees. This same evidence also shows that favorable ankylosis of the entire thoracolumbar spine was absent. The May 2021 VA examination indicated IVDS with episodes of bed rest having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, which would correspond with a 40 percent rating. However, the basis for this conclusion is unclear as the VA medical records do not indicate prescribed bed rest. To this end, the VA medical records appear complete, and there is no indication of outside treatment for the lumbar spine during this time period. Hence, it is assumed that prescribed bed rest would be documented in the VA medical records if such had occurred. Because there is no documented bed rest, there is no evidentiary foundation to find prescribe bed rest as indicated by the VA examiner. See Delrio v. Wilkie, 32 Vet. App. 232, 241 (2019); See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015); Horn v. Shinseki, 25 Vet. App. 231, 239 n.7 (2012); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). The Veteran's representative argued that an extraschedular rating is warranted based on the severity of the condition and the impact on his daily life. The Board finds to the contrary. Comparison of the Veteran's symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The record shows that he has complaints and findings of pain with corresponding functional limitations. VA Rheumatology consultations in May 2019 through January 2021 indicate back pain waking him up at night. For all musculoskeletal disabilities, the Rating Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the Rating Schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. The Board finds that waking up at night is a functional impact analogous to those enumerated in the rating schedule. Otherwise, the disability picture described does not indicate an exceptional or unusual disability picture beyond that described by the rating schedule. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran's disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. For the foregoing reasons, a 20 percent rating is more nearly approximated throughout the appeal period; the preponderance of the evidence is against a rating in excess of 20 percent. As such, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Thus, even higher ratings are not warranted. 4. A disability rating for radiculopathy of the right femoral nerve in excess of 20 percent beginning December 27, 2012, in excess of zero percent beginning March 9, 2016, and in excess of 10 percent for May 23, 2021. 5. A rating for radiculopathy of the left femoral nerve in excess of 20 percent beginning December 27, 2012, in excess of zero percent beginning March 9, 2016, and in excess of 10 percent for May 23, 2021. 6. A compensable disability rating for sciatic nerve pain lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom. 7. A compensable disability rating for sciatic nerve pain lower extremity prior to April 9, 2019, and in excess of 10 percent therefrom. The Veteran is service-connected for radiculopathy of the femoral and sciatic nerves associated with the service-connected lumbar spine disability. Pursuant to the rating schedule, these disabilities are part and parcel of the appeal raised for the lumbar spine disability. Hence, the same appeal period beginning December 27, 2012 applies. To this end, the radiculopathies have been assigned various staged ratings. The Board will address these issues together as the evidence overlaps. A. Rating Schedule The Veteran's sciatic nerve pain has been assigned a disability rating under DC 8520 of 38 C.F.R. § 4.124a. The applicable rating schedule is set forth as follows: 8520 Paralysis of: Complete; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost 80 Incomplete: Severe, with marked muscular atrophy 60 Moderately severe 40 Moderate 20 Mild 10 8620 Neuritis. 8720 Neuralgia. Anterior crural nerve (femoral) 8526 Paralysis of: Complete; paralysis of quadriceps extensor muscles 40 Incomplete: Severe 30 Moderate 20 Mild 10 8626 Neuritis. 8726 Neuralgia. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120; see also 38 C.F.R. § 4.123, 124. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Introductory Note. Combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. See 38 C.F.R. § 4.124, DC 8719, Note. B. Discussion Regarding the femoral nerves, a disability rating higher than 20 percent beginning December 27, 2012, to March 9, 2016, is not warranted. An August 2014 VA Orthopedic evaluation indicated numbness to the left thigh. Reflexes were 1+. He had strength 5/5 on evaluation at VA in January 2015 with decreased sensation in the left 5th toe. A March 2015 VA examination found femoral involvement medically graded as moderate. At a March 2015 VA examination, he had strength 5/5, reflexes 1+, and normal sensation. The examiner found involvement of the femoral nerve medically graded as moderate. At his VA primary care provider in April l2015, he again had reflexes of 1+; he also had weakness. This evidence is consistent with a moderate disability picture involving symptoms described by the Veteran and medically graded as significantly disabling, plus combinations of significant sensory changes and reflex or motor changes of a lower degree and motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. Hence, a rating higher than 20 percent is not supported. From March 9, 2016, when a noncompensable was assigned for femoral involvement, the Board finds that the prior 20 percent disability level continued to manifest. A March 2016 VA examination found strength 5/5; reflexes were zero at the knee, but otherwise 1+ throughout; and sensation was normal. The examiner found no radicular signs or symptoms. An August 2016 VA Neurology consultation indicated strength 5/5, but reflexes 1+ at the ankles with slight reduction in sensation; the diagnosis was chronic lumbar radiculopathy. A December 2016 VA Neurology follow-up consultation indicated similar findings, plus diminished strength involving decreased bulk at the right hypothenar prominence. A February 2017 VA Neurology consultation reflected similar findings except that reflexes were 2+. A September 2017 VA examination found strength 5/5; reflexes 1+; and no sensory deficit, which the examiner interpreted as no signs or symptoms due to radiculopathy. An October 2019 VA examination found moderate involvement of the sciatic nerve but no indication of involvement of the femoral nerve. A December 2020 VA examination found moderate involvement of the femoral nerve. This evidence tends to show a disability picture materially the same as that prior to March 9, 2016, indicating a 20 percent disability picture. From May 23, 2021, when a 10 percent rating was in effect, a May 2021 VA spine examination showed decreased sensation with moderate signs and symptoms of radiculopathy, including pain and numbness. A May 2021 VA Peripheral Nerves examination found strength 5/5; reflexes 2+; and sensation decreased. The examiner graded the femoral involvement as medically mild. This evidence indicates a disability picture involving minimal symptoms with slight or no reflex or motor deficits. Hence, it is consistent with the current 10 percent rating. Regarding the sciatic nerve involvement prior to April 9, 2019, when a compensable rating had not yet been assigned, the March 2015 VA examination found normal sciatic nerves. The September 2017 VA examination also provides no indication of sciatic nerve involvement. There is an indication of sciatic nerve shown at an October 2019 VA examination, which found moderate involvement of the sciatic nerve. Sensation was decreased, strength was 5/5, and reflexes were absent. There was moderate intermittent pain and mild other symptoms. A December 2020 VA examination, by comparison, found no involvement of the sciatic nerve. The Board finds that a compensable rating is not assignable based on this evidence. Although the October 2019 VA examination indicated sciatic nerve involvement, this appears to have been a typographical error. The examiner's ultimate diagnosis was femoral nerve radiculopathy. This is consistent with the other contemporaneous evidence indicating femoral nerve involvement, but negative sciatic nerve involvement until May 23, 2021. Beginning May 23, 2021, when a 10 percent rating became effective, a May 23, 2021 VA examination indicated symptoms involving moderate constant pain and severe parestheasia/dysesthesias and numbness. The Veteran had strength 5/5, reflexes 2+, and decreased sensation. He also had some weakness in the legs on walking, tending to drag his feet. The examiner graded the sciatic nerve involvement as medically mild. This evidence indicates a disability picture involving minimal symptoms with slight or no reflex or motor deficits. Although the Veteran reported dragging his feet, this was not supported by the objective medical findings. Hence, his own statements are according limited credibility. Overall, this evidence is consistent with the current 10 percent rating. Based upon the evidence in this case, the earliest that that it can be factually ascertained that the Veteran met the criteria for a percent rating is May 23, 2021, the date he was examined by VA. Based on the foregoing, a 20 percent rating for femoral nerve involvement is warranted from March 9, 2016, to May 22, 2021. Otherwise, the preponderance of the evidence is against even higher ratings. REASONS FOR REMAND 1. Whether the severance of service connection for Lyme disease was proper. This issue is remanded to attempt to obtain missing service treatment records (STRs). Service connection for this disability was granted in a December 2002 rating decision. The RO determined that service connection was established as directly related to service. The RO cited STRs in April 2002 showing a diagnosis of the condition with a history of the condition being mentioned numerous times in the STRs without specific residuals identified. In September 2017, the RO proposed to sever service connection. The RO concluded that there had been a clear and unmistakable error in the grant of service connection because a March 2016 VA examiner concluded that the Veteran did not have, and had not ever been diagnosed with, Lyme disease and the grant of service connection was clearly and unmistakably erroneous. The RO also cited a September 2017 VA opinion, which also concluded that the initial diagnosis of Lyme disease was erroneous as he did not have Lyme disease. On this basis, the RO concluded that the grant was in error as he was not diagnosed with Lyme disease. In a December 2017 rating decision, the RO made the severance final as of March 1, 2018. The RO reiterated the reasons set forth in the September 2017 proposed action. At present, the collective medical evidence indicates that the initial diagnosis of Lyme disease was in error. The Veteran was worked-up for the condition after service from April 2011 through July 2011, when the laboratory test results indicated positive Lyme disease. On further work-up in October 2011 with an Infectious Disease specialist, however, the finding was that the symptoms were not consistent with Lyme disease and the earlier positive test results were likely due to latent syphilis. On follow-up in November 2011, it was unequivocally stated that he did not have Lyme disease. In January 2012, he had negative Lyme disease titers, and again in August 2014 it was noted that a Lyme disease test was negative. VA examiners in March 2016 and September 2017 likewise concluded that the Veteran did not have Lyme disease. The examiners relied on the post-service medical records. What remains missing are the STRs showing the initial onset and diagnosis for Lyme disease. The available STRs refer to the positive diagnosis of Lyme disease, but they do not contain the actual presenting symptoms or work-up for the disease. To this end, it is not clear at present that the RO made all necessary efforts to attempt to obtain these STRs or that any further attempts would be futile. Remand is therefore needed on this basis. Upon receiving the STRs, a new VA opinion would be warranted to comprehensively review the record. 2. Service connection for unspecified arthritis as secondary to Lyme disease. 3. Service connection for headaches. 4. Service connection for a neck condition. 5. Service connection for right shoulder arthritis. 6. Service connection for left shoulder arthritis. 7. Service connection for a right hand thumb/finger condition. 8. Service connection for a left hand thumb/finger condition. 9. Service connection for right hand arthritis. 10. Service connection for left hand arthritis. 11. Service connection for a right hip condition. 12. Service connection for right knee arthritis. 13. Service connection for left knee arthritis and meniscal tear. 14. Service connection for right shin splints. 15. Service connection for left shin splints. 16. Service connection for a right ankle condition. 17. Service connection for a left ankle condition. The Veteran contends that he has arthritis and joint conditions due to service or related to Lyme disease. The STRs tend to show complaints corresponding to these claims. For example, he complained in January 2000 of his shins. In May 2000, he complained of bilateral shins and left knee. In July 2000, he complained of pain in his legs and knees. In a July 2000 respirator use questionnaire, he endorsed weakness in his arms, hands, legs or feet. In an October 2000 medical history questionnaire, he endorsed bone, joint, or muscle problems noted as "just in knees." In November 2000, he complained of right hip pain starting after physical therapy. In November 2000, he was seen for right wrist sprain after falling when his hip gave out. In May 2001, he was noted to have chronic cervical sprain/strain. In June 2001, he was in physical therapy with improved upper back and neck (plus low back). He also gave a positive history of hip/back pain, lower leg, ankle, shin pain, and forearm/wrist pain. In July 2001, he was seen for right wrist and forearm pain of 8 months related to his earlier fall. In September 2001, it was noted he hurt his right arm. In December 2001, he was again seen for right hip and hand pain. In January 2002, he was seen for bilateral knee pain diagnosed as patellofemoral syndrome. A July 2002 medical history screening indicated positive foot pain (including ankle and heel); frequent or severe joint stiffness, pain, swelling; leg cramps; muscle weakness, pain or tenderness; knee pain; shoulder pain; neck stiffness; tremor or shaking of hands or head starting about a year ago; and numbness or pain in hands and fingers at night. An August 2002 dental consultation noted a diagnosis of Lyme disease in April of that year, but a prior history of arthralgias for 1 year. A September 2002 dental consultation noted diagnoses of chronic arthralgias and chronic right hip pain. He again gave a positive history in September 2002 of swollen painful joints; frequent/severe headaches; cramps in legs; painful/trick shoulder or elbow; no arthritis, no bone/joint/other deformity; no trick/locked knee; and no foot trouble. The summary was chronic arthralgias; chronic right hip pain; cephalgia - controlled by Tylenol; leg cramps; bilateral patellofemoral syndrome with brace for knees. An October 2002 separation examination was normal. After service, as indicated, he was found to not have Lyme disease. According to a January 2018 VA Rheumatology consultation, he most likely had a diagnosis of rheumatoid arthritis. On follow-up in May 2019, it was noted he had HLAB27+ peripheral spondyloarthritis affecting MCPS, PIP , DIP joints bilaterally as well as bilateral ankles/enthesitis of the achilles tendon. This same diagnosis was carried forward since that time. Regarding the joints, a VA examination in March 2015 diagnosed degenerative joint disease and/or degenerative disc disease of the cervical spine; acromioclavicular joint osteoarthritis of the shoulders; degenerative arthritis of the hand/fingers and osteoarthritis of the wrist; right hip osteoarthritis; degenerative joint disease of the knees and meniscal tear of the left knee; bilateral shin splits; and no diagnosis involving the ankles. Regarding headaches, the examiner diagnosed migraine including migraine variants. The examiner gave a negative opinion for all of the diagnosed conditions. The Board finds that the VA examination is not entirely adequate. First, the examiner generally found a "lack of available documentation to support a nexus." Regarding shin splints, the examiner found no continuity of symptomatology. The examiner reasoned that bilateral shin splint symptoms complained of 15 years later cannot reasonably be connected to service when there were multiple other aging/occupational/daily activity factors in the intervening years. Regarding the ankle, the examiner found no diagnosis, but even if there were a diagnosis the examiner found "no documentation to support a nexus." Regarding headaches, the examiner found no diagnosis or treatment for chronic headaches while in the service with the only mention of headaches being in the separation report of medical history. This VA examiner impermissibly relied on an absence of documented evidence of an injury or symptoms during and after service without explaining why, as a medical matter, the Veteran would have sought treatment or complained of the condition during service, or why an absence of treatment (as opposed to symptoms) was otherwise medically significant. See, McKinney v. McDonald, 28 Vet. App. 15, 30 (2016); Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015); Buczynski v. Shinseki, 24 Vet. App. 221, 223-24 (2011). With regard to the ankles, the examiner also did not account for the pain alone and whether it reached the level of a functional impairment. See Saunders v. Wilkie, 886 F.3d 1356, 1362 (Fed. Cir. 2018); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020) (Saunders applies to any condition that results in "functional impairment of earning capacity," not just pain). Thus, the Board finds that a new opinion is warranted. 18. A disability rating in excess of 30 percent for folliculitis. The Veteran last underwent a VA examination in October 2017. This examination does not fully address the rating criteria pertaining to the skin as it is not clear if the Veteran's medication fits the definition of a systemic therapy. See Burton v. Wilkie, 30 Vet. App. 286, 291-92 (2018); Johnson v. Shulkin, 862 F.3d 1351, 1355-56 (Fed. Cir. 2017). His VA medical records show consistent and ongoing treatment with various medications, including doxycycline, isotretinoin, ketoconazole shampoo, clindamycin swabs, and ILTAC. See, e.g., September 2019, March 2020 VA Dermatology. Likewise, unretouched color photographs were not taken, as required by the rating schedule. Thus, a new VA examination is warranted. 19. A compensable rating for hypertension. This issue is remanded to attempt to obtain missing STRs. A 10 percent rating may be assigned for hypertension if there is a history of diastolic pressure predominantly 100 or more and requires continuous medication for control. The Veteran's STRs show that he was prescribed medication for the condition. The available STRs do not contain the medical records pertaining to the initial diagnosis and reason for medication for hypertension. These medical records are needed to fully evaluate the condition. 20. A TDIU. Of note, the VA medical records show that the Veteran has been gainfully employed throughout the appeal period beginning from approximately November or December 2017. The Veteran's representative argued in a January 2018 brief that this employment represented only a three-four month stretch of work that cannot be considered stabilized enough to be deemed a successful attempt to return to the workforce. The most recent VA medical records from May 2021, however, show continued full-time employment in this same position. The Veteran has not argued that this is a protected work environment or similar workplace. Because he has not withdrawn his claim, it is therefore assumed that he is essentially claiming TDIU prior to when he started working full time employment. To the extent the remanded matters may develop evidence relevant to this issue, the matters are intertwined. 21. An effective date prior to October 24, 2014, for the award of service connection for MDD with anxious distress. 22. An increased initial disability rating in excess of 50 percent for MDD with anxious distress. Issues 21-22 must be remanded for issuance of an SOC. Service connection was granted in a December 2017 rating decision. The Veteran filed an NOD in March 2018 disagreeing with the effective date and rating assigned. At present, an SOC has not been issued. Under such circumstances, the Board shall remand this claim to the RO with instructions to prepare and issue an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Obtain the Veteran's complete STRs, including those pertaining to the initial work-up for Lyme disease and hypertension. 2. If additional STRs are obtained pertaining to Lyme disease, obtain an opinion from an appropriate clinician. An in-person examination of the Veteran should be arranged if determined necessary by the appointed examiner. (a.) The examiner is asked to address whether the Veteran now has or ever had a disease of Lyme disease. If not, the examiner should explain the erroneous basis for the prior diagnosis. (b.) If so deemed, the examiner should certify that, in the light of all accumulated evidence, the initial Lyme disease diagnosis was clearly erroneous. If this certification cannot be made, it should be explained why. 3. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the claimed headaches, neck, shoulder, hand, thumb/fingers, right hip, knee, shin splint, ankle, and arthritis conditions. The examiner is asked to address each of the following: (a.) Does the Veteran have a current diagnosis corresponding to the claimed headaches, neck, shoulder, hand, thumb/fingers, right hip, knee, shin splint, ankle, and arthritis conditions? The examiner must provide a diagnosis for any conditions found extant. In doing so, the examiner must conduct all necessary diagnostic testing, unless it can be explained why such testing is not medically necessary. If a current diagnosis is not present, does the Veteran nevertheless have symptoms, such as pain, causing a functional impairment in the affected joints? (b.) If any condition is diagnosed or if there has been a functional impairment present, opine whether such condition is at least as likely as not related to an in-service injury, event, or disease. (c.) Whether the current conditionor functional impairmentis at least as likely as not (1) proximately due to a different medical condition, or (2) aggravated beyond its natural progression by a different medical condition. If so, the examiner is asked to identify the primary medical condition. 4. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to assess the severity of his service-connected skin conditions. (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (b.) For any medication taken, the examiner must identify (1) whether it is a systemic therapy (including a topical medication that affects the entire body as a whole in its treatment of the skin condition), and (2) whether it is, or is like, a corticosteroid or immunosuppressive drug. (c.) If any medication is not equivalent, it should be explained why this is so. (d.) Unretouched color photographs must be taken. 5. Issue the Veteran an SOC with respect to the appealed involving an earlier effective date and increased initial rating for MDD. This issuance should include notification of the need to timely file a substantive appeal to perfect an appeal on the issues. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Bosely, 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.