Citation Nr: 21074419 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-38 856 DATE: December 15, 2021 ORDER Entitlement to a rating in excess of 20 percent for lumbosacral strain/degenerative arthritis of the spine/disc displacement (back disability) is denied. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity (LLE) is denied. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the right lower extremity (LLE) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU), including on an extraschedular basis, is remanded. FINDINGS OF FACT 1. The Veteran's back disability did not manifest forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. 2. As of March 14, 2014, but no earlier, the Veteran's back disability is manifested by radiculopathy of the LLE that resulted in no more than incomplete paralysis of the sciatic nerve. 3. As of March 14, 2014, but no earlier, the Veteran's back disability is manifested by radiculopathy of the RLE that resulted in no more than incomplete paralysis of the sciatic nerve. 3. For the entire appeal period, the Veteran's service-connected disabilities did not render him unable to secure or follow a substantially gainful occupation consistent with his education and work history. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for lumbosacral strain/degenerative arthritis of the spine/disc displacement have not been met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1, 4.2., 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 2. The criteria for an initial rating in excess of 10 percent for radiculopathy of the LLE, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.120, 4.124a, DC 8520. 3. The criteria for an initial rating in excess of 10 percent for radiculopathy of the RLE, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.120, 4.124a, DC 8720. 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1968 to March 1970. The AOJ's October 2014 rating decision, on appeal, partially increased the Veteran's back disability from 10 to 20 percent, effective March 14, 2014 (date of claim) and granted separate compensable ratings for associated radiculopathies of the left and right lower extremities, respectively, at 10 percent for each side, also effective March 14, 2014. The Veteran has appealed for increased ratings. In March 2019, the Veteran testified at a Board hearing before a Veterans Law who is no longer employed by the Board. A transcript of the hearing is associated with the record. In November 2020, the Veteran was notified that the Veterans Law Judge who conducted the hearing was no longer employed by the Board. He was provided a 30-day period to notify the Board whether he desired another hearing before a Veterans Law Judge who would decide his case. He was further informed that, if he did not respond within 30 days, the Board will assume that he did not want another hearing and proceed accordingly. The Veteran has not responded and, therefore, the Board will presume that he does not want another hearing and proceed with the adjudication of his appeal. Further, at the Veteran's March 2019 Board hearing and documents of record, he alleged that his service-connected disabilities render him unemployable. Therefore, the Board has assumed jurisdiction over the issue of entitlement to a TDIU as part and parcel of the Veteran's increased claims. Rice v. Shinseki, 22 Vet. App. 447 (2009). In June 2019 and March 2021, the case was remanded for additional development, and now returns for further appellate review. Increased Rating Claims 1. Entitlement to a rating in excess of 20 percent for a back disability. At the Veteran's, he testified to excruciating pain and muscle spasms from his back disability, as well as radiating pain, such that he has limited ability to walk and pick up anything, such as groceries. See March 2019 Board hearing, at 2-3, 5. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The appeal period before the Board for the Veteran's increased rating claim begins on March 14, 2014, the date VA received his claim for an increased rating, plus the one-year look-back period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Veteran's back disability is rated as 20 percent disabling pursuant to DC 5242, which provides that degenerative arthritis is evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). While portions of the rating schedule addressing the musculoskeletal system were revised as of February 7, 2021, such amendments do not affect the criteria pertaining to the evaluation of the Veteran's back disability. Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. The General Rating Formula also includes the following notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and 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. IVDS may be evaluated under either the General Rating Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Rating Formula), whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.25 (combined ratings table). The IVDS Rating Formula provides that a 10 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he has IVDS with incapacitating episodes as defined by VA regulations. In this regard, October 2014, March 2019, and June 2021 VA examinations found that the Veteran did not have IVDS. Therefore, a higher rating under the IVDS Rating Formula is not warranted at any point pertinent to the appeal. Turning to the evidence of record, at his October 2014 VA examination, the Veteran reported pain that worsened with radiation to his lower extremities, with flare-ups that caused him to stay in bed. He further reported he was unable to stand or walk for more than 5 minutes and was unable to bend over. Upon physical examination, his posture, gait, and spinal contour were normal, but there was evidence of muscle spasms. Range of motion (ROM) of the lumbar spine was to 60 degrees of flexion and a combined ROM of the thoracolumbar spine to 130 degrees with pain, to include on weight-bearing. Following repetitive use testing, there was no additional degrees in which he was limited. The examiner stated the Veteran's pain, fatigability, and loss of motion will worsen and significantly impact functional ability during flare-ups or when the joint is used repeatedly over time. However, the examiner stated it was not feasible to comment on specific degrees of lost motion during flare-ups or after the joint is used repeatedly over time without mere speculation. The examiner specifically found no ankylosis and no other neurologic abnormalities. At a March 2019 VA examination, the Veteran reported being in pain 90 percent of the time in the lumbar spine region, with a sharp pain in the spine that radiates into the legs. He further reported his pain is worse when walking or trying to lift heavy things, and has a hard time picking up grocery bags, walking, standing, and is unable to run. ROM testing revealed flexion to 80 degrees and a combined ROM of the thoracolumbar spine to 200 degrees with pain, to include on weight-bearing. There was no additional loss of ROM following repetitive use testing and, while the examination was not conducted following repeated use over time or during a flare-up, the examiner opined that there would be additional functional loss to 75 degrees of flexion and a combined ROM of the thoracolumbar spine to 170 degrees. Nonetheless, he noted that the Veteran could potentially have additional functional limitations or decreased ROM during flare-ups, but an examiner would need to be present at such time to measure any changes. Further, the Veteran did not have guarding or muscle spasm of the thoracolumbar spine. The examiner specifically found no ankylosis and no other neurologic abnormalities. At his most recent VA examination in June 2021, the Veteran reported worsening severe pain in his lower back, with intermittent sharp pain, and occasional lower extremity radicular symptoms. He stated he had difficulty with squatting, prolonged standing, and bending. However, he denied flare-ups. ROM revealed flexion to 75 degrees and a combined ROM of the thoracolumbar spine to 220 degrees, including consideration of pain on exam, but no additional loss of ROM following repetitive use testing. The examiner specifically found no ankylosis, no IVDS, and no other neurologic abnormalities. The remainder of the medical evidence of record, which reflects treatment for low back pain, does not reflect specific ROM findings or reflect that the Veteran has favorable or unfavorable ankylosis of the thoracolumbar spine. Notably, the VA examiners specifically found no ankylosis. Thus, based on the foregoing, the Board finds that, for the entire appeal period, the Veteran's back disability resulted in, at most, flexion limited to 60 degrees and a combined ROM of the thoracolumbar spine limited to 130 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Furthermore, there is no evidence the Veteran's back disability resulted in limitation of forward flexion to less than 30 degrees or ankylosis, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Consequently, a rating in excess of 20 percent is not warranted. With regard to Note (1) of the General Rating Formula, the Board discusses below whether the Veteran is entitled to higher initial ratings for RLE and LLE radiculopathy as associated with his back disability. However, the evidence fails to show that such disability is manifested by any other associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment or erectile dysfunction. In this regard, all of the VA examiners, as well as treatment records, fail to show the presence of any such associated objective neurologic abnormalities. Consequently, separate ratings for associated objective neurologic abnormalities, other than radiculopathy of the RLE and LLE, are not warranted. 2. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity (LLE) is denied. 3. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the right lower extremity (LLE) is denied. As noted previously, the Veteran has been assigned separate ratings for radiculopathy of the bilateral lower extremities associated with his back disability. Specifically, for the entire appeal period, he is in receipt of 10 percent rating for his radiculopathy of the LLE of the sciatic nerve pursuant to DC 8520, and a 10 percent rating for radiculopathy of the RLE of the sciatic nerve pursuant to DC 8720, which pertains to neuralgia affecting the sciatic nerve. In this regard, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale of the affected nerve, with a maximum equal to moderate incomplete paralysis. In this regard, DC 8520 pertains to incomplete or complete paralysis of the sciatic nerve. Specifically, such provides a 10 percent rating for mild incomplete paralysis of the sciatic nerve, a 20 percent rating for moderate incomplete paralysis of the sciatic nerve, a 40 percent rating for moderately severe incomplete paralysis, and a 60 percent rating for severe incomplete paralysis, with marked muscular atrophy. An 80 percent rating is assigned when there is complete paralysis with foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or (very rarely) lost. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of 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. 38 C.F.R. § 4.124a. Although the words, "mild," "moderate," and "severe" are not defined in the VA rating schedule, the Board must evaluate all the evidence in order to render a decision that is "equitable and just." 38 C.F.R. § 4.6. At the aforementioned October 2014 VA examination, the Veteran reported pain with radiation and paresthesia in both lower legs. Upon examination, muscle strength of the bilateral lower extremities was normal at 5/5, and deep tendon reflexes and sensory testing was normal. The examiner also noted that the Veteran had mild intermittent pain and paresthesias and/or dysesthesias, bilaterally. Based on the foregoing, the examiner found that the Veteran had mild radiculopathy of the bilateral lower extremities affecting the sciatic nerve. At the March 2019 VA examination, the Veteran reported radicular pain into the legs with numbness and paresthesias. Upon examination, muscle strength of the bilateral lower extremities was normal at 5/5 and deep tendon reflexes were normal at 2+ at the knees and ankles. Sensory examination revealed normal sensation in the upper anterior thigh and thigh/knee, but decreased sensation in the lower leg/ankle, and foot/toes bilaterally. The examiner noted that the Veteran had mild intermittent pain, numbness, and paresthesias and/or dysesthesias, without constant pain, bilaterally. Based on the foregoing, the examiner found that the Veteran had mild radiculopathy of the bilateral lower extremities affecting the sciatic nerve. Upon VA examination in June 2021, muscle strength of the bilateral lower extremities was again normal at 5/5, and deep tendon reflexes and sensory testing was normal. The examiner noted that the Veteran mild intermittent pain, paresthesias and/or dysesthesias, and numbness, without constant pain, bilaterally. Based on the foregoing, the examiner found the Veteran had lumbar radiculopathy of the bilateral lower extremities affecting the sciatic nerve but did not opine as to the severity of such disabilities. Based on the foregoing, the Board finds that, for the entire appeal period, a rating in excess of 10 percent is not warranted for the Veteran's LLE and RLE radiculopathy of the sciatic nerve. In this regard, the Veteran's LLE and RLE was manifested by symptoms of mild intermittent pain, mild numbness, and mild paresthesias and/or dysesthesias, bilaterally. Specifically, muscle strength was normal at 5/5 bilaterally, reflexes were normal at +2 bilaterally, and sensation was normal bilaterally at his October 2014 and June 2021 examinations, with decreased sensation in the lower leg/ankle, and foot/toes bilaterally at his March 2019. Additionally, VA treatment records reflect that, throughout the appeal, the Veteran has denied numbness, tingling, and weakness. See April 2015, June 2017, August 2018, August 2019 records. Moreover, in consideration of such subjective symptoms and objective findings, all VA examiners found that the Veteran's radiculopathy of the BLE resulted in, at most, mild incomplete paralysis of the sciatic nerves. Thus, ratings in excess of 10 percent for such disabilities as of March 14, 2014, is not warranted under DC 8520 or DC 8720. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran's belief that his back and LLE and RLE sciatic nerve impairment disabilities are more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of his back and LLE and RLE sciatic nerve impairment disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such disabilities. The Board has considered whether staged ratings under Hart, supra, and Fenderson, supra, are appropriate for the Veteran's service-connected back and LLE and RLE sciatic nerve impairment disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, other than his claim for a TDIU, which is addressed below, and no other issues been reasonably raised by the record, in regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (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). In reaching the foregoing determinations, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against of the Veteran's claims for increased ratings for his back and LLE and RLE nerve sciatic impairment disabilities. Therefore, the benefit of the doubt doctrine is not applicable and such increased rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a TDIU, including on an extraschedular basis, is remanded. At his March 2019 Board hearing and in documents of record the Veteran stated he is unable to work due to his service-connected low back disability. Specifically, at his hearing he reported that he has not been able to work for 20 years when he retired as a butcher as he was unable to lift more than 7 to 10 pounds and was unable to be in the cold [of the meat freezer]. As an initial matter, the Board notes the Veteran does not meet the schedular criteria for a TDIU at any point during the appeal period pertinent to his March 14, 2014 increased rating claim for his low back disability. In this regard, for the entire appeal period, the Veteran is service-connected for a low back disability, evaluated as 20 percent disabling; LLE radiculopathy of the sciatic nerve, evaluated as 10 disabling; and RLE radiculopathy of the sciatic nerve, evaluated as 10 disabling. Consequently, the Board finds that the schedular requirements for a TDIU are not met under 38 C.F.R. § 4.16 (a). Nonetheless, if it is determined that the Veteran's service-connected disability renders him unable to secure and follow a substantially gainful occupation, the Board may refer his claim for a TDIU to the Director of Compensation Service for extra-schedular consideration under 38 C.F.R. § 4.16 (b). Turning to the evidence of record, the Board notes there is conflicting information as to the Veteran's educational and employment history. In this regard, in the March 2021 remand, the Board directed that, on remand, the Veteran should be requested to complete and return a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability; however, he did not do so. As such, from the record, the Board has considered the Veteran's employment history to the extent possible. In regard to the Veteran's education, an August 2019 VA treatment record reflects he completed high school. With respect to the Veteran's work history, at his Board hearing, he testified he retired from his job as a butcher about 20 years ago. However, at his October 2014 VA examination, he reported he retired "a few years ago," and September 2019 and November 2020 VA treatment records note the Veteran was employed, most recently as a butcher for the Department of Defense (DOD). Nonetheless, turning to the impact the Veteran's service-connected disabilities have on his ability to secure or follow a substantially gainful occupation, in August 2014 the Veteran submitted a Department of Labor (DOL) record which noted the Veteran was unable to work for 8 hours a day due to chronic back pain which limits standing, sitting, stooping, and leaning, and would need to reposition frequently if doing an activity for a long period of time. The record also reflects the Veteran was further impacted by bilateral knee and ankle pains and well as a right shoulder impingement, and neck pains with headaches. However, the Veteran is not service-connected for such disorders. Thus, such disorders may not be considered in connection with his eligibility for a TDIU. The October 2014 examiner opined the Veteran's service-connected disabilities impacted his work as a butcher in that due to the pain in his back and limited motion he was forced to retire several years ago as he was unable to stand for long periods of time or lift heavy objects as required by the job. In September 2016, Dr. R,H. opined that any work conditions such as bending twisting, lifting, or carrying would exacerbate his current chronic back pain symptoms as well as his shoulder pain. See VA Physical Medicine and Rehabilitation Service note. The March 2019 examiner noted the Veteran's low back disability would impact his ability to work as the Veteran would have difficulty with walking, heavy lifting or standing. September 2019 and August 2020 DOL records noted the Veteran's functional ability was impacted by his chronic low back pain and shoulder pain which limited lifting, twisting, bending, and carrying, as well as the prolonged standing. Again, the Board notes the Veteran is not service-connected for a shoulder disorder. The June 2021examiner opined that due to his low back disability, the Veteran reports difficulty with prolonged sitting, walking, standing, bending, squatting, and going up and down stairs. However, the examiner found that sedentary employment would not be limited in any way by his service-connected low back disability, but provided no rationale for such opinion, such that its probative value is limited. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Overall, then, the VA examiners note the Veteran to be limited in walking or standing for long durations and lifting more than 10 pounds. Again, the Veteran's education is limited to high school, with a work history primarily as a butcher and no indication of work history in any sedentary type of work. 38 C.F.R. § 4.16 (b) requires extraschedular referral in cases where the Veteran is unemployable by reason of service-connected disabilities, but does not meet the schedular percentage standards set forth in 38 C.F.R. § 4.16 (a). The proper procedure is to refer the matter to the Director of Compensation Service for extraschedular consideration. Thereafter, the Board has jurisdiction to review the Director's determination. See Wages v. McDonald, 27 Vet. App. 233 (2015) (explaining that "the Board is required to obtain the Director's decision before the Board may award extraschedular TDIU"). On remand, the AOJ must refer the matter of entitlement to a TDIU on an extraschedular basis to the Director, Compensation Service for a determination as to whether the Veteran is entitled to an assignment of a TDIU under the provisions of 38 C.F.R. § 4.16 (b). The matters are REMANDED for the following action: The AOJ must refer the matter of entitlement to a TDIU to the Director of VA's Compensation Service for consideration of entitlement to a TDIU on an extraschedular basis in accordance with 38 C.F.R. § 4.16 (b). B. Chatterjee Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.