Citation Nr: 21008933 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 09-17 185 DATE: February 18, 2021 ORDER 1. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected depressive disorder, not otherwise specified, is denied. 2. Entitlement to a rating in excess of 40 percent for residuals of a back injury (back disability) (except for a period when a temporary total rating was in effect) is denied. 3. Entitlement to an initial disability rating in excess of 10 percent for left lower extremity radiculopathy is denied. 4. Entitlement to an initial disability rating in excess of 10 percent for right lower extremity radiculopathy prior to January 13, 2016 is denied. 5. Entitlement to an initial disability rating of 20 percent, but no higher, for right lower extremity radiculopathy since January 13, 2016 is granted. REMANDED 6. Entitlement to separate compensation for neurologic abnormalities, including bowel or bladder impairment, due to the lumbar spine disability is remanded. 7. Entitlement to service connection for a bilateral arm disability other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities is remanded. 8. Entitlement to service connection for a disability manifested by tremors, to include as secondary to service-connected disabilities is remanded. 9. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran has not been diagnosed with fibromyalgia. 2. The Veteran’s back disability has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine; unfavorable ankylosis of the entire spine; or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 3. The Veteran’s radiculopathy of the left lower extremity is not manifested by moderate incomplete paralysis of the sciatic nerve. 4. The Veteran’s radiculopathy of the right lower extremity is not manifested by moderate incomplete paralysis of the sciatic nerve prior to January 13, 2016. 5. The Veteran’s radiculopathy of the right lower extremity is not manifested by moderately severe incomplete paralysis of the sciatic nerve since to January 13, 2016. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 2. The criteria for entitlement to a disability rating in excess of 40 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5010-5243. 3. The criteria for an initial disability rating in excess of 10 percent for radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520. 4. The criteria for an initial disability rating in excess of 10 percent for radiculopathy of the right lower extremity prior to January 13, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520. 5. The criteria for an initial disability rating of 20 percent, but no higher, for radiculopathy of the right lower extremity since January 13, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to January 1980 and from October 1982 to October 1984. He had additional service with the Army National Guard from November 1986 to March 1995, which included a period of inactive duty for training (INACDUTRA) in June 1992. These matters come before the Board of Veterans' Appeals (Board) from July 2007 and June 2013 rating decisions. The Veteran requested a Board hearing before a Veterans Law Judge on his March 2009 VA Form 9, Appeal to the Board. He subsequently withdrew his Board hearing request in October 2015. Thus, there is no hearing request pending at this time. In March 2009, the RO granted an increased (40 percent) rating for residuals of a back injury, from October 30, 2006. In February 2015, the RO granted a temporary total (100 percent) rating for the service-connected back disability, due to surgical or other treatment requiring convalescence, from May 28, 2014 through August 31, 2014. A 40 percent rating was resumed from September 1, 2014. As the Veteran has been granted the full benefit sought for residuals of a back injury during the entire period from May 28, 2014 through August 31, 2014, his claim for an increased rating for this disability during that period will not be addressed by the Board. Service Connection 1. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected depressive disorder, not otherwise specified The Veteran believes he has fibromyalgia, which is related to his military service. Specifically, the Veteran contends that his fibromyalgia is secondary to his service-connected depressive disorder. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for fibromyalgia. Specifically, there is a lack of competent evidence of a current diagnosis of fibromyalgia. For example, the Veteran was afforded a VA examination in September 2017. The Veteran stated to the examiner that he had been concerned that he has fibromyalgia because he had diffuse body pain and fatigue. However, the examiner concluded that the Veteran has no formal diagnosis of fibromyalgia and found that the Veteran’s symptoms did not meet the criteria for a diagnosis at the examination. The examiner documented the Veteran’s report of symptoms but noted that the Veteran did not have findings, signs, or symptoms attributable to fibromyalgia. The Board finds this medical opinion probative, as the examiner physically examined the Veteran and explained why a diagnosis of fibromyalgia was not warranted. This is evidence against the claim. The Board has also considered if the Veteran has pain associated with fibromyalgia that results in functional impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board acknowledges that the Veteran experiences pain. However, the Veteran has been diagnosed with a wide variety of disabilities capable of producing pain, which have either already been service connected or separately denied service connection. He is service connected for residuals of a back injury, degenerative arthritis of the cervical spine, right and left shoulder strain, upper extremity cervical radiculopathy, and bilateral lower extremity radiculopathy, all of which are capable of producing pain. In addition, he has been denied service connection for the diagnosed hip and buttocks disabilities. A review of the Veteran’s medical record showed that in June 2006, Dr. Mark Cook stated that the Veteran’s current diagnosis was neck and diffuse joint pain and stiffness. His symptoms included fatigue, pain, weakness, and tremors. In August 2006, the Veteran was seen by Dr. Alan Schaffert as part of a neurological examination. The Veteran complained of muscles spasms, right side neck pain, and weakness in the right arm. Dr. Schaffert stated that the Veteran’s nerve conduction studies were normal, and the limited needle electrode examination did not demonstrate any evidence of a myopathy. Dr. Schaffert concluded that it does not appear that the Veteran has a significant neurological complaint causing his problems with stiffness, spasms, and pain in the right arm and leg more than the left. As the Veteran has multiple disabilities and diagnoses that are pain-inducing, the Board cannot find there is a basis upon which to grant the service-connection claim for chronic pain due to fibromyalgia. Additionally, in May 2011, the Veteran submitted an abstract to a posttraumatic stress disorder and fibromyalgia study. However, the Board finds this is nonprobative evidence, as it does not establish that the Veteran was diagnosed with fibromyalgia. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to diagnose fibromyalgia, as medical expertise is required. In this regard, the question of diagnosis involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of whether the Veteran has a valid diagnosis of fibromyalgia may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. For all the reasons laid out above, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for fibromyalgia. Thus, as the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim is denied. 38 U.S.C. § 5107(b). Increased Rating 2. Entitlement to a rating in excess of 40 percent for residuals of a back injury (except for a period when a temporary total rating was in effect) The Veteran believes his back disability warrants a higher disability rating than the current 40 percent rating. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. The service-connected lumbar spine disability is evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher rating. 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, a 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is assigned for unfavorable ankylosis of 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 normal combined range of motion of the thoracolumbar spine is 240 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 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. The Formula for Rating IVDS Based on Incapacitating Episodes provides a 60 percent rating for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than 2 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the assignment of an increased disability rating in excess of 40 percent. The reasons follow. The Veteran was afforded a VA examination in April 2007. During that examination, the Veteran stated he had pain in the mid back and the lower back. He also reported that he had pain, weakness of the arms, hands, and feet; burning sensations and weakness in most of his muscles of his body and spasms in his back. Upon examination, the Veteran had a normal gait, he was able to demonstrate good balance and coordination. There was no evidence of lack of coordination or balance and no evidence of pain or guarding of the joints. His extension was to 20 degrees and flexion to 20 degrees. His bilateral lateral flexion was to 15 degrees and bilateral lateral rotation to 25 degrees. The combined range of motion was to 120 degrees. The examiner stated that the Veteran was able to perform an exercise test and did so, demonstrating speed and good muscle strength and endurance. He also was given a stack of papers to lift, he was asked to stand and lift this from the waist level. The Veteran was able to do so, demonstrating good strength and endurance without pain. The examiner stated that he could not prove that the Veteran had significant pain and certainly there was no flare-up during the examination. The Board notes that the Veteran was also evaluated by a VA neurologist at this time, who diagnosed the Veteran with idiopathic polyneuropathy in the lower extremities. The neurologist opined that the polyneuropathy or muscular pains were not related to his service-connected back disability. Upon VA examination in February 2015, the Veteran reported he has ongoing, constant low back pain. He reported urinary and fecal incontinence, that may be caused by the low back condition. The Veteran did not report flare-ups that impacted the function of his pain. However, he reported that his lumbar spine disability makes it so he cannot walk, stand, or sit for long periods of time without back pain. Upon examination, the Veteran’s range of motion was noted as forward flexion from zero to 50 degrees, extension from zero to 10 degrees, bilateral lateral flexion from zero to 30 degrees, and bilateral lateral rotation to 30 degrees. His combined range of motion was to 180 degrees. The examiner noted that the range of motion interfered with bending down to pick up objects. Pain was noted on examination and it causes functional loss. The examiner stated that the Veteran had muscle spasms but they did not result in abnormal gait or abnormal spinal contour. The Veteran did not have muscle atrophy, his muscle strength was normal (rated 5 out of 5), and his sensation was normal. His deep tendon reflexes were hyperactive without clonus in the right knee and absent in the left. His deep tendon reflexes were absent in both ankles. Additionally, there was no ankylosis present and the Veteran had neurologic abnormalities, such as urinary and fecal incontinence that may be caused by the low back condition. The Veteran’s noted IVDS had not resulted in any incapacitating episodes in the past 12 months. The Veteran reported occasional use of a cane and scooter for ambulation. The examiner stated that the examination neither supports nor contradicts the Veteran’s statements describing function loss during flare-ups. The examiner was unable to say without mere speculation if pain, weakness, fatigability, or incoordination significantly limits functional ability with flare-ups because the limitations do not follow dose response curve. Upon subsequent VA examination in January 2016, the Veteran reported the numbness in his legs improved a little. However, he continued to have chronic back pain and weakness in his legs. His back is constant, aching, sharp, and severe. He has flare-ups of back pain several times a day, that last a few minutes to half the day. He has shooting pain in both legs, usually on the right side. He stated he has numbness and tingling in both legs. He also said his pain is worse with standing more than 10 minutes, lifting, carrying, prolonged sitting or walking, bending, climbing stairs, and cold weather. Initial range of motion findings included forward flexion to 45 degrees, extension to 20 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. There was pain noted on examination and it caused functional loss. Additionally, there was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joints. The examiner was not able to make comments about additional loss of range of motion during flare ups without resorting to mere speculation. The Veteran denied flare ups while being examined and he was not examined after repetitive use. The Veteran had muscle spasms that resulted in abnormal gait or abnormal spinal contour. The examiner noted that a loss of lordosis was observed. Additionally, the Veteran had localized tenderness that did not result in abnormal gait or abnormal spinal contour. Muscle strength was normal (5/5), without atrophy or ankylosis. The Veteran’s reflexes were hyperactive without clonus in the left knee and normal within the right knee, right ankle, and left ankle. A sensory examination was normal, and a straight-leg raising test was negative on the left side. The straight-leg raising test was positive on the right. There was evidence of radiculopathy and neurologic abnormalities. The Veteran stated that he has daily urinary incontinence, but he does not wear a pad. If he eats too many fatty foods, he will occasionally have diarrhea or fecal incontinence. The Veteran has IVDS but did not have any incapacitating episodes of IVDS during the past 12 months. The Veteran stated that he uses a cane daily and he uses his electric cart if he is going somewhere that would require long walking. Finally, the examiner noted that the Veteran would be unable to do work requiring lifting, carrying, stair climbing, standing or prolonged walking. Moreover, the probative evidence of record does not document that the Veteran’s service-connected residuals of a back injury has resulted in unfavorable ankylosis of the entire thoracolumbar spine for any period on appeal. Additionally, there is no evidence that the Veteran had incapacitating episodes of IVDS during the appeal period. As such, the Board finds that the preponderance of the evidence is against a finding that the Veteran had at least six weeks of incapacitating episodes during the past 12 months and it does not warrant the assignment of an increased disability rating. The Board has considered the effects of the Veteran’s symptoms, including pain and functional loss, and the Board concludes that the preponderance of the evidence is against a finding of unfavorable ankylosis of the entire thoracolumbar spine, which is the criteria needed for a 50 percent rating. Examination results during this part of the appeal period show that the Veteran had, at worst, forward flexion to 20 degrees and absent reflexes. However, he also did not have muscle atrophy, which is evidence against weakness. Taking into account the evidence of record indicating the Veteran’s regular complaints of pain and other findings of functional loss, the Board finds that the evidence does not reflect that such pain and functional limitations resulted in unfavorable ankylosis of the entire thoracolumbar spine, which would be required for a finding that the Veteran was entitled to a 50 percent disability rating. At this point, the Veteran is at the maximum rating for limitation of motion, and he does not have ankylosis. Thus, a higher rating under the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 criteria is not approximated in the Veteran’s disability picture for this appeal period. The General Rating Formula also directs that neurological manifestations of the spine should be rated separately from orthopedic manifestations. At the outset, the Board notes that the issue of whether a separate compensable rating is warranted based on urinary or bowel dysfunction as associated with the Veteran’s lumbar spine disability is addressed in the remand below. However, no other objective neurological abnormality arising from the thoracolumbar spine disability has been identified on any of the VA examinations of record. Accordingly, any additional separate rating for associated objective neurologic abnormalities are not warranted. The Veteran is competent to report his observable symptoms, such as ongoing chronic back pain; however, to the extent that the Veteran asserts that the residuals of his back injury are more severe than his currently assigned staged disability ratings, the Board affords more probative value to the objective evidence of record, including as discussed above, which does not weigh in favor of the Veteran’s claim for any period on appeal. In sum, the preponderance of the evidence is against entitlement to a disability rating in excess of 40 percent for residuals of a back injury. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 3. Entitlement to an initial disability rating in excess of 10 percent for left lower extremity radiculopathy Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, DC 8520. Under this criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” 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 is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an award of an initial increased rating of 10 percent for radiculopathy of the left lower extremity. The reasons follow. The evidence shows that the Veteran’s radiculopathy of the left lower extremity is manifested with mild incomplete paralysis of the left lower extremity. For instance, during the February 2015 VA examination, the VA examiner specifically noted that the severity of the Veteran’s left radiculopathy was mild. The Veteran had no muscle atrophy in the left lower extremity. The muscle strength testing was normal at hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. Deep tendon reflexes were noted to be absent at the left knee, left ankle, and right ankle. Sensation to light touch testing of the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were all normal. The examiner noted that the Veteran had no constant pain or intermittent pain. However, the Veteran had mild paresthesias and/or dysesthesias, and mild numbness, which the Board finds is indicative of no more than mild incomplete paralysis. The Veteran was provided another VA examination in January 2016. At that time, the examiner found the Veteran’s left radiculopathy as mild. The Veteran had no muscle atrophy in the left lower extremity. Muscle strength testing was normal at hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. The Veteran’s deep tendon reflexes were normal in the right knee, right ankle, and left ankle. They were hyperactive without clonus in the left knee. Sensation to light touch testing of the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were all normal. The examiner noted that the Veteran no constant pain but had mild intermittent pain in the left lower extremity. A January 2017 VA medical treatment record shows that the Veteran complained of lumbar radicular pain. On examination, the evaluator found the Veteran’s lower extremity reflexes were “quite brisk but symmetrical.” Furthermore, the evaluator noted that the strength was less on the left leg. The Veteran was able to get up on his heels and his toes, but his left was weaker compared to the right. To the extent that the Board is denying entitlement to a disability rating in excess of 10 percent, the Board notes specifically that the Veteran’s reports of radiating pain have been considered in evaluating the Veteran’s neurological manifestations. See 38 C.F.R. § 4.6 (Board must evaluate all of the evidence, to the end that its decisions are “equitable and just”). Although the Veteran reported pain when seen at his VA examinations, and generally contended pain in other VA treatment records, the Veteran was found to have a negative straight leg test result and normal sensory findings on his left side when examined in February 2015. The Veteran did have absent reflexes on the left side. Additionally, at the January 2016 VA examination, the Veteran had a negative straight leg test on the left side, as well as normal sensory findings, hyperactive without clonus at the left knee reflex, and normal left ankle reflexes. The Board affords the clinical findings documented in the February 2015 and January 2016 VA examination reports of more probative value, as the examiners utilized medical testing, such as the straight leg test and sensory testing that covered from L2 to S1 of the lumbar spine and objective medical criteria to assess the Veteran’s symptoms and found that the Veteran had mild symptoms of radiculopathy. The Veteran is in receipt of a 10 percent rating during this part of the appeal period, which contemplates mild incomplete paralysis of the sciatic nerve. Although the Veteran also reported pain on other occasions, these reports of pain do not constitute evidence of moderate incomplete paralysis of the Veteran’s left lower extremity sciatic nerve for the appeal period. In sum, the preponderance of the evidence is against entitlement to a disability rating in excess of 10 percent for Veteran’s sciatic radiculopathy of the left lower extremity. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. – 5. Entitlement to an initial disability rating in excess of 10 percent for right lower extremity radiculopathy Prior to January 13, 2016 The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an award of an initial increased rating in excess of 10 percent for radiculopathy of the right lower extremity prior to January 13, 2016. The reasons follow. The evidence shows that the Veteran’s radiculopathy of the left lower extremity is manifested with mild incomplete paralysis of the left lower extremity. For instance, during the February 2015 VA examination, the VA examiner specifically noted that the severity of the Veteran’s right radiculopathy was mild. The Veteran had no muscle atrophy in the right lower extremity. Muscle strength testing was normal at hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. Deep tendon reflexes were noted to be hyperactive without clonus on the right knee and absent at the left knee, left ankle, and right ankle. Sensation to light touch testing of the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were all normal. The examiner noted that the Veteran had no constant pain or intermittent pain. However, the Veteran had mild paresthesias and/or dysesthesias, and mild numbness, which the Board finds is indicative of no more than mild incomplete paralysis. To the extent that the Board is denying entitlement to a disability rating in excess of 10 percent, the Board notes specifically that the Veteran’s reports of severe radiating pain have been considered in evaluating the Veteran’s neurological manifestations. Although the Veteran reported pain of the right lower extremity at the February 2015 VA examination, the VA examiner found that the Veteran to not have muscle atrophy and normal sensory findings. Furthermore, during this period on appeal, the preponderance of the evidence shows that the Veteran reported pain on other occasions, but these reports of pain do not constitute evidence of moderate incomplete paralysis of the Veteran’s right lower extremity. In sum, the preponderance of the evidence is against entitlement to a disability rating in excess of 10 percent for Veteran’s sciatic radiculopathy of the left lower extremity prior to January 13, 2016. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.   Since January 13, 2016 The Board finds the evidence supports a finding that the Veteran’s sciatic radiculopathy of the right lower extremity results in moderate incomplete paralysis since January 13, 2016, but does not result in moderately severe incomplete paralysis to warrant a 40 percent rating. At worst, the Veteran was found to have normal sensory results, normal reflexes, moderate intermittent pain, and no constant pain in the right lower extremity. The January 2016 VA examiner noted there was no muscle atrophy and characterized the Veteran’s right lower extremity radiculopathy as being of moderate severity. A January 2016 VA examination documented that the Veteran experienced right lower radiculopathy symptoms. The examiner concluded that the right lower radiculopathy was moderate. The Veteran had no muscle atrophy in the left or right lower extremity. Muscle strength testing was normal at hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. The Veteran’s deep tendon reflexes were normal in the right knee, right ankle, and left ankle. They were hyperactive without clonus in the left knee. Sensation to light touch testing of the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes were all normal. The examiner noted that the Veteran no constant pain but had mild intermittent pain in the left lower extremity and moderate intermittent pain in the right lower extremity. A January 2017 VA medical treatment record shows that the Veteran complained of lumbar radicular pain. On examination, the evaluator found the Veteran’s lower extremity reflexes were “quite brisk but symmetrical.” Furthermore, the evaluator noted that the strength was less on the left leg. The Veteran was able to get up on his heels and his toes, but his left was weaker compared to the right. To the extent that the Board is denying entitlement to a disability rating in excess of 20 percent during this period on appeal, the Board notes specifically that the Veteran’s reports of radiating pain have been considered in evaluating the Veteran’s neurological manifestations. Although the Veteran was found to have moderate intermittent pain of the right lower extremity in January 2016, the VA examiner and other medical examiners found that the Veteran did not have muscle atrophy and normal sensory findings. Although the Veteran also reported pain on other occasions, these reports of pain do not constitute evidence of moderately severe incomplete paralysis of the Veteran’s right lower extremity. The Board finds that the reports of moderate intermittent pain is more consistent with a moderate incomplete paralysis of the right lower extremity, but no more. In sum, the evidence supports an increased disability rating to 20 percent, but no higher, for Veteran’s sciatic radiculopathy of the right lower extremity since January 13, 2016. REASONS FOR REMAND 6. Entitlement to separate compensation for neurologic abnormalities, including bowel or bladder impairment, due to the lumbar spine disability When considering the appropriate rating for a lumbar spine disability, VA is also required to evaluate “any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.” See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). At the February 2015 and January 2016 VA examinations, the Veteran reported that he had urinary and fecal incontinence, which the examiners noted may be caused by the low back condition. However, as the Veteran also has polyneuropathy and Parkinson’s disease, additional clarification is warranted to determine the etiology of the Veteran’s neurologic abnormalities. 7. Entitlement to service connection for a bilateral arm disability other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities The Veteran is service connected for bilateral upper extremity cervical radiculopathy and bilateral shoulder strain. Additionally, the Veteran is seeking service connection tremors. The Board believes a remand is necessary to seek clarification from the Veteran to identify the bilateral arm disability, to include the specific symptoms he is experiencing that he believes are part of his arm disability, that he is claiming that is separate from his service-connected upper extremity disabilities. 8. Entitlement to service connection for a disability manifested by tremors, to include as secondary to service-connected disabilities The most recent VA treatment records relating to the Veteran’s tremors are from September 2017. A review of the medical records shows conflicting information on the etiology of the Veteran’s tremors. For example, the Veteran has a family history of Parkinson’s disease. However, in August 2011, VA neurologist believed the Veteran’s tremor is most likely not Parkinson’s and has a definite somatoform component along with depression and alcohol abuse. In August 2017, the VA neurologist noted that the Veteran’s symptoms are consistent with Parkinson’s disease. However, his presentation would be atypical in that his tremor seems to be distractible at times. Due to this conflicting information, the Board finds a remand is necessary to obtain updated VA treatment records to clarify the Veteran’s etiology of the tremors. 9. Entitlement to a TDIU rating due to service-connected disabilities is remanded. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. As such, Board consideration of the merits of the Veteran’s TDIU claim is deferred pending adjudication of the Veteran’s claims for service connection of a bilateral arm disability and tremors. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records from September 2017. 2. Schedule the Veteran for the appropriate VA examination to determine the nature, extent, onset and etiology of his reported urinary and/or bowel dysfunction. The claims file must be provided to the examiner for review. All indicated studies deemed necessary by the examiner should be performed, and all findings of these tests should be reported in detail. The examiner should specifically provide an opinion as to whether the Veteran’s urinary and/or bowel dysfunction is etiologically related to his service-connected lumbar spine disability. The examiner must also consider the Veteran’s lay statements regarding this disorder. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. 3. Ask the Veteran to identify the bilateral shoulder disability, including the specific symptoms he is experiencing that he believes are part of his arm disability and that are separate from his service-connected disabilities. 4. After obtaining the updated VA treatment records, refer the claims file for review by a VA examiner to determine the etiology of the Veteran’s tremors and provide a nexus opinion. If the examiner finds that an in-person examination(s) is necessary, then schedule an examination. If an examination(s) is scheduled, any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The Veteran’s claims file should be reviewed by the examiner in conjunction with the examination, to specifically include the Veteran’s lay statements, medical history noted by the examiner in chronological order, and opinions prior to answering the following question: Whether it is at least as likely as not (50 percent or greater possibility) that the claimed tremors incurred in or caused by service? Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Griffin, 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.