Citation Nr: 21009956 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 14-24 685A DATE: February 23, 2021 ORDER Throughout the entire period on appeal, an evaluation of 40 percent but no higher for a lumbar spine disability is granted. Throughout the entire period on appeal, an evaluation of 20 percent but no higher for sciatica of the left lower extremity is granted. Throughout the entire period on appeal, an evaluation of 20 percent but no higher for sciatica of the right lower extremity is granted. REMANDED Entitlement to service connection for a hypertension disability, to include as secondary to a service-connected lumbar spine, sciatica of bilateral lower extremities disability, or obesity caused by a service-connected disability is remanded. FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, the Board finds that symptoms of his lumbar spine disability throughout the entire period on appeal more closely reflects favorable ankylosis of the entire thoracolumbar spine. 2. Throughout the entire period on appeal, the Veteran’s sciatica of the left lower extremity more closely reflects moderate incomplete paralysis of the sciatic nerve. 3. Throughout the entire period on appeal, the Veteran’s sciatica of the right lower extremity more closely reflects moderate incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. Throughout the entire period on appeal, an evaluation of 40 percent, but no higher, for a lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 5242. 2. Throughout the entire period on appeal, an evaluation of 20 percent, but no higher, for sciatica of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8620. 3. Throughout the entire period on appeal, an evaluation of 20 percent, but no higher, for sciatica of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8620. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1985 to May 1989. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2017, the Veteran testified before the undersigned Veterans Law Judge during a Board video conference hearing. These matters were previously before the Board in March 2018 but were remanded to obtain current VA examinations for the Veteran’s service-connected lumbar spine disability, sciatica of the right and left lower extremities, and hypertension. His claims were readjudicated in a June 2020 supplemental statement of the case (SSOC). These matters are again before the Board for adjudication. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is 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 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings). 1. Lumbar spine disability The Veteran contends that he is entitled to an initial rating in excess of 20 percent from July 15, 2011 and in excess of 10 percent thereafter. Specifically, he asserts that his ongoing treatment records and worsening conditions supports an increased evaluation for his lumbar spine disability. See June 2014 VA Form 9. As an initial matter, the Board notes that the Veteran was initially assigned a 10 percent disability rating for his lumbar spine disability effective on January 21, 2010. In a November 2012 rating decision, the RO found clear and unmistakable error in the assignment of a 10 percent rating and retroactively increased his disability rating from 10 percent to 20 percent effective January 21, 2010. In a June 2014 rating decision, his lumbar spine disability was assigned staged ratings with a 20 percent evaluation from January 21, 2010 to July 15, 2011 and a 10 percent thereafter. The Veteran’s lumber spine disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is 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. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Under Note 5, unfavorable ankylosis is a condition in which the entire cervical spine or the entire spine is fixed in flexion or extension, and the ankylosis results in more or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, DC 5235-5243. As the Veteran’s medical treatment record reflects a diagnosis of intervertebral disc syndrome (IVDS), he must also be evaluated under DC 5243 to determine whether he is entitled to a higher rating under that code. Under DC 5243, a 10 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. A 20 percent disability rating 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. Id. A 40 percent disability rating 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. Id. A 60 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Id. 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. Id. at Note (1). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In light of multiple VA examinations that do not adequately address effects of flare-ups and additional functional loss, the Board resolves all doubt in favor of the Veteran and find that his lumbar spine at worst warrants a 40 percent rating but no higher throughout the entire appeal period. A review of the Veteran’s June 2008 private treatment records throughout the period on appeal shows he was treated at a hospital for low back pain after bending over to clean his pool after working a 20-hour shift. He reported having moderate to severe low back pain and the private doctor noted he had decreased range of motion (ROM) due to pain. However, no range of motion (ROM) measurements were recorded. Similarly, an August 2009 private treatment record showed that he complained of low back pain described as aching, burning, constant, jabbing, numbness, pressure, sharp, throbbing, tingling, and twisting. Again, no ROM measurements were provided. The Veteran was afforded VA examinations in April 2010 and July 2011. However, the Board finds that the VA examiner’s examination did not comply with the recent holdings under Correia and Sharp. In the April 2010 VA examination, the Veteran reported having sharp pain of moderate severity with radiation from his hips to legs and severe flare-ups occurring two to three weeks for about three to seven days after engaging in prolonged activities. When asked about the extent of additional limitation of motion or other functional impairment during his flare-ups, the Veteran reported that he was additionally limited in his daily activities by at least 50 percent. Examination of the Veteran showed he had normal posture and gait and no ankylosis or muscle spasm. The Veteran did have guarding, pain with motion, and bilateral tenderness but the VA examiner noted these symptoms did not result in abnormal gait or spinal contour. The Veteran also had incapacitating episodes of spine disease which resulted in the Veteran being transported via ambulance to the hospital twice. The Veteran’s ROM measurements for forward flexion was limited to 60 degrees with pain beginning at 60 degrees and his combined ROM was 160 degrees. It was further noted that the Veteran used a brace for his lumbar spine disability. There was no report on whether the Veteran had pain with passive and active range of motion testing or with weight or non-weight bearing. Moreover, while the VA examiner obtained the severity and frequency of the Veteran’s flare-ups there is no reports of whether the Veteran’s pain during repetitive use over time or during a flare-up resulted in additional loss in ROM. In a July 2011 VA examination, the Veteran described his low back pain as sharp and stabbing which were moderately severe. He also reported muscle spasm, decreased motions, stiffness, and radiating pain. Upon examination, the VA examiner noted that the Veteran had guarding, pain with motion, and tenderness of the left and right muscle of the spine. He also had abnormal spinal curvature noted as lumbar flattening. His ROM measurement showed his forward flexion was limited at 65 degrees and a CROM of 210 degrees. The VA examiner noted that pain was present with active ROM testing and upon repetitive use testing but did not result in additional limitations after three repetition. The VA examiner further noted that the Veteran showed objective pain/facial grimace and guarding/splinting at the last 5 to 10 degrees of ROM. However, like the April 2010 VA examination, the VA examiner did not report whether passive ROM testing or weight bearing and non-weight bearing testing were conducted. The July 2011 VA examiner also did not discuss whether pain causes functional impairment consistent with the findings under Correia or Sharp. On May 2017, the Veteran submitted a private treatment record showing that he had bilateral point tenderness, swelling, hypertonicity, and nodular muscle spasm in his thoracic spine. While the private examiner reported that his forward flexion of the lumbar spine was limited at 48 degrees, the private examiner did not discuss the Veteran’s flare-ups or whether there was pain on active or passive range of motion or during weight or non-weight bearing. A review of the Veteran’s medical treatment records in February 2019 showed that the Veteran complained of pain described as heaviness, numbness, pinching, pressure, pricking, pulling, shooting, stabbing, and burning. See October 2019 CAPRI. A March 2019 VA treatment record further reflects that while he received multiple spinal blocks it has not helped him. Id. A September 2019 VA doctor further noted the Veteran had significant sacroiliac pain with palpation, a positive lumbar facet loading pain test, and mild to moderate pain with palpation of the lumbar spine. Id. Following the Board’s March 2018 remand, the Veteran was provided with another VA examination in October 2019. During that VA examination, the Veteran reported that his flare-ups were sudden and radiated to his legs. The flare-ups lasted about five to six seconds and occurs about three to four times per day. He endorsed having functional loss and/or impairment of the thoracolumbar spine and reported difficulties with ambulating and sitting down. He also stated that he needed to get up frequently due to his back pain. Upon examination, the VA examiner was unable to test the Veteran due to “too much pain with ROM” and that his ROM was extremely limited. The Veteran was also unable to perform the repetitive use testing with at least three repetitions due to too much pain. Nevertheless, the VA examiner noted there was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the lumbar spine which was of moderate severity. There was also evidence of pain on weight bearing. The VA examiner noted that the Veteran’s pain significantly limited his functional ability during repetitive use over time and during a flare-up but was unable to describe in terms of ROM as initial ROM testing was not performed. The VA examiner also noted the Veteran used a cane occasionally to help with standing and walking due to his degenerative disc disease. In light of the medical evidence, the Board finds that the Veteran is entitled to a 40 percent evaluation for his lumbar spine but no higher throughout the entire period on appeal. While the Veteran was provided with a VA examination in April 2010 and July 2011, the Board finds that the VA examinations are inadequate for rating purposes as they do not comply with the recent holdings under Correia and Sharp. However, in light of the October 2019 VA examination, the Board finds that the Veteran’s extreme pain and inability to perform ROM testing is consistent with definition of favorable ankylosis of the entire thoracolumbar spine. While the Veteran does not have a diagnosis of favorable ankylosis, the Board finds the functional limitations due to pain and restricted motion are analogous to the degree of limitation contemplated by a disability manifested by favorable ankylosis. Accordingly, in resolving all doubts in favor of the Veteran, the Board finds that the Veteran is entitled to an increased rating of 40 percent but no higher under DC 5242 throughout the entire period on appeal. The Board has considered whether he is entitled to a rating of 50 percent or higher. However, the medical evidence fails to show that his entire spine or entire thoracolumbar spine is fixed at flexion or extension with one or more symptoms noted under Note (5). As such, the Board finds that he does not have a diagnosis of unfavorable ankylosis of the entire spine or entire thoracolumbar spine. The Board acknowledge that the Veteran has been diagnosed with intervertebral disc syndrome as noted in his October 2019 VA examination. The Board has further considered whether he is entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). Unfortunately, under DC 5243 the Veteran would not be entitled to a 60 percent rating as the October 2019 VA examination shows that he does not have incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. As there is no further evidence to the contrary, the Board finds that he is not entitled to a higher rating under DC 5243. The Board has further considered the Veteran’s lay reports of symptoms associated with his lumbar spine disability and finds that they are credible. The Veteran has consistently complained of flare-ups and severe low back pain throughout the period on appeal which has not been alleviated even with the use of ESI. As there are no evidence to the contrary, the Board finds that the Veteran is credible. Accordingly, in resolving any doubt in favor of the Veteran, the Board finds that the Veteran’s lumbar spine disability warrants a 40 percent rating but no higher throughout the entire period on appeal. 2. Sciatica of the right lower extremity 3. Sciatica of the right lower extremity The Veteran further seeks increased ratings for his sciatica of the right and lower extremity. No specific contentions have been asserted. The Veteran’s sciatica of the right and lower extremity disability has assigned staged ratings. He was initially assigned a 10 percent rating prior to July 15, 2011 and a 20 percent thereafter under DC 8620. Diagnostic Code 8620 is rated under the criteria for neuralgia of sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8620. Diagnostic Code 8620 provides that mild incomplete paralysis of the sciatic nerve is rated as 10 percent and that moderate incomplete paralysis is rated as 20 percent. Moderately severe incomplete paralysis is rated as 40 percent, and severe incomplete paralysis with marked muscular atrophy is rated 60 percent. Complete paralysis is rated as 80 percent, and is manifested by the foot dangling and dropping, no active movement possible of the muscles below the knee, and flexion of the knee weakened and (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8620. Under the provisions of 38 C.F.R. § 4.124a , the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to 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. In rating peripheral nerve disability, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes 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. 38 C.F.R. §§ 4.123, 4.124. Upon review of the evidence, the Board finds that throughout the entire period on appeal, the Veteran’s severity of his symptoms associated with his sciatica of bilateral lower extremities has been moderate warranting a 20 percent evaluation. The Veteran initially complained of constant low back pain with right anterior thigh numbness in a December 2003 private treatment record. At the examination, he rated his anterior right thigh pain as 7 or 8 out of 10. The private doctor examined further examined the Veteran and noted that he had decreased muscle length over the piriformis and hamstrings bilaterally, but with the right side greater than the left side. The private doctor further noted that his neurologic or sensory was decreased over the right anterior thigh and lateral border of the right foot. Private treatment records from 2004 to 2008 also reflect continuous complaints of numbness and tingling in the lateral right thigh. During an August 2009 private examination, he continued to complain of low back pain which radiated to his right thigh. He described the pain as aching, burning, constant, jabbing, numbness, pressure, sharp, throbbing, tingling, and twisting. He stated that he had severe pain which worsened with episodes. Upon evaluation, the private examiner noted that the Veteran walked with a stoop gait and with a limp to the right. The Veteran also had positive straight leg tests, bilaterally, and severe burning sensation along the lateral aspect of his right thigh. In an April 2010 VA examination, the Veteran reported constant pain rated as 7 out 10 which went down from his hips to his feet. He stated that his condition has worsened over the past two years. Upon review of his musculoskeletal systems, paresthesias and sharp pain which radiated down from the hips to the legs were present. However, he had no urinary or fecal issues, numbness or muscle atrophy. He also had normal posture and gait. Evaluation of his hip and knee flexion and extension and ankle dorsiflexion and plantar flexion were 5/5. During the sensory examination of the lower extremity, the Veteran’s left-side vibration, pinprick, light tough, and position sense were noted as 2/2. However, his right-side lower extremity vibration, pinprick, light tough, and position sense were all noted as 1/2, indicating palpable or visible contraction. The Veteran’s VA treatment records following the April 2010 VA examination continues to show constant sciatic pain of his bilateral lower extremity. In a February 2011 VA treatment records, he complained of numbing and burning sensation from his right and left thigh but that his right thigh was more symptomatic. He assessed the pain as 7 out of 10. Subsequently, in March 2011, he received a lumbar transforaminal epidural steroid injection (ESI) for his lumbar spine and bilateral extremity pain. However, in a March 2011 follow-up treatment session, it was reported that the transforaminal ESI was not effective and the Veteran was provided with interlaminar ESI. In a July 2011 VA examination, the Veteran was diagnosed with intermittent bilateral sciatica with symptoms of burning pain, numbness, and tingling of the thighs. His sensory examination showed vibration, position sense, pain or pinprick, and light touch were all normal. There was also no dysesthesias or muscle atrophy. 38 C.F.R. §§ 4 However, contrary to the July 2011 VA examination, his VA treatment records continues to reflect ESI treatment for low back pain and radiating pain in 2012 and 2013. He further continued to report that his back pain and leg symptoms remains unchanged. In a September 2015 VA treatment record, motor testing for his bilateral lower extremities were 5/5 in all major muscle groups. He had normal muscle tone and no muscle atrophy. However, his sensory examination was 1/2 to PP in pinpoint dermatomes in the right L2-L3-L4, L S1, and bilateral L5. His deep tendon reflexes also indicated trace achilles on the right side and he had grade of 1+ of the patellar and achilles toes downgoing. The Veteran further underwent a 2015 electromyography (EMG) showing that he had chronic right S1 and left L-5 radiculopathy with reinnervation but there was no evidence of acute denervation and no gross motor weakness. Although he continued to undergo ESI treatment for his low back pain, a December 2016 VA doctor noted that the injections were becoming less and less effective during a VA pain consultation. During that consultation, the Veteran reported that his pain was 10 out 10. Upon evaluation, his bilateral lower extremities were normal and symmetric and there was no atrophy or tone abnormalities. However, the VA doctor noted that he had decreased sensation to light touch of the upper thighs bilaterally and an antalgic gait. The VA doctor further noted that the Veteran used a cane. In a May 2017 private treatment record, a private doctor noted that he had a normal gait and was able to walk on his toes and heels and perform a tandem walk normally. The Veteran’s motor examination showed that he had normal tone and 5/5 strength in all extremities. His sensory examination showed normal to pinprick, light touch, vibration, motion, position, and temperatures. His June 2018 VA pain consultation further indicated that he had normal gait and symmetrical bilateral lower extremity strength with no atrophy or tone abnormalities. Finally, in an October 2019 VA examination, a VA examiner noted his muscle strength testing for the left and right hip flexion was rated as 4/5 (active movement against some resistance). Again, no muscle atrophy was present. The Veteran’s reflex examination showed his right knee and ankle was hypoactive and reflex in his left ankle was absent. His sensory examination for the right and left upper anterior thigh was normal. However, sensory examination of the right and left thigh/knee was decreased and sensory examination of the right and left lower leg/ankle and foot/toes were absent. He also had positive straight leg raising tests in both the right and left leg. With regards to his radiculopathy, he had moderate constant pain, severe paresthesias/dysesthesias, and severe numbness of his left and right lower extremity. The VA examiner noted that the severity of his radiculopathy for both the left and right lower extremity was moderate. Based on the medical evidence, the Board finds that the Veteran’s symptoms more closely reflect moderate incomplete paralysis of the sciatic nerve throughout the entire period on appeal. The medical evidence demonstrates that the Veteran had decreased sensation over his thighs and consistently complained of constant radicular pain down to his right and left extremity. He rated his radicular pain consistently within the range of 7 through 10 out of 10. These symptoms, as described by the Veteran, were sharp, burning, and numbing and were not relieved with multiple ESI. Although the July 2011 VA examination and May 2017 private treatment record indicate that his sensory examination was normal, most of his treatment for sciatica of his bilateral lower extremity has been consistent with showing decreased sensation over his bilateral lower extremities. Thus, the Board finds that the Veteran’s sciatica of his bilateral lower extremity is most consistent with a 20 percent rating for incomplete moderate paralysis of the sciatic nerve. The Board has further considered whether he is entitled to a 40 percent or higher under DC 8620. However, as provided under 38 C.F.R. § 4.124a, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Here, the Board finds that the Veteran’s symptoms is primarily manifested by pain, sensory disturbances, and some loss of reflexes. Throughout the entire period on appeal, the Veteran’s muscle strength has been predominantly normal and there has been no evidence of any muscular atrophy. Additionally, while the October 2019 VA examiner noted the Veteran had moderate constant pain, severe paresthesias/dysesthesias, and severe numbness of his left and right lower extremity, the VA examiner concluded that the severity of his radiculopathy was moderate. As there is no probative or persuasive evidence to the contrary, the Board finds that he is not entitled to a 40 percent rating or higher. The Board acknowledges the lay assertions of that his radiculopathy in his legs felt like someone just lit up a match on him and that the temperature of his legs changes from hot to cold suddenly. However, the Board finds the October 2019 VA examiner’s findings to be consistent with the record and entitled to significant weight. Again, the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran’s complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. As noted above, pursuant to DC 8620, a finding of moderate neuritis should be rated at 20 percent. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. Based on the foregoing, the Board finds that throughout the entire period on appeal, a 20 percent rating but no higher for sciatica of his bilateral lower extremity is warranted. REASONS FOR REMAND 1. Hypertension, to include as secondary to a service-connected lumbar spine disability, sciatica of bilateral lower extremities, or obesity caused by a service-connected disability. Upon review of the evidence, a remand is warranted before the Board can properly adjudicate the merits of the claim. Generally, obesity is not a disease for service connection purposes. VAOPGCPREC 1-2017 (Jan 6, 2017). Nonetheless, obesity may be an intermittent step between a service-connected disability and a current disability that may be service connected on a secondary basis. Id. at 2. To grant service connection, the adjudicators would have to resolve the following issues: (1) whether a service-connected disability caused a veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability for which a veteran is seeking service connection; and (3) whether the current disability for which a veteran is seeking service connection would not have occurred but for the obesity caused by the service-connected disability. Id. at 9-10. The opinion stated regarding this hypothetical that: adjudicators would have to resolve the following issues: (1) whether the service-connected back disability caused the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing hypertension; and (3) whether the hypertension would not have occurred but for obesity caused by the service-connected back disability. If these questions are answered in the affirmative, then hypertension may be service connected on a secondary basis. The Court in Walsh v. Wilkie, No. 18-0495, 2020 U.S. App. Vet. Claims LEXIS 295 (Vet. App. Feb. 24, 2020) addressed VAOPGCPREC 1-2017 and indicated that service connection may also be granted on a secondary basis where the claimed disability would not have occurred but for obesity aggravated by a service-connected disability. See Walsh at *14 (“to be clear: Despite [VAOPGCPREC 1-2017’s] silence regarding aggravation, the Board, in accordance with § 3.310(b), must consider aggravation in this context when the theory is explicitly raised by the veteran or reasonably raised by the record”). Here, the Board finds that a secondary service connection claim on the theory of obesity as an intermediary step has been raised by the Veteran’s representative in a January 2021 appellate brief. Additionally, the evidence appears to suggest draw an association between the Veteran’s obesity and hypertension as noted in a July 2011 and September 2018 VA examination. More notably, a July 2011 VA examiner noted that obesity is associated with an increased prevalence and incidence of hypertension and weight gain appears to be a main determinant of the rise of blood pressure. The July 2011 VA examiner further noted that there is an increased risk of developing hypertension due to physical inactivity. Moreover, the Board further observes that a July 2011 VA examination for the Veteran’s lumbar spine disability indicated that his lumbar spine disability moderately affected his ability to exercise or to engage in sports. An October 2019 VA examiner also noted also that his service-connected lumbar spine disability causes difficulty sitting, standing, or ambulating. The Veteran was also unable to carry objects more than 10-15 pounds. However, no VA medical opinion has been obtained to address this theory of obesity as an intermediary step for secondary service connection. Based on the foregoing, a remand is warranted to obtain a supplemental VA medical opinion addressing whether the Veteran’s hypertension disability is secondary to obesity caused by the Veteran’s service-connected disabilities to include a lumbar spine disability or sciatica of bilateral lower extremities. The matter is REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records related to the Veteran’s hypertension disability and associate them with the claims file. 2. Arrange for a qualified medical professional to review the claims file and provide an addendum opinion concerning the nature and etiology of the Veteran’s hypertension disability. The need for another in-person examination is left to the discretion of the medical professional offering the addendum opinion. After, the examiner should attempt to answer the following questions concerning the relationship between obesity and the claim of secondary service connection: (a) Is it at least as likely as not (50 percent or greater probability) that one of the Veteran’s service-connected disabilities (for example, his lumbar spine disability and sciatica disability) caused the Veteran to become obese (for example, by preventing regular exercise)? (b) If so, is it at least as likely as not (50 percent or greater probability) that the Veteran’s obesity was a substantial factor in causing or aggravating the Veteran’s hypertension disability? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension disability would not have occurred or would not have been aggravated beyond its natural progression without the obesity caused by a separate service-connected disability? The examiner must provide a complete rationale which thoroughly explains the medical reasons for these conclusions. 3. After, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran with a supplemental statement of the case (SSOC) and provide him with an appropriate opportunity to respond M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Xiong, 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.