Citation Nr: 21015492 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 10-36 366 DATE: March 17, 2021 ORDER Entitlement to an evaluation in excess of 20 percent, excepting a period of temporary total disability from May 25, 2011, to July 31, 2011, for a lumbar spine disability is denied. Entitlement to an initial evaluation in excess of 20 percent for radiculopathy of the left lower extremity is denied. Entitlement to an initial evaluation in excess of 20 percent for radiculopathy of the right lower extremity is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Except during the period of temporary total disability from May 25, 2011, to July 31, 2011, the Veteran’s lumbar spine disability manifested in pain, stiffness, and limitation to, at most, 40 degrees of flexion. 2. Throughout the period on appeal, the Veteran’s radiculopathy of the left lower extremity manifested in pain, numbness, tingling, and a slight “slapping” of the left foot prior to stepping. 3. Throughout the period on appeal, the Veteran’s radiculopathy of the right lower extremity manifested in mild pain, numbness, and tingling. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent, excepting a period of temporary total disability from May 25, 2011, to July 31, 2011, for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.71a, Diagnostic Code 5242-5239. 2. The criteria for an initial evaluation in excess of 20 percent for radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.71a, Diagnostic Code 8520. 3. The criteria for an initial evaluation in excess of 20 percent for radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.71a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from September 1968 to September 1988. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in January 2015. This case was previously before the Board in March 2015, June 2019, and October 2020, when it was remanded for development. The case has been returned to the Board for further appellate review. A March 2019 rating decision granted service connection for radiculopathy of the left lower extremity associated with the lumbar spine disability, assigning a 20 percent rating effective August 30, 2010. A December 2020 rating decision granted service connection for radiculopathy of the right lower extremity associated with the lumbar spine disability, assigning a 20 percent rating effective November 24, 2020. While these rating decisions were not appealed, the Board finds that the ratings for radiculopathy of the lower extremities are part and parcel of the claim for a higher disability rating for the service-connected lumbar spine disability. See 38 C.F.R. § 4.71a, General Rating for Diseases and Injuries of the Spine, Note 1. Therefore, the Board will consider the radiculopathy evaluations in conjunction with the evaluation of the lumbar spine disability that was appealed from the September 2008 rating decision noted above. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant’s ordinary activity. 38 C.F.R. § 4.10; see generally Schafarth v. Derwinski, 1 Vet. App. 589 (1991). 1. Entitlement to an evaluation in excess of 20 percent for a lumbar spine disability The Veteran’s lumbar spine disability is currently rated as 20 percent disabling under Diagnostic Code (DC) 5242-5239 from October 1, 1988, excepting a period of temporary total disability from May 25, 2011, to July 31, 2011. Spine disabilities are typically rated under the same general formula, except for intervertebral disc syndrome (IVDS), which has an alternate rating formula for incapacitating episodes. 38 C.F.R. § 4.71a, DCs 5235-5243. Under the General Rating Formula for Diseases or Injuries of the Spine, a 20 percent evaluation is assigned where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or there is 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 evaluation is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. All of these evaluations under the general formula for rating spine injuries consider the disabilities 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. The Formula for Rating IVDS Based on Incapacitating Episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Note (1) to DC 5243 provides that, for purposes of ratings under DC 5243, 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. Certain changes to the musculoskeletal rating criteria went into effect on February 7, 2021, including to the diagnostic code relevant to IVDS. This code now requires there be disc herniation with compression and/or irritation of the adjacent nerve root. The rating criteria formula remained the same, and no changes were made to DCs 5239 and 5242, or to the general rating formula. The Board will apply the new criteria for the period beginning February 7, 2021, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (regulations may not have retroactive effect unless their language specifies so). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Section 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, would not be reflected on initial range-of-motion testing. 38 C.F.R. § 4.40. Section 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. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the additional 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.”). Here, throughout the period on appeal, the record reflects consistent reports of pain and limited forward flexion ranging between 40 degrees and 85 degrees. The Veteran claimed an increase for his lumbar spine disability rating in July 2007, reporting that he was experiencing decreased mobility and required use of a cane for assistance in walking. In addition to the specific notes discussed below, the Veteran’s private and VA treatment records document consistent complaints of low back pain throughout the appeal period, often reported as radiating to the lower extremities. The Veteran also regularly complained of stiffness in his back, particularly in the morning, for a few minutes to a few hours. In October 2006, the Veteran sought treatment with his primary care physician for low back pain, reporting that he was unable to stand for longer than 30 minutes due to pain. The physician noted a full range of motion, but did not provide measurements in the treatment note. In December 2006, the Veteran complained that the low back pain had worsened, in that now it was constant rather than intermittent. In August 2007, the Veteran attended a VA spine examination, at which he reported stiffness in his back upon waking in the morning. The Veteran denied having weakness in his back, but did endorse constant pain in his low back worsened by lifting, bending, walking, standing, or sitting too long. He also reported being unable to lie on his back for more than a minute, noting that he had to lie on his side instead. The initial range of motion was measured to be 74 degrees in forward flexion; 30 degrees in extension, right and left lateral flexion, and right lateral rotation; and 26 degrees in left lateral rotation. Pain was noted in flexion and left lateral rotation, causing the loss of range of motion in those planes. IVDS and ankylosis were not noted on the examination. In May 2010, the Veteran received an epidural steroid injection to treat his low back pain. In November 2010, he reported the back pain worsened with standing and walking, with relief by sitting or reclining and partial relief by leaning slightly forward. He attributed 80 percent of his complaints to the pain radiating to his right anterior thigh and 20 percent to the pain in the back itself. In December 2010, the Veteran attended a second VA spine examination, at which he reported he had been experiencing increased low back pain since the August 2007 examination, which worsened with activity. The initial range of motion was measured to be 80 degrees in forward flexion; 20 degrees in extension; and 25 degrees in right and left lateral flexion and rotation. Pain was noted on the examination, but no additional loss of range of motion was noted after three repetitions. IVDS and ankylosis were not noted on the examination. The examiner opined the Veteran’s lumbar spine disability would have moderate effects on his ability to complete chores or engage in recreation, exercise, and sports, and that it would have mild effects with hygiene and dressing. In May 2011, the Veteran underwent surgery to treat his lumbar spine disability; from May 25, 2011, to July 31, 2011, he is in receipt of a 100 percent evaluation, and no increase will be considered during this period. In August 2011, the Veteran underwent a course of physical therapy for his lumbar spine disability, at which he reported very mild low back pain compared to his pre-surgery baseline. In January 2013, the Veteran was afforded another VA spine examination, at which he reported intermittent sharp pain on the right side of his lower back. The initial range of motion was measured to be 70 degrees in forward flexion; 20 degrees in extension; and 30 degrees in right and left lateral flexion and rotation. Objective evidence of pain was noted in flexion and extension, but no additional loss of range of motion was noted after three repetitions. IVDS and ankylosis were not noted on the examination. In May 2013, the Veteran visited his primary care provider to follow-up on his low back disability. The physician noted normal alignment and normal range of motion of the spine, although no measurements were recorded in the treatment note. In November 2014, the Veteran denied back pain in two separate visits. At a cardiac health encounter, he reported an improvement in his chronic back pain, and reported exercising on a daily basis, including weight training, aerobics, and stationary bike. At a rheumatology clinic visit, he reported no joint or back pain, although he did endorse about an hour of stiffness upon waking in the mornings. In January 2015, the Veteran and his wife testified at the Board hearing. They reported the Veteran’s back pain had worsened approximately seven months prior, requiring him to sleep with his legs crossed in a figure four. The Veteran testified that he could only stand for about 10 or 15 minutes due to pain, and his wife testified that he was unable to walk for more than hour while grocery shopping, leaning on the grocery cart for support. She also reported that he was unable to ride in the car for long periods of time, and that she avoids asking him to do things that require standing, bending, sitting for long periods, or walking long distances. Beginning September 2016 until August 2017, the Veteran denied back pain during regular check-ups until complaining of bilateral back, arm, and shoulder pain that began two weeks prior to the August 2017 visit. In June 2018, the Veteran sought treatment for complaints of worsening low back pain and muscle spasms, which were noted in his lumbar region. At this visit, the range of motion of the lumbosacral spine was noted to be normal, although measurements were not recorded in the treatment note. Also noted was that range of motion testing did not elicit pain. In July 2018, the Veteran attended another VA spine examination, at which he reported sharp lower back pain and flare-ups upon over-exertion. He described difficulty walking or standing for long periods of time, and reported that he uses the grocery cart for support when shopping, that he cannot mow his lawn, and that he has difficulty bending over. The initial range of motion was measured to be 50 degrees in forward flexion; 10 degrees in extension; 15 degrees in right and left lateral flexion; 15 degrees in right lateral rotation; and 20 degrees in left lateral rotation. Objective evidence of pain was noted in forward flexion, causing functional loss. No additional loss of range of motion was noted after three repetitions; the examiner declined to provide an opinion regarding additional loss of range of motion during a flare-up. The examiner noted muscle spasms and guarding in the left lumbar paraspinal muscles that resulted in abnormal gait or spinal contour. IVDS and ankylosis were not noted on the examination. In January 2019, the Veteran attended another VA spine examination, at which he denied flare-ups of the low back disability. The initial range of motion was measured to be 85 degrees in forward flexion and 30 degrees in extension and right and left lateral flexion and rotation. Objective evidence of pain was noted in forward flexion and extension, but did not cause functional loss. No additional loss of range of motion was noted after three repetitions. A prior Board remand found one portion of this examination to be inadequate, as it did not provide requisite range of motion testing in passive motion and non-weight-bearing, so the Board will only consider the initial findings and the Veteran’s credible reports. IVDS and ankylosis were not noted on the examination. In December 2019, the Veteran was afforded another VA spine examination, at which he reported mild to severe flare-ups that occur dependent on activity and last several days, alleviated by rest. He reported that his lumbar spine disability limits prolonged walking, standing, bending, leaning forward, and carrying heavy items. The initial range of motion was measured to be 45 degrees in forward flexion; 10 degrees in extension; 15 degrees in right and left lateral flexion; and 10 degrees in left and right lateral rotation. Objective evidence of pain was noted in all ranges of motion, causing functional loss. No additional loss of range of motion was noted after three repetitions; the examiner opined the Veteran would have an additional five degrees of loss of motion in forward flexion, extension, and right and left lateral flexion during a flare-up. The examiner noted guarding of the thoracolumbar spine that resulted in abnormal gait or spine contour. The examiner identified IVDS, but there were no episodes of acute symptoms that required physician-prescribed bedrest in the previous 12 months. Ankylosis was not noted. Again, the examination did not include range of motion testing results in passive motion and non-weight-bearing, despite notations regarding the absence of pain on passive testing and the presence of pain on non-weight-bearing testing. The Board again found this portion of the examination inadequate, but will consider the other evidence elicited in the examination report. In November 2020, the Veteran was afforded another VA spine examination, at which he reported continued low back pain, as well as soreness and stiffness. The Veteran reported increased pain with prolonged walking and standing, but did not endorse flare-ups of the low back. He also reported constant use of his cane. The initial range of motion was measured to be 45 degrees in forward flexion; 10 degrees in extension; 15 degrees in right lateral flexion; 10 degrees in left lateral flexion; 20 degrees in right lateral rotation; and 15 degrees in left lateral rotation. No pain was noted on the examination, but the Veteran was unable to perform three repetitions due to instability and weakness without use of his cane. The examiner opined that pain and weakness limit the Veteran’s functional ability with repeated use of the lumbar spine over time, and opined that the Veteran would lose an additional five degrees of motion in all ranges after repeated use. IVDS and ankylosis were not noted on the examination. After careful review of the evidence of record, the Board finds that an increase is not warranted. To begin with, the Veteran’s range of motion was not measured to be 30 degrees or less at any point during the appeal period, nor is there any evidence of ankylosis of the entire thoracolumbar spine. Next, the Board acknowledges the Veteran’s consistent complaints of pain, but notes that pain is contemplated as part of the 20 percent evaluation already assigned. Further, the Board finds the functional limitation described in the record, including stiffness upon waking and limitations on standing, sitting, and walking, does not approximate a limitation of lumbar flexion to 30 degrees or less, nor does it approximate favorable ankylosis of the thoracolumbar spine. That is, although the Veteran described being unable to stand for longer than 15 minutes or half an hour, this limitation does not mimic an inability to bend forward more than 30 degrees. As for the Veteran’s complaint that he is limited in bending, the Board notes both the VA examinations and the check-ups in the Veteran’s private treatment records consistently indicate a functional range of motion in forward flexion throughout the appeal period. Further underscoring this finding are the December 2019 and November 2020 examiners’ opinions that the Veteran would lose only approximately five degrees more in motion during repetitive use or flare-up. To the extent the Veteran is limited in bending forward, the Board finds this limitation is due to pain, which, as noted above, is specifically contemplated as part of the 20 percent evaluation already assigned. Further, the Board notes the reports and findings of muscle spasms and guarding at various points in the record; however, muscle spasms are enumerated in the rating schedule as indicative of disability evaluated at the 10 and 20 percent levels. There is no indication in the record that these symptoms are severe enough to approximate favorable ankylosis of the entire thoracolumbar spine or limitation of forward flexion to 30 degrees or less. Therefore, the Board finds an evaluation in excess of 20 percent, excepting the period of temporary total evaluation from May 25, 2011, to July 31, 2011, for the lumbar spine disability is not warranted. Extraschedular Consideration The Board notes the Veteran’s representative contended at the January 2015 Board hearing that the Veteran should receive an extraschedular evaluation for his lumbar spine disability. The representative asserted that the rating schedule, in considering the need for bed rest and range of motion, does not contemplate the nature of the Veteran’s lumbar spine disability, which results in limited movement, a lot of pain, being unable to sit or stand for very long, needing a cane to walk, and needing to sit in a reclined position. Consideration of an extraschedular rating requires three steps. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second element, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. at 115. Here, regarding the first element, the Board finds that the Veteran’s disability is fully capable of evaluation under the rating schedule. The record shows that he has pain, which is worsened with activity such as prolonged standing, walking, or sitting, with limitation of motion of the lumbar spine. As previously discussed, the Veteran is currently rated under Diagnostic Code 5242-5239, which is rated using the General Rating Formula for Diseases and Injuries of the Spine. Ratings under this formula specifically address limitation of motion of the spine, with or without pain. Further, for all musculoskeletal disabilities, the Rating Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints, the Rating Schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. As such, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Therefore, the Board finds the Veteran’s symptoms are all contemplated by the schedular rating criteria as they apply to his lumbar spine disability. The threshold issue under Thun is therefore not met, and further consideration of an extraschedular rating is not warranted. 2. Entitlement to an initial evaluation in excess of 20 percent for radiculopathy of the left lower extremity The Veteran is currently assigned a 20 percent disability rating for radiculopathy of the left lower extremity under Diagnostic Code 8520. See 38 C.F.R. § 4.124a. Diagnostic Code 8520 pertains to the sciatic nerve, and provides that incomplete paralysis of the nerve is rated 20 percent when moderate, 40 percent when moderately severe, and 60 percent when severe, with marked muscular atrophy. Complete paralysis of the sciatic nerve, where the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of the knee weakened or, very rarely, lost warrants an 80 percent rating. 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. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” “moderately severe,” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to ensure that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Here, in addition to the specific instances noted below, the Veteran’s VA and private treatment records contain consistent reports of intermittent radicular symptoms in his left lower extremity, particularly the left foot, and a prescription for medication to treat radicular pain and other symptoms. In December 2010, the Veteran attended a VA spine examination, at which he reported he had been experiencing increased dull pain radiating from his low back at the belt line down his legs. He also reported numbness in his legs. Sensory testing produced normal results. In August 2011, the Veteran underwent a course of physical therapy after his lumbar spine surgery, at which he reported painful paresthesia in his left anterior leg, dorsal foot, and web space. He reported a reduction in the leg symptoms after surgery with the exception his left foot “slapping” when he walked, which had also occurred prior to the surgery. In September 2011, the Veteran complained of intermittent burning and tingling the left dorsal foot region, which was more prevalent with prolonged standing and walking. In January 2013, the Veteran attended another VA spine examination, at which he reported some dull, burning pain to the dorsum of his left foot. The sensory testing was normal in the left leg, and the examiner noted mild intermittent radicular pain in the left lower extremity. In January 2015, the Veteran’s wife testified at the Board hearing that the Veteran’s gait was affected by his radicular symptoms. She described his left foot slapping down prior to taking a step with that foot, and that he does not realize it is happening. The Veteran’s wife also testified that he needed support while walking for stability and balance, and had increasingly come to rely upon his cane. The Veteran testified that the radicular pain was the main reason he could not stand for long periods of time. In January 2018, the Veteran was afforded another VA spine examination. Sensory testing revealed decreased sensation to light touch in the left foot, and the examiner characterized the radiculopathy as moderate in severity. In June 2018, the Veteran sought treatment for low back pain and muscle spasms. At this check-up, sensory testing was normal and no decreased response to tactile stimulation was clinically noted. In January 2019, the Veteran attended another VA spine examination, at which sensory testing was normal. In December 2019, the Veteran was afforded another VA spine examination. The examiner noted moderate intermittent pain and paresthesias in the left lower extremity, and sensation to light touch was decreased in the left ankle and foot. The examiner opined the radiculopathy was moderate in severity. In November 2020, the Veteran was afforded another VA spine examination, at which he reported pain, numbness, and tingling radiating from his hips to his great toes in both lower extremities. Sensory testing for light touch was normal, but the examiner noted mild intermittent pain, paresthesias, and numbness in both lower extremities. The examiner opined the radiculopathy of both lower extremities was mild in severity. After review of the record, the Board finds an evaluation in excess of 20 percent for radiculopathy of the left lower extremity is not warranted. Throughout the period on appeal, the Veteran credibly reported radiating pain and numbness in his left lower extremity. For a portion of the appeal period, the record also reflects consistent and credible complaints of his left foot “slapping” the ground prior to stepping. The record reflects that the radiculopathy inhibits the Veteran’s ability to stand for long periods of time. The Board notes that the sensory testing was normal throughout the appeal period, with the exception of the December 2019 VA examination, at which moderate intermittent pain and paresthesias was noted. Taken as a whole, the Board finds the radicular symptoms, both sensory and those affecting the Veteran’s gait and ability to stand, are moderate in severity. In particular, the Board notes the pain and tingling were reported by the Veteran to be mild to moderate in severity, and there is no notation in the record of reduced muscular strength. Although the Veteran reported the left foot “slapping” and increased reliance on a cane for balance, the left foot complaint is not diagnosed at any point as foot drop or some degree of loss of control of the foot. Further, in conjunction with the normal sensory testing throughout most of the appeal period, these complaints do not rise to the level of moderately severe. Therefore, an increased evaluation is not warranted, and an evaluation in excess of 20 percent for radiculopathy of the left lower extremity is denied. 3. Entitlement to an initial evaluation in excess of 20 percent for radiculopathy of the right lower extremity The Veteran is currently assigned a 20 percent disability rating for radiculopathy of the right lower extremity under Diagnostic Code 8520, the same diagnostic code as the left lower extremity discussed above. See 38 C.F.R. § 4.124a. This evaluation was assigned effective November 24, 2020. The only evidence pertaining to radicular symptoms during the period on appeal is the November 2020 VA spine examination. At this examination, the Veteran reported pain, numbness, and tingling radiating from his hips to his great toes in both lower extremities. Sensory testing for light touch was normal, but the examiner noted mild intermittent pain, paresthesias, and numbness in both lower extremities. The examiner opined the radiculopathy of both lower extremities was mild in severity. Upon review of this evidence, the Board finds that an evaluation in excess of 20 percent is not warranted for radiculopathy of the right lower extremity. The reports from the Veteran of mild pain, numbness, and tingling to his right lower extremity are found to be credible. However, considering the sensory testing for light touch was normal, the Board does not find the reports of radicular symptoms to illustrate a moderately severe disability, and an increased evaluation is denied. REASONS FOR REMAND Entitlement to a TDIU is remanded. Throughout the record, there are conflicting reports of the Veteran retiring from full-time employment in 2008, 2009, and 2010. As the period on appeal encompasses all of these dates, a remand is necessary to obtain a detailed work history, either with a TDIU application (VA form 21-8940) or other evidence of his work history. The matter is REMANDED for the following action: Develop the Veteran’s claim for a TDIU by obtaining a detailed work history, to include providing him with proper notice and the opportunity to complete an VA Form 21-8940, as well as any further steps the RO deems necessary to fully develop the claim. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.