Citation Nr: 21026150 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-05 056 DATE: April 29, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for right shoulder (major) sprain with osteoarthritis (OA) is denied. Entitlement to an initial rating of 20 percent, but no higher, prior to April 11, 2019, for left shoulder sprain with OA is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 20 percent since April 11, 2019, for left shoulder sprain with OA is denied. Entitlement to an initial rating in excess of 10 percent prior to April 11, 2019, for cervical spine (neck) sprain with OA is denied. Entitlement to a rating in excess of 20 percent since April 11, 2019, for neck sprain with OA is denied. Entitlement to a temporary 100 percent rating based on hospitalization in excess of 21 days for service-connected psychiatric disability is granted subject to the law and regulations governing the payment of monetary benefits.   REMANDED Entitlement to service connection for a thoracolumbar spine disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. At its worst, the Veteran’s right shoulder sprain with OA was manifested by pain, flexion limited to 82 degrees, and abduction limited to 67 degrees; it has not been manifested by limitation of motion of the arm midway between side and shoulder. 2. Prior to April 11, 2019, at its worst, the Veteran’s left shoulder sprain with OA was manifested by pain, flexion limited to 65 degrees, and abduction limited to 55 degrees; it was not manifested by limitation of motion of the arm to 25 degrees from side. 3. Since April 11, 2019, the Veteran’s left shoulder sprain with OA has been manifested by pain, flexion limited to 65 degrees, and abduction limited to 70 degrees with repeated use over a period of time and with flare-ups; it has not been manifested by limitation of motion of the arm to 25 degrees from side. 4. Prior to April 11, 2019, the Veteran’s cervical spine sprain with OA was manifested by pain and full range of motion; it was not manifested by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 5. Since April 11, 2019, the Veteran’s cervical spine sprain with OA has been manifested by pain and forward flexion limited to 25 degrees with repeated use over a period of time and with flare-ups; it has not been manifested by forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. 6. The Veteran’s hospitalization from September 2012 to December 2012 was pursuant to his service-connected psychiatric disability. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for right shoulder sprain with OA have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 2. Prior to April 11, 2019, the criteria for an initial rating of 20 percent, but no higher, for left shoulder sprain with OA were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 3. Since April 11, 2019, the criteria for a rating in excess of 20 percent for left shoulder sprain with OA were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 4. Prior to April 11, 2019, the criteria for an initial rating in excess of 10 percent for cervical spine sprain with OA were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 5. Since April 11, 2019, the criteria for a rating in excess of 20 percent for cervical spine sprain with OA have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 6. The criteria for a temporary total rating based on hospitalization for over 21 days for a service-connected disability have been met. 38 U.S.C. § 1155; C.F.R. §§ 4.1, 4.29.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from July 1979 to July 1992. This matter is before the Board of Veterans’ Appeals (Board) following a Board Remand in July 2018. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection for both shoulders and neck disabilities. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). VA’s schedule for rating musculoskeletal and muscle injury disabilities was revised effective February 7, 2021, during the pendency of the appeal. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). Prior to February 7, 2021, the old rating criteria solely applies. From February 7, 2021, the most favorable rating criteria of the two applies. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 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). 1. Entitlement to an initial rating in excess of 20 percent for right shoulder sprain with OA 2. Entitlement to an initial rating in excess of 10 percent prior to April 11, 2019, for left shoulder sprain with OA 3. Entitlement to a rating in excess of 20 percent since April 11, 2019, for left shoulder sprain with OA The Veteran contends that he is entitled to higher ratings for his shoulder disabilities. The Veteran’s shoulder disabilities have been rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. As noted above, effective February 7, 2021, § 4.71a, Schedule of ratings musculoskeletal system was revised. Prior to February 7, 2021, pursuant to Diagnostic Code 5003, arthritis, degenerative (hypertrophic or osteoarthritis), established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. 38 C.F.R. § 4,71a, Diagnostic Code 5003. Effective February 7, 2021, Diagnostic Code 5003 was revised as follows: Degenerative arthritis, other than post-traumatic: Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent disability rating is warranted. With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent disability rating is warranted. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 CFR Part 4, Schedule for Rating Disability: Musculoskeletal System and Muscle Injuries; Correction, 85 Fed. Reg. 249, 85523 (December 29, 2020). Under Diagnostic Code 5201, prior to February 7, 2021, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Effective February 7, 2021, the criteria for limitation of motion of the arm under Diagnostic Code 5201 was revised to clarify that limitation of motion of the arm at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201). Normal range of motion of the shoulder is flexion and abduction from 0 to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with 0 degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Veteran underwent VA examination in July 2013 at which time he reported shoulder pain but denied giving away, subluxation, swelling, redness, and flare-ups. Physical examination demonstrated right shoulder flexion and abduction to 90 degrees and left shoulder flexion and abduction to 115 degrees with pain at the endpoints. There was no additional loss of motion on repetitive use testing. There was localized tenderness or pain on palpation of joints/soft tissue/biceps tendons of both shoulders. There was no guarding. Muscle strength was normal; and there was no ankylosis. VA treatment records indicate that the Veteran underwent physical medicine rehabilitation consultation on October 25, 2017 at which time physical examination demonstrated right shoulder flexion to 82 degrees, extension to 30 degrees, abduction to 67 degrees, external rotation to 24 degrees, and internal rotation to 16 degrees; left shoulder flexion to 65 degrees, extension to 15 degrees, abduction to 55 degrees, external rotation to 15 degrees, and internal rotation to 20 degrees. Passive range of motion of the left shoulder was impaired in all planes of movement (30 degrees) and right shoulder in external rotation only. Shoulder strength was diminished (3/5). Phalen’s, Speed’s, Empty Can, Gerbers Lift Off, Apley Scratch, Neers, Hawkins Kennedy, Apprehension, Yergasons were all positive. Tenderness was noted at anterior and superior aspect of both shoulders. The Veteran underwent physician therapy; and on December 6, 2017, physical examination demonstrated right shoulder flexion to 142 degrees, extension to 48 degrees, abduction to 120 degrees, external rotation to 46 degrees, and internal rotation to 45 degrees; left shoulder flexion to 110 degrees, extension to 28 degrees, abduction to 72 degrees, external rotation to 18 degrees, and internal rotation to 24 degrees. The Veteran underwent VA examination in April 2019 at which time he reported pain with flare-ups with lifting, pulling, and pushing. The pain was noted to be sharp 6/10 along the superior aspect of both shoulders. Physical examination demonstrated right shoulder flexion to 115 degrees and abduction to 100 degrees as well as left shoulder flexion to 70 degrees and abduction to 75 degrees. Both shoulders demonstrated internal and external rotation to 70 degrees, and there was pain on all motion including passive motion as well as with weightbearing and non-weight bearing. There was also localized tenderness of the glenohumeral joints. There was no additional functional loss or range of motion on repetitive use testing. The examiner noted that pain significantly limited functional ability with repeated use over a period of time and with flare-ups with an additional loss of 5 degrees in all motions of both shoulders. Muscle strength was normal; and there was no ankylosis. The Board finds that the preponderance of the evidence supports a rating of 20 percent during the entire appeal period for the Veteran’s left shoulder disability as there was objective evidence of pain and limitation of motion. However, the preponderance of the evidence is against a rating in excess of 20 percent for either shoulder disability. The evidence shows that the Veteran is right-handed as noted by the April 2019 VA examiner. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain; however, even considering the Veteran’s lay reports, such would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level of the major extremity or limitation of motion of the arm to 25 degrees from the side of the major or minor extremity. At their worst, right arm motion was significantly higher (82 degrees of flexion in October 2017) than the 45 degrees needed for a 30 percent rating and left arm motion was higher (65 degrees in October 2017 and April 2019) than the 25 degrees needed for a 30 percent rating. As noted above, passive range of motion of the right arm was diminished 30 degrees in all planes. As 180 degrees is the normal range of motion for flexion and abduction of the shoulder and 90 degrees is the normal range of motion for internal and external rotation, a 30 degree loss in passive motion would still be higher than the 45 degrees needed for a 30 percent rating for the right arm and 25 degrees needed for the left arm. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. There is has been no evidence of ankylosis of scapulohumeral articulation and no evidence of malunion, fibrous union, nonunion, or recurrent dislocations of the humerus. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. On VA examinations there was no objective evidence of rotator cuff conditions, instability, dislocation, labral pathology, acromioclavicular (AC) joint conditions, or any impairment of the clavicle or scapula. MRI of the left shoulder in December 2017 showed small focus of partial-thickness undersurface tearing at the insertion of the supraspinatus tendon posterior fibers extending into the infraspinatus tendon anterior fibers. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 20 percent for right and left shoulder sprain with OA. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Entitlement to an initial rating in excess of 10 percent prior to April 11, 2019, for neck sprain with OA is denied. Entitlement to a rating in excess of 20 percent since April 11, 2019, for neck sprain with OA is denied. The Veteran contends that he is entitled to higher ratings for his service-connected neck disability. As noted above, VA has recently revised portions of the rating criteria for the musculoskeletal system, effective February 7, 2021. 82 Fed. Reg. 35719. However, the regulations for rating cervical spine disabilities under Diagnostic Code 5242 have not changed. The Veteran’s cervical spine (neck) disability has been 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 cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating 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. VA treatment records indicate that in April 2013, the Veteran had full neck range of motion. The Veteran underwent VA examination in July 2013 at which time he was diagnosed as having cervical spine strain and OA. The Veteran reported intermittent morning stiffness but no radiculopathy or flare-ups. It appears that initial range of motion (ROM) measurements were normal with pain at the endpoints although the examiner noted that extension was 45 degrees or greater; however, this appears to be a mistake. Muscle strength, reflex, and sensory examinations were all normal; and there was no radiculopathy, other neurologic abnormalities, or intervertebral disc syndrome (IVDS). VA treatment records indicate that in October 2013, the Veteran underwent VA physical therapy initial evaluation for low back pain at which time he noted that two weeks prior, he had episodes of muscle spasms which affected his back, neck, and shoulders, had been unable to get out of bed, and was taking a muscle relaxer and naproxen for pain relief. In November 2015, the Veteran had an intercurrent neck injury; he was involved in an altercation with an extended family member and was “body slammed” to the floor; he complained of, inter alia, 5/10 neck pain. He arrived by ambulance at the emergency room; x-rays of the cervical spine showed no acute findings. In September 2016, the Veteran reported that the month prior, he suffered a spasm from his neck down to his hip and was unable to do anything for a week. In December 2017, the Veteran had full neck range of motion. The Veteran underwent VA examination in April 2019 at which time he reported neck pain with flare-ups with lifting, pulling, and pushing. at which time he was diagnosed as having cervical spine strain and OA. On physical examination, flexion, extension, and right and left lateral flexion were all from zero to 30 degrees, and right and left lateral rotation were from zero to 50 degrees. There was pain on all motion including passive motion and on weight bearing. The examiner noted that non-weight bearing testing could not be performed because weight was applied even while at rest in all positions. There was tenderness to cervical spine and paraspinal muscles. There was no additional loss of function or range of motion on repetitive use testing. The examiner noted that pain significantly limited functional ability with repeated use over a period of time and with flare-ups with an additional loss of 5 degrees in all motions of the cervical spine. There was no guarding or muscle spasm. Muscle strength, reflex, and sensory examinations were all normal; and there was no radiculopathy, other neurologic abnormalities, or IVDS. The Board finds that prior to April 11, 2019, the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran’s cervical spine disability. In April 2013 and December 2017, the Veteran had full neck range of motion; and on VA examination in July 2013, range of motion measurements were normal with pain at the endpoints. The Board notes again that the measurement for extension of 45 degrees at the July 2013 VA examination appears to be a mistake especially in light of the fact that the record is absent any evidence of limitation of extension on objective testing including at the April 2019 VA examination. The Board also finds that since April 11, 2019, the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran’s cervical spine disability. On physical examination at the April 2019 VA examination, flexion was to 30 degrees with an additional 5-degree loss estimated for pain which significantly limited functional ability with repeated use over a period of time and with flare-ups. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain; however, even considering the Veteran’s lay reports, such symptoms would not result in symptoms more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees prior to April 11, 2019. Additionally, the Veteran’s lay reports of symptoms would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine since April 11, 2019. Further, although the Veteran reported suffering from muscle spasms, there is no objective evidence of muscle spasms severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, both the July 2013 and the April 2019 VA examiners indicated that the Veteran did not have IVDS. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Both the July 2013 and the April 2019 VA examiner indicated that muscle strength, reflex, and sensory examinations were all normal and that there was no radiculopathy or other neurologic abnormalities. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent prior to April 11, 2019, and in excess of 20 percent since April 11, 2019, for cervical spine sprain and OA. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a temporary 100 percent rating based on hospitalization for more than 21 days for service-connected psychiatric disability In October 2012, the Veteran filed a claim for a temporary total rating due to his stay and treatment in the PTSD program at VAMC Miami from September 12, 2012 to December 12, 2012. Under 38 C.F.R. § 4.29, a temporary total disability rating will be assigned when it is established that one or more service-connected disabilities has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. Subject to the provisions of paragraphs (d), (e), and (f) of § 4.29, this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. 38 C.F.R. § 4.29 (a). If a hospital admission was for disability not connected with service, and during such hospitalization, hospital treatment for a service-connected disability is instituted and continued for a period in excess of 21 days, the increase to a total rating will be granted from the first day of such treatment. If service connection for the disability under treatment is granted after hospital admission, the rating will be from the first day of hospitalization if otherwise in order. See 38 C.F.R. § 4.29 (b). The assignment of a total disability rating on the basis of hospital treatment or observation will not preclude the assignment of a total disability rating otherwise in order under other provisions of the rating schedule, and consideration will be given to the propriety of such a rating in all instances and to the propriety of its continuance after discharge. Particular attention, with a view to proper rating under the rating schedule, is to be given to the claims of veterans discharged from hospital, regardless of length of hospitalization, with indications on the final summary of expected confinement to bed or house, or to inability to work with requirement of frequent care of physician or nurse at home. See 38 C.F.R. § 4.29 (c). VA treatment records indicate that the Veteran was admitted to VA’s Psychosocial Residential Rehabilitation Treatment Program (PRRTP) on September 12, 2012. A Mental Health PRRTP Initial Evaluation Note indicates that the Veteran was referred to the program by his psychiatrist. He was diagnosed as having mood disorder NOS, and the intervention was elective admission to the PRRTP-FA-PA, the 91-day residential rehabilitation treatment program for chronic co-morbid psychiatric, substance abuse, and medical problems. A September 14, 2012, Recreational Therapy Treatment Plan Note indicated that the Veteran “comes to the 5A with a diagnosis of Major Depression that is effecting his day to day life.” A Discharge Summary noted that the Veteran was admitted to 5A- PRRTP on September 12, 2012, with admitting diagnosis of mood disorder NOS; he was discharged on December 12, 2012 with discharge diagnosis of MDD, mild. As service connection for MDD with anxious distress and psychotic features has been established from January 12, 2012, and the Veteran’s hospitalization from September 12, 2012 to December 12, 2012 was based on the Veteran’s MDD, the criteria for entitlement to a temporary total rating based on for a period in excess of 21 days is granted. REASONS FOR REMAND 1. Entitlement to service connection for a thoracolumbar spine disability In July 2018, the Board remanded this issue for additional development. Specifically, the Board noted that the June 2011 VA exminer neglected to comment on the possibility that the Veteran’s symptoms of the neck and upper back pain in service could have been indicative of the incurrence of a low back condition. The Board specifically directed, “… the examiner must first determine the proper diagnosis to account for the Veteran’s long history of low back symptomatology, and then provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed low back condition is related to the Veteran’s military service. In setting forth this opinion, the examiner should consider, and comment upon as necessary, the Veteran’s documented complaints of neck and upper back pain in service.” The Veteran underwent VA examination in April 2019. Although the examiner discussed a September 1989 note documenting back pain, he does not discuss the February and March 1992 complaints of upper back pain as required by the July 2018 Board remand. As such, an additional remand is required to obtain an addendum opinion that specifically addresses whether the in-service complaints of upper back pain is in anyway related to his current thoracolumbar spine disorder. 2. Entitlement to service connection for a left knee disability In July 2018, the Board remanded this issue for additional development. Specifically, the Board noted that the Veteran contended that his left knee condition was secondary to his service-connected hallux valgus. The Board directed that the examiner provide an opinion as to whether the Veteran’s left knee condition was caused or aggravated by one or more service-connected disabilities paying particular attention to service-connected hallux valgus. In April 2019, the VA examiner found that the knee was less likely than not aggravated by the hallux valgus condition and noted, Because of the hallux valgus condition, the veteran does less activity than he otherwise would have. A s a result of the reduced activity level, the veteran places less stress on the left knee than he otherwise would have. Therefore (sic) the left knee condition most likely progressed less rapidly than it otherwise would have as a result of the reduced activity due to the hallux valgus. The left knee condition is unlikely to be secondary to or to have been aggravated by the hallux valgus condition. The Board notes that the examiner diagnosed the Veteran as having left knee strain. During the examination, the Veteran reported that his knee pain was worse with prolonged standing, walking, and running as well as kneeling. The examiner noted that the there was evidence of pain with weight bearing as well as tenderness at medial and lateral joint lines. At the time of the examination, service connection had been established for hallux valgus of both feet and right ankle degenerative arthritis with residuals of fracture and chronic sprain. In addition, VA treatment records noted intermittent periods (April 2011; October 2012; October and December 2013; January, July, and December 2014; and September and November 2015; and August 2017. The April 2019 VA examiner did not discuss the Veteran’s intermittent antalgic gait due to hallux valgus and right ankle pain and any impact it may have on the Veteran’s left knee. As such, an additional remand is required to obtain an addendum opinion that specifically addresses whether the intermittent antalgic gait, caused at least in part by service-connected disabilities, is in anyway related to his current left knee disorder. 3. Entitlement to service connection for GERD In July 2018, the Board remanded this issue for additional development. Specifically, the Board noted that the Veteran contended that his GERD was due to his use of medication to alleviate his symptoms of anxiety or directly attributable to his acquired psychiatric disorder. The Veteran underwent VA examination in May 2019. Although the examiner discussed whether the Veteran’s GERD was related to his active duty service and to service-connected MDD, he did not discuss whether the medications taken for any service-connected disability caused or aggravated the Veteran’s GERD. At the time of the May 2019 VA examination, the Veteran was prescribed acetaminophen for pain, sildenafil citrate for erectile dysfunction, and escitalopram for MDD. As such, an additional remand is required to obtain an addendum opinion that specifically addresses whether the medication prescribed for the Veteran’s service-connected disability is in anyway related to his GERD. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. Entitlement to a TDIU In the May 2018 Informal Hearing Presentation, the Veteran’s representative indicated that the Veteran’s service-connected musculoskeletal disabilities and suicide attemps prevented him from obtaining and maintaining gainful employment. In its July 2018 decision, the Board added the issue as being reasonably raised by the record and deferred adjudication pending development of the remanded issues. In May 2020, the Veteran was invited to submit the form to apply for benefits in connection with his TDIU claim. To date, no application for a claim of TDIU is of record. This was conveyed to the Veteran in a June 2020 Supplemental Statement of the Case which denied entitlement to a TDIU. The record indicates that the Veteran has experienced homelessness and unemployment for a large part of the appeal period; however, a February 2021 Mental Health Treatment Plan Note indicates that the Veteran had adequate housing situation and was currently employed. Due to the conflicting record, the Board finds that the Veteran should have another opportunity to complete and submit for consideration VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The matters are REMANDED for the following action: 1. Send the Veteran a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, and request that he complete the form and provide any additional information to substantiate a claim of entitlement to TDIU. 2. Obtain addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s thoracolumbar spine disorder. The clinician must first determine the proper diagnosis to account for the Veteran’s long history of thoracolumbar spine symptomatology, and then provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed lumbar spine low back condition had its onset in service or is in any way related to service-connected complaints, to include the complaints of back pain in 1989 and complaints of upper back pain in 1992. 3. Obtain addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s left knee disorder. The clinician should provide an opinion as to whether it is at least as likely as not that the Veteran’s current left knee disorder is proximately due to service-connected disability/aggravated beyond its natural progression by service-connected disability, specifically hallux valgus of both feet and right ankle degenerative arthritis with residuals of fracture and chronic sprain, including intermittent periods during the appeal period of antalgic gait. 4. Obtain addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s GERD. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s GERD is proximately due to service-connected disability/aggravated beyond its natural progression by service-connected disability, including medications taken during the appeal period for service-connected MDD, erectile dysfunction, and pain due in part to service-connected disabilities. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the issue of entitlement to a TDIU. Emily Tamlyn Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Olson, Patricia 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.