Citation Nr: 21026716 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-04 170A DATE: May 3, 2021 ORDER An initial rating in excess of 10 percent for degenerative arthritis of the right knee with patellar tendinitis is denied. Prior to July 5, 2019, a separate rating for service-connected radiculopathy of the right lower extremity is denied. REMANDED Entitlement to an initial rating in excess of 10 percent prior to July 5, 2019, and in excess of 20 percent from July 5, 2019 and thereafter, for service-connected lumbar spine degenerative disc disease is remanded. Entitlement to an initial rating in excess of 20 percent for left shoulder impingement syndrome (non-dominant) is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's degenerative arthritis of the right knee with patellar tendinitis is manifested by limitation of flexion to 80 degrees with pain on motion; but no ankylosis, subluxation, lateral instability, cartilage condition, limitation of extension, nonunion or malunion of the tibia or fibula, or genu recurvatum has been shown. 2. Prior to July 5, 2019, the Veteran did not have a diagnosis of radiculopathy of the right lower extremity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for degenerative arthritis of the right knee with patellar tendinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 2. Prior to July 5, 2019, the criteria for a separate evaluation for service-connected radiculopathy of the right lower extremity were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to January 1985. On appeal are two rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The first is a February 2015 rating decision that granted service connection for: (1) right knee patellar tendinitis and assigned a 10 percent rating effective June 12, 2014; (2) lumbar spine degenerative disc disease at 10 percent effective June 12, 2014; and, (3) left shoulder impingement syndrome (non-dominant) at 10 percent effective June 12, 2014. The second is a December 2015 rating decision that denied TDIU. During the pendency of the appeal, in an April 2020 rating decision, the RO increased the rating for the Veteran's left shoulder impingement syndrome to 20 percent effective June 12, 2014; increased the rating for lumbar spine degenerative disc disease to 20 percent effective July 5, 2019; and, granted service connection for radiculopathy, right lower extremity, at 10 percent effective July 5, 2019. As the disability rating assigned does not represent a total grant of benefits sought on appeal, the claim for an increase remains before the Board. AB v Brown, 6 Vet. App. 35, 39 (1993). When these matters were initially before the Board of Veterans' Appeals (Board), the Board remanded for additional development in July 2018, June 2020, and November 2020. The case has now been returned to the Board for appellate review. The issues involving the Veteran's right knee and radiculopathy are addressed in the decision below. The issues involving the Veteran's lumbar spine, left shoulder and TDIU are addressed in the REMAND section below. Duty to Notify and Assist The Veteran has not raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. Also of record are VA examinations and/or medical opinions obtained in January 2015, December 2016, July 2019, September 2020, December 2020, and January 2021. The Veteran has not referred to any additional, unobtained, relevant, available evidence. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). 1. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the right knee with patellar tendinitis. The Veteran was granted service connection for right knee patellar tendinitis and assigned a 10 percent rating effective June 12, 2014. On appeal, the Veteran contends he is entitled to a higher disability rating. Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court clarified that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The Veteran's right knee patellar tendinitis is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5260, pertaining to limitation of flexion. Under that code, a 20 percent evaluation is warranted for flexion limited to 30 degrees. A maximum 30 percent evaluation is warranted for flexion limited to 15 degrees. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. The Veteran underwent VA examination of his knees in January 2015. The examiner noted a diagnosis of right knee patellar tendinitis. It was noted that the Veteran reported onset of the symptoms in 1977, as he started to have right knee pain since basic training. He stated further that his right knee gives out and becomes stiff sometimes, making it hard to walk and that he has fallen due to this. He also reported flare-ups, during which he is unable to walk without using a cane and knee brace. Upon examination, range of motion measurements were taken, with flexion to 130 degrees with evidence of painful motion, and extension to 0 degrees, with no evidence of painful motion. Repetitive use testing was conducted with no additional limitation in range of motion. Functional loss was described as less movement than normal in the right knee and pain on movement of the right knee. Joint stability tests were normal for the right knee. There was no evidence or history of recurrent patellar subluxation/dislocation and the Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran did not have any meniscal condition or any surgical procedures. The Veteran used a cane regularly. Imaging studies of the knee had been performed and arthritis was not indicated. The examiner noted there was no x-ray evidence of patellar subluxation but testing of the right knee showed "chronic tendinitis of the suprapatellar tendon at its insertion on the patella/otherwise normal right knee." The Veteran underwent another VA examination of his knees in December 2016. The examiner noted a diagnosis of right knee tendonitis. It was noted that the Veteran reported he uses a cane and a brace for his knee when working around house, and that he had physical therapy within the year for his knee. He did not report flare-ups of the knee. Upon examination, range of motion was normal, with flexion to 140 degrees, extension to 0 degrees, and no pain noted on exam. Repetitive use testing was conducted with no additional limitation in range of motion. The examiner stated it would be speculative to opine as to whether or not pain, weakness, fatigability, or incoordination could significantly limit the Veteran's functional ability during flare-ups, or when the joint is used repeatedly over a period of time. The examiner stated there was no muscle atrophy and no ankylosis. Joint stability tests were conducted and there was no joint instability noted by the examiner. There was no history of recurrent subluxation; no history of lateral instability; and no recurrent effusion. The examiner also noted the Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran did not have any meniscal condition or any surgical procedures. The Veteran used a cane regularly and a brace occasionally. Imaging studies had been performed and results were available: degenerative or traumatic arthritis was not documented, but other results showed small quadriceps and patellar insertional enthesophyte. The examiner stated enthesophyte suggests chronic tendonitis. The Veteran underwent another VA examination in July 2019. The Veteran reported his pain is now worse in the right knee, and that he has to use a cane to prevent falls due to weakness in his knee. The Veteran did not report flare-ups and indicated the functional impact is that he cannot stand for prolonged periods of time, squat, or take a long walk or run. Upon examination, range of motion measurements were taken, with flexion to 80 degrees, extension to 0 degrees, and pain noted on exam. Repetitive use testing was conducted with no additional limitation in range of motion. The examiner opined that there was no additional loss of function or motion when it comes to repeated use over time. The examiner noted there were other factors contributing to disability: disturbance of locomotion and interference with standing. There was no ankylosis. Joint stability tests were conducted and there was no joint instability noted by the examiner. There was no history of recurrent subluxation; no history of lateral instability; and no recurrent effusion. The examiner also noted the Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran did not have any meniscal condition or any surgical procedures. The Veteran used a cane and a brace occasionally. Imaging studies of the knee had been performed and arthritis was indicated. The examiner also noted that July 2019 x-rays of the right knee showed a patellar spur. In terms of functional impact, the examiner stated it is difficult for the Veteran to stand and walk for prolonged time due to knee pain. In closing, the examiner stated the Veteran has a new diagnosis of right knee degenerative arthritis, a progression of the right knee tendinitis. In January 2021, a medical opinion was obtained to address the severity of the Veteran's degenerative arthritis of the right knee with patellar tendinitis throughout the appellate period, and to address flare-ups, and whether, after review of the January 2015, December 2016, and July 2019 VA examination reports, a retrospective estimate of additional loss of range of motion during flare-ups could be provided. After review of the medical evidence, the examiner first noted two pieces of evidence. A June 2014 right knee x-ray shows no acute fracture or dislocation; a fabella, normal variant; small quadriceps and patellar insertional enthesophyte; and no significant joint effusion. A July 2019 right knee x-ray shows a patellar spur. First, the examiner states the June 2014 examination showed patellar insertional enthesophyte and the July 2019 x-ray shows a patella spur with no other changes. As such, there is no change to the severity of the service-connected right knee condition during the period from June 2014 to July 2019. Next, the examiner stated a retrospective estimate of additional loss of range of motion during flare-ups cannot be provided after review of the examination and claims file without speculation. Lastly, the examiner stated that an enthesophyte is a type of bone spur. As the June 2014 showed patellar insertional enthesophyte, and the July 2019 x-ray shows a patella spur with no other changes, the file did not support improvement of the right knee condition, it supports no change. Post service VA treatment records from the American Lake, Seattle VAMC are associated with the Veteran's claims file. In summary, these records contain the VA examinations noted above, without indicating any separate treatment for the knee. A July 2014 treatment note reflects the Veteran was seen with complaints of right knee pain and that his right knee tends to "give out" at times when he walks, preceded by pain, especially when he is walking up an incline. An October 2015 record reflects the Veteran noticed that his knees are giving out worse since he started physical therapy for his back. An October 2015 Orthotics Prosthetics Note reflects the Veteran came to the Prosthetics Clinic for pain in the right knee. It was noted he was previously issued a medium brace but had requested a larger brace. He was issued a large brace that he stated fit very well and was comfortable. Upon review of the relevant evidence, the Board finds that while the Veteran's diagnosis has progressed from tendonitis to degenerative arthritis, a rating in excess of 10 percent is not warranted for the entire period on appeal. In order to obtain a higher rating for limitation of flexion under DC 5260, flexion must be limited to 30 degrees to obtain a 20 percent rating. However, in the three VA examinations noted above (January 2015, December 2016, and July 2019), flexion was measured at 130 degrees, 140 degrees (normal), and 80 degrees, respectively, even when pain on motion and during flare-ups is considered. As such, a higher rating under DC 5260 is not warranted. The Board has also reviewed the other diagnostic codes that pertain to evaluation of knee disabilities to determine if any other diagnostic code is applicable to the Veteran's right knee disability. Here, however, the Board concludes that no separate or higher ratings are warranted. The Board has also considered both the prior and current provisions of Diagnostic Code 5257, which governs instability. The Board finds the Veteran's complaints to be competent and credible insofar as they report feelings of the knee "giving way." However, the term instability can have multiple meanings and here, all clinical joint stability testing of record is negative. As the Veteran does not have any recurrent subluxation or instability that could be objectively elicited, or patellar instability after surgical repair, the Board does not find that the Veteran has any instability to warrant a separate 10 percent evaluation; therefore, a higher rating under Diagnostic Code 5257 is not warranted. In addition, in this case, rating under Diagnostic Code 5256 is not warranted as the Veteran has not been shown to have ankylosis. A separate or higher rating under Diagnostic Code 5258 is also not warranted as the Veteran has not been shown to have dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A separate or higher rating under Diagnostic Code 5259 is not warranted as the Veteran has not been shown to have removal of any semilunar cartilage. A separate or higher rating under Diagnostic Code 5261 is not warranted as the Veteran's extension in his right knee has been shown to be no worse than 0 degrees. A separate or higher rating under Diagnostic Code 5262 is not warranted as the Veteran has not been shown to have impairment of the tibia or fibula or any medial tibial stress syndrome. A separate or higher rating under Diagnostic Code 5263 is not warranted as the Veteran has not been shown to have a diagnosis of genu recurvatum. Finally, the Board has also considered Diagnostic Code 5010 as it governs degenerative arthritis, but the Board finds that the Veteran's arthritis is not assignable for involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. The Board has also considered the Veteran's reported impairment of function and has considered additional limitation of motion due to pain. Even considering additional limitation of motion or function of the left knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), the evidence does not show that the right knee disability more nearly approximates the criteria for any higher rating for any period on appeal. Lastly, the Board has also considered the Veteran's lay statements, especially the Veteran's reports that his right knee gives out occasionally. While lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), in this case, such an opinion falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). To the extent that the Veteran contends that his right knee disability is more severe than evaluated, while he is competent to describe that he has knee pain, he is not competent to report that his pain is of sufficient severity to warrant a certain evaluation under VA's rating criteria because such an opinion requires medical expertise which he does not possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, the three VA examiners noted above conducted joint stability testing and each examiner found that there was no joint instability. As a result, the Board finds the results of the VA examinations to be more probative than the lay evidence, particularly the findings of the January 2015, December 2016, and July 2019 VA examiners, each of whom found there was no joint instability and/or lateral instability, as discussed above. In sum, the Board concludes that for the entire period on appeal, a rating in excess of 10 percent for the Veteran's degenerative arthritis of the right knee with patellar tendinitis is not warranted at any point during the appeal period. 2. Entitlement to a separate evaluation prior to July 5, 2019, for service -connected radiculopathy of the right lower extremity. In February 2015, the Veteran was granted service-connection for degenerative disc disease of the lumbar spine and assigned a 10 percent rating effective June 12, 2014. As that issue was being appealed, in an April 2020 rating decision, the Veteran was granted a separate evaluation for the downstream issue of radiculopathy, right lower extremity at 20 percent effective July 5, 2019. The Veteran is now challenging whether he was entitled to the separate evaluation for radiculopathy prior to July 5, 2019. When this issue was initially before the Board, the Board noted in its most recent Remand in November 2020, that service connection for radiculopathy, right lower extremity, was granted effective July 5, 2019 - the date of a VA examination reflecting evidence of radiculopathy. However, the Board also noted that there was medical evidence of record prior to the Veteran's July 2019 examination noting numbness and tingling in the legs. Accordingly, the Board found that an opinion was warranted to ascertain whether the Veteran was entitled to a separate evaluation for radiculopathy of the right lower extremity prior to July 5, 2019. A January 2015 VA examination noted a diagnosis of lumbar spine degenerative disc disease, but the examiner specifically stated the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. A December 2016 VA examination of the Veteran's lumbar spine noted the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. A July 5, 2019 VA examination of the Veteran's lumbar spine noted the Veteran had a diagnosis of lumbar spine degenerative disc disease as well as a diagnosis of radiculopathy, right lower extremity. Pursuant to the Board's remand, a VA medical opinion was obtained in December 2020. The examiner conducted an in-person examination, reviewed the Veteran's claims file, and specifically referred to 5 pieces of evidence of record in the examiner's written report: (1) A January 2015 back DBQ that indicates no radiculopathy; (2) An October 2015 UW Medicine Valley Medical Center record that indicates pain in lower back and down both legs; (3) A December 2015 physical therapy note that indicates back pain with lower extremity numbness/ tingling; (4) a December 2016 VA exam that indicates no radiculopathy during exam; and, (5) a July 2019 VA exam that indicates the presence of right lower extremity radiculopathy during exam. The examiner began by noting the Veteran was seen in October 2015 and complained of "fairly severe pain in his neck and back, but also get pain and paresthesia in the arms," and described unusual feeling along the right side of his entire hemibody. However, the examiner states these symptoms are not specific to radiculopathy of the right lower extremity condition. Next, the examiner noted physical therapy in December 2015 diagnosed the Veteran with back pain with lower extremity numbness/tingling. Per records, the assessment indicates "straight leg raise continues to produce numbness in feet." The examiner stated, "unable to confirm severity of condition at the time of this examination as it was not stated by examiner." Next, the examiner noted the C&P lumbar back exam in December 2016 indicates there is no radiculopathy noted during examination. The examiner noted that there are no available records between the December 2016 and July 2019 VA examinations; therefore, the examiner was unable to confirm severity of any right lower extremity radiculopathy within this period. The July 2019 C&P lumbar back exam, for the first time, indicates presence of right lower extremity radiculopathy (mild sciatica) during examination, which has remained no more than mild in severity since the July 2019 examination. Another VA medical opinion was obtained in January 2021. This examiner conducted a records review of the Veteran's case file. The examiner noted an MRI lumbar spine 2015 shows mild degenerative changes, and 2015 and 2016 VA examinations did not show evidence of a lumbar radiculopathy. The examiner noted that the 2019 back examination for the first time shows a mild right lower extremity radiculopathy and supports a change during the appellate period. Upon review of the relevant evidence, and the opinions of the VA examiners noted above, the Board finds that the Veteran is not entitled to a separate evaluation for radiculopathy prior to July 5, 2019. Although the record contains complaints of leg numbness and/or tingling, radiculopathy was simply not diagnosed until the July 5, 2019 VA examination. Moreover, both the December 2020 and the January 2021 VA examiners who were asked to render an opinion on this issue, each concluded that it was not until the July 2019 VA examination that the Veteran was shown to have mild radiculopathy. Their opinions are supported by the evidence of record, in particular the December 2016 VA examination of the Veteran's back that specifically stated the Veteran did not have radiculopathy at that time. The Board has also considered the Veteran's lay statements. While lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), in this case, such an opinion falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). While the Veteran is competent to describe that he has leg pain and numbness, his radiculopathy is not the type of disorder that is amenable to lay determination regarding diagnosis, as specific findings are needed to properly determine diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In sum, the Board concludes that the Veteran is not entitled to a separate evaluation for radiculopathy for the period prior to July 5, 2019. REASONS FOR REMAND The Board regrets any further delay in this matter but finds that additional development is needed before the Board can render a decision on the remaining issues in this case. 3. Entitlement to an initial disability rating in excess of 10 percent prior to July 5, 2019; and in excess of 20 percent from July 5, 2019, and thereafter, for service-connected lumbar spine degenerative disc disease is remanded. A previous remand confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, upon review of the claims file, the examiner was to render an opinion addressing, among other directives, after review the January 2015, December 2016, and July 2019 VA examination reports, whether a retrospective estimate of additional loss of range of motion during flare-ups can be provided based on the information contained in those reports. If so, the examiner was to provide that estimate with a complete explanation. Otherwise, the examiner was to explain why such an estimate cannot be provided based on the available information. Unfortunately, the January 2021 VA medical opinion did not address whether, after review of the January 2015, December 2016, and July 2019 VA examination reports, a retrospective estimate of additional loss of range of motion during flare-ups could be provided. The Court has held that once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). Based on the above, the Board finds that another remand is necessary for an addendum medical opinion to be obtained, consistent with the directives given in the Board's November 2020 Remand. See Barr, 21 Vet. App at 311. 4. Entitlement to an initial rating in excess of 20 percent for left shoulder impingement syndrome (non-dominant) is remanded. A previous remand confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, upon review of the claims file, the examiner was to render an opinion addressing whether, after review the January 2015, December 2016, and July 2019 VA examination reports, a retrospective estimate of additional loss of range of motion during flare-ups can be provided based on the information contained in those reports. If so, the examiner was to provide that estimate with a complete explanation. Otherwise, the examiner was to explain why such an estimate cannot be provided based on the available information. Unfortunately, the January 2021 VA medical opinion did not address whether, after review of the January 2015, December 2016, and July 2019 VA examination reports, a retrospective estimate of additional loss of range of motion during flare-ups could be provided. The Court has held that once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). Based on the above, the Board finds that another remand is necessary for an Addendum medical opinion, or new VA examination if necessary, to be obtained, consistent with the directives given in the Board's November 2020 Remand. See Barr, 21 Vet. App at 311. 5. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. The Board finds that the TDIU claim is inextricably intertwined with the pending claims for an increased rating of the Veteran's service-connected lumbar spine disorder and left shoulder impingement syndrome. As any allowance of the increased rating claims remanded herein could affect the outcome of the TDIU claim, the appropriate remedy for inextricably intertwined issues is to remand them pending resolution of the inextricably intertwined issues. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Provide the claims file to an appropriate medical professional to address the Veteran's service-connected lumbar spine degenerative disc disease. If the examiner determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) is necessary, one is to be provided. The examiner must opine on the severity of the Veteran's lumbar spine degenerative disc disease throughout the appellate period. Based on review of the claims file, the examiner should render an opinion addressing whether, at any point from the initial claim to the present the record reflects any changes in the severity of the Veteran's lumbar spine degenerative disc disease and, if so, the approximate dates of any such changes, and the extent of severity of the disability on each such date. The examiner must also review the January 2015, December 2016, and July 2019 VA examination reports and provide a thorough discussion as to whether a retrospective estimate of additional loss of range of motion during flare-ups can be provided based on the information contained in those reports. If so, the examiner must provide that estimate with a complete explanation. Otherwise, the examiner must provide a thorough explanation as to why such an estimate cannot be provided based on the available information. 2. Provide the claims file to an appropriate medical professional to address the Veteran's service-connected left shoulder impingement syndrome. If the examiner determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) is necessary, one is to be provided. The examiner must opine on the severity of the severity of Veteran's left shoulder impingement syndrome throughout the appellate period. Based on review of the claims file, the examiner must render an opinion addressing whether, at any point from the initial claim to the present the record reflects any change(s) in severity of the Veteran's left should impingement syndrome and, if so, the approximate date(s) of any such change(s). The examiner must also review the January 2015, December 2016, and July 2019 examination reports and provide a thorough discussion as to whether a retrospective estimate of additional loss of range of motion during flare-ups can be provided based on the information contained in those reports. If so, the examiner must provide that estimate with a complete explanation. Otherwise, the examiner must provide a thorough explanation as to why such an estimate cannot be provided based on the available information. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Jiggetts 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.