Citation Nr: 21027059 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-58 950A DATE: May 4, 2021 ORDER Entitlement to service connection for bilateral carpal tunnel syndrome (CTS), claimed as a hand condition, is granted. Entitlement to service connection for left elbow tendinosis is granted. Entitlement to service connection for cervical spine degenerative disc disease (DDD) with bilateral upper extremity radiculopathy as secondary to service-connected lumbar spine disability, on a causation basis, is granted. Entitlement to service connection for left ankle osteoarthritis, as secondary to service-connected lumbar spine disability, on a causation basis, is granted. Entitlement to service connection for a bilateral knee disorder, as secondary to service-connected lumbar spine disability, on a causation basis, is granted. Entitlement to an effective date of August 5, 2015, but no earlier, for service connection for arthritis and strain, lumbar spine (lumbar spine disability) is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to an effective date of August 5, 2015, but no earlier, for service connection for femoral radiculopathy, right lower extremity is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to an effective date of August 5, 2015, but no earlier, for service connection for femoral radiculopathy, left lower extremity is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to an initial 40 percent disability rating from August 5, 2015, but no higher, for lumbar spine disability is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to an initial disability rating in excess of 20 percent from August 5, 2015 until March 29, 2016, for radiculopathy, right lower extremity is denied. Entitlement to a 40 percent disability rating, but no higher, from March 29, 2016, for radiculopathy, right lower extremity is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 20 percent from August 5, 2015 until March 29, 2016, for radiculopathy, left lower extremity is denied. Entitlement to a 40 percent rating, but no higher, from March 29, 2016 for radiculopathy, left lower extremity is granted, subject to the laws and controlling regulations governing the payment of monetary awards. Entitlement to a total disability rating due to individual unemployability (TDIU) from March 15, 2016, but no earlier, is granted, subject to the laws and controlling regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a right ankle disorder, to include as secondary to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's current bilateral CTS is related to service. 2. The evidence is at least evenly balanced as to whether the Veteran's current left elbow tendinosis is related to service. 3. The evidence is at least evenly balanced as to whether the Veteran's cervical spine DDD with bilateral upper extremity radiculopathy is caused by his service-connected lumbar spine disability. 4. The evidence is at least evenly balanced as to whether the Veteran's left ankle osteoarthritis is caused by his service-connected lumbar spine disability. 5. The evidence is at least evenly balanced as to whether the Veteran's bilateral knee pain is caused by his service-connected lumbar spine disability. 6. The July 2001 and March 2014 rating decisions denying service connection for a lumbar spine disability are final. 7. An intent to file a new claim was received on August 5, 2015 and formal claim for service connection for a lumbar spine disability was received on November 30, 2015. There was no pending formal or informal claim for service connection for a lumbar spine disability prior to August 5, 2015. 8. The service-connected disabilities of left and right femoral radiculopathy are intertwined with the service connection claim for a lumbar spine disability. 9. From August 5, 2015, the Veteran's lumbar spine disability symptomatology more nearly approximates flexion to 30 degrees or less with consideration to functional impairment but does not more nearly approximate unfavorable ankylosis of the thoracolumbar spine or the entire spine to include consideration of functional impairment. 10. From August 5, 2015 until March 29, 2016, the Veteran had right and left lower extremity lumbar radiculopathy approximating no more than moderate incomplete paralysis of the sciatic nerve. 11. From March 29, 2016, the Veteran had right and left lower extremity lumbar radiculopathy approximating no more than moderately severe incomplete paralysis of the sciatic nerve. 12. From March 15, 2016, the evidence is at least evenly balanced as to whether the Veteran's service connected disabilities preclude him from securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral CTS have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left elbow tendinosis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for cervical spine DDD with bilateral upper extremity radiculopathy have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for left ankle osteoarthritis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for a bilateral knee disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for an August 5, 2015 effective date, but no earlier, for the award of service connection for arthritis and strain, lumbar spine have been met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400. 7. The criteria for an August 5, 2015 effective date, but no earlier, for the award of service connection for service connection for femoral radiculopathy, right lower extremity are met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400. 8. The criteria for an August 5, 2015 effective date, but no earlier, for the award of service connection for service connection for femoral radiculopathy, left lower extremity are met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400. 9. From August 5, 2015, the criteria for entitlement to an initial rating of 40 percent, but no higher, for lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.71, Diagnostic Code (DC) 5242. 10. From August 5, 2015 until March 29, 2016, the criteria for an initial rating in excess of 20 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, DCs 8520, 8526. 11. From March 29, 2016, the criteria for a 40 percent rating, but no higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, DCs 8520, 8526. 12. From August 5, 2015 until March 29, 2016, the criteria for an initial rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, DCs 8520, 8526. 13. From March 29, 2016, the criteria for a 40 percent rating, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.124a, DCs 8520, 8526. 14. From March 15, 2016, but no earlier, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1996 to May 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2016 Regional Office (RO) rating decision. In that decision, the RO granted service connection for lumbar strain and radiculopathy of both lower extremities and assigned initial ratings and effective dates of November 30, 2015. The Veteran timely appealed the assigned effective dates as well as the initial ratings for these claims. Cf. Rudd v. Nicholson, 20 Vet. App. 296 (2006) (prohibiting freestanding earlier effective date claims). The May 2016 rating decision also denied service connection for a chronic condition, claimed as muscle pain and painful joints, bilateral hand condition and neck strain. In May 2017, the Veteran testified at a RO hearing. A hearing transcript is of record. In May 2020, the Veteran testified at a Virtual Board hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. The Board has recharacterized the claim of muscle pain and painful joints, to reflect the individual joints encompassed by this claim. The recharacterization is based on the attorney's request at the May 2020 Board hearing that this claim include the ankle, knee and elbow joints. Additional private medical records were received following the most recent adjudication by the agency of original jurisdiction (AOJ) in the September 2017 Statement of the Case (SOC). The Veteran waived his right to AOJ review of these records at the May 2020 Board hearing. Moreover, these private medical records are subject to the automatic waiver provision of the pre-amended 38 U.S.C. § 7105(e) for legacy appeals. See 38 U.S.C. § 7105(e) (2012) (providing for initial review by the Board "if the claimant or the claimant's representative . . . submits evidence"). The Appeals Modernization Act removed the new 38 U.S.C. § 7105(e). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). At the outset, the Board notes that this decision is substantially favorable. It results in an additional TDIU award from March 15, 2016, the date the Veteran stopped working, and significantly higher ratings. For the lumbar spine initial rating claim, the Board notes specific considerations for rating orthopedic disabilities. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). The Board has made a partial grant to account for functional impairment. As explained below, the evidence weighs against any finding that lumbar spine functional impairment from flare-ups or repeated use over time more nearly approximates unfavorable ankylosis of the entire thoracolumbar spine. Thus, any error in this regard was nonprejudicial. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009). The Board notes that Social Security Administration (SSA) disability records for the Veteran's lumbar spine are not of record. Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) ("The legal standard for relevance requires VA to examine the information it has related to medical records and if there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits, the duty to assist requires VA to obtain the records."). In this case, with the sequence of lumbar spine symptoms as indicated by the evidence below, the Board finds that there does not exists a reasonable possibility that the records would help the veteran substantiate his claim for benefits in excess of those awarded in this decision. The Veteran was last afforded a VA lumbar spine examination in January 2016 and his disability has worsened since then. However, he has submitted numerous private medical records and a May 2020 Disability Benefits Questionnaire (DBQ) completed by his chiropractor. The information found in the updated DBQ is responsive to the applicable rating criteria. The Board finds that another examination would raise no reasonable possibility of substantiating his claim for benefits in excess of those awarded in this decision. Id. In sum, to the extent there are duty to assist deficiencies, they are not prejudicial to the Veteran since the instant adjudication is substantially favorable to the Veteran. See Shinseki, 556 U.S. at 409-10. Further delay to obtain additional SSA records or examination would not raise a reasonable possibility of entitlement to additional benefits than those awarded in the instant decision. See Lamb v. Principi, 22 Vet. App. 227, 234 (2008) (remand not required when it would serve no useful purpose); Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) ("[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant."); see also Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). Accordingly, the higher rating claims are ready to be considered on the merits. II. Service connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disease or injury. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Bilateral hand disability DD Form 214 shows that the Veteran had a military occupational specialty (MOS) of microwave equipment operator. Service treatment records (STRs) do not show any complaints or treatment for a hand condition. A January 2000 physical examination and report of medical history do not include any pertinent findings. May 2015 private medical records show that the Veteran was evaluated for right CTS. He had a history for left CTS with a residual incision noted. The physician reported that the Veteran was very familiar with CTS because of his history. A treatment plan was created. June 2015 private medical records show that the Veteran was scheduled for right CTS surgery. At the May 2017 RO hearing, the Veteran reported that he had CTS surgery for both wrists. He stated that his CTS symptoms started immediately after service. He reported having surgery on one wrist in 2001 and the other around 2013 or so. He did not receive any current treatment since his medical care was focused on back pain management. At the May 2020 Board hearing, the Veteran reported that he had surgeries for both hands. He reported that both hands were very painful and constantly numb. He stated that in-service he performed extensive manual labor working with heavy parts and maintaining satellites. He had hand problems ever since then and sought private treatment right after separation. He confirmed that he had CTS surgeries for both hands. Currently, he had problems dropping and gripping objects. In May 2020, Dr. Z, who is qualified as a chiropractor, submitted a medical opinion in support of this claim. He reviewed the Veteran's medical history and medical records. In pertinent part, he stated that the Veteran had bilateral CTS. He noted that the Veteran's military occupational duties as a microwave equipment operator included installing, operating and maintaining multichannel media equipment. During service, the Veteran constantly used tools, as well as lifting and carrying equipment. Dr. Z stated that CTS is caused by overuse and repetitive movements. Consequently, he opined that the current bilateral CTS was related to service. For the following reasons, the Board concludes that service connection for bilateral CTS, claimed as a hand disability, is warranted. The disputed issue is whether the claimed bilateral hand disorder, diagnosed as CTS, is related to service. As to the lay evidence, pain and numbness affecting the hands are readily observable. The Veteran is competent to report about hand pain associated with manual labor activities in service and his medical treatment history, including two CTS surgeries. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007). The Veteran reports that his bilateral hand pain started in service with manual labor activities and has persisted since then. Although STRs do not document hand pain or CTS type symptoms, his reports about overuse and repetitive activity are consistent with his reported microwave equipment operator MOS. The Board finds that the Veteran's report about continuous bilateral hand pain symptoms starting in service are entitled to probative weight. As to the medical evidence, Dr. Z issued a medical opinion in support of the claim. He corroborated the Veteran's reports about hand pain symptoms starting in service and leading to post-service treatment for CTS. He explained that the military occupational activities reported by the Veteran are known causes for CTS. The Board attaches probative value to Dr. Z's May 2020 medical opinion since it includes a clear rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). There is no conflicting medical opinion. For the foregoing reasons, the evidence as to a relationship to service for bilateral CTS, claimed as a bilateral hand condition, is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral CTS is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Left elbow tendinosis Again, DD Form 214 shows that the Veteran had a military occupational specialty (MOS) of microwave equipment operator. STRs do not show any complaints or treatment for a left elbow condition. A January 2000 physical examination and report of medical history did not include any pertinent findings. June 2015 private orthopedic records showed that the Veteran complained about significant left elbow pain. It flared up with lifting activities. Physical examination showed severe epicondylitis and exquisite tenderness. The orthopedist assessed epicondylitis and conservative care as well as advising that it would improve with conservative care. October and November 2018 private medical records showed that the Veteran's left elbow pain returned. The orthopedist noted that the Veteran was treated about a year ago for lateral epicondylitis with excellent results. Physical findings were noted. The orthopedist diagnosed lateral epicondylitis of the left elbow. An April 2019 magnetic resonance imaging (MRI) left elbow study showed moderate tendinosis at the origin of the common extensor tendon without evidence of a tear. At the May 2020 Board hearing, the Veteran reported that he had severe left elbow pain since 2015 or so. It was associated with cane use as an ambulatory aid. The Veteran reported using a cane due to his service-connected lumbar spine disability and associated radiculopathy. In May 2020, Dr. Z, who is qualified as a chiropractor, submitted a medical opinion in support of this claim. He reviewed the Veteran's medical history and medical records. In pertinent part, he stated that the Veteran had left elbow tendinosis. He noted the Veteran's military occupational duties as a microwave equipment operator including installing, operating and maintaining multichannel media equipment. The Veteran was reportedly constantly using tools and lifting and carry equipment to perform his job duties. Dr. Z stated that left elbow tendonitis is caused by overuse and repetitive movements such as those in service. Consequently, he opined that the current left elbow tendinosis was related to service. There is no conflicting medical opinion. For the following reasons, the Board concludes that service connection for left elbow tendinosis is warranted. The disputed issue is whether the claimed left elbow disability is related to service. As to the lay evidence, elbow pain is readily observable, and the Veteran is competent to report about it as well as its history. Jandreau, 492 F.3d at 1377, n. 4. He reports having an extensive history of manual labor in service and developing left elbow pain when he started using a cane for ambulation. His reports about his military occupational history and current left elbow pain are credible and entitled to probative weight. However, he does not assert continuous symptoms since service. As to the medical evidence, Dr. Z furnished a positive medical opinion for service connection on a direct basis. He corroborated the Veteran's reports about left elbow pain and military occupational activities with repetitive stress and overuse. He explained that the military occupational activities reported by the Veteran are known causes for the post service left elbow tendinosis. The Board attaches probative value to Dr. Z's May 2020 medical opinion since it includes a clear rationale. Nieves-Rodriguez, 22 Vet. App. at 301. There is no conflicting medical opinion. For the foregoing reasons, the evidence as to a relationship to service for left elbow tendinosis is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for left elbow tendinosis is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Since service connection is being granted on a direct basis, further discussion of alternative theories of entitlement is not required. Cervical spine disability and bilateral upper extremity radiculopathy STRs do not show any complaints or treatment for a neck condition. A January 2000 physical examination and report of medical history do not include any pertinent findings. March and April 2017 private medical records showed that the Veteran was treated for his low back disability and found to have an antalgic gait. At the May 2020 Board hearing, the representative reported that the Veteran had an altered gait due to his service-connected lumbar spine disability. She asserted the cervical spine disability was secondary to the service-connected lumbar spine disability. In May 2020, Dr. Z, who is qualified as a chiropractor, completed a Disability Benefits Questionnaire (DBQ) for the cervical spine. He reported reviewing the claims folder. He diagnosed cervical spine DDD and associated bilateral upper extremity radiculopathy. He detailed clinical findings for the Veteran's cervical spine disability and associated bilateral upper extremity radiculopathy. Then, Dr. Z issued an accompanying medical opinion based upon review of the Veteran's service records and past medical history. He stated that the Veteran's lumbar spine disability limited his mobility, which can alter posture and place added stress on the cervical spine. He believed the Veteran's cervical spine DDD was secondary to his service-connected lumbar spine disability. For the following reasons, the Board concludes that service connection for cervical spine DDD with bilateral upper extremity radiculopathy is warranted. The disputed issue is whether the claimed cervical spine DDD is related to the service-connected lumbar spine disability. As to the lay evidence, neck pain is readily observable, and the Veteran is competent to report about neck pain. Jandreau, 492 F.3d at 1377, n. 4. The Veteran reports having an altered gait due to low back pain and developing neck pain. His reports about an altered gait are supported by medical records. He does not assert continuous neck pain symptoms since service. The Board considers his reports about current neck pain and altered gait associated with low back pain credible. As to the medical evidence, Dr. Z furnished a positive medical opinion. He corroborated the Veteran's reports about neck pain with an underlying diagnosis of cervical spine DDD. He explained how the effects of the lumbar spine disability through gait abnormalities or imbalance can result in additional cervical spine disability. The Board attaches probative value to Dr. Z's May 2020 medical opinion since it includes a clear rationale. Nieves-Rodriguez, 22 Vet. App. at 301. There is no conflicting medical opinion. For the foregoing reasons, the evidence as to a secondary relationship, on a causation basis, to the service-connected lumbar spine disability is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for cervical spine DDD with bilateral upper extremity radiculopathy as secondary to service-connected lumbar spine disability, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Left ankle disability STRs from November 1997 show that the Veteran was treated for left ankle sprain associated with a basketball injury. In December 1998, the Veteran had a left ankle X-ray that returned normal. The indication was fall with a twisted ankle and to rule out ankle fracture. A January 2000 physical examination and report of medical history do not include any pertinent findings. April 2017 private medical records list the Veteran as having a fall history associated with his lumbar spine disability. November 2017 private medical records report that the Veteran was wearing a left ankle walking boot that had been issued by a different private provider. January 2018 private medical records note chronic pain of the left ankle as a problem. In May 2020, Dr. Z, who is qualified as a chiropractor, submitted a medical opinion in support of this claim. He reviewed the Veteran's medical history and medical records. In pertinent part, he stated that the Veteran had residuals of a left ankle fracture. He noted the 2017 fall resulting in a left ankle fracture. He stated that the Veteran's current left ankle osteoarthritis was related to his lumbar spine disability and associated radiculopathy since it caused the fall resulting in the left ankle fracture. For the following reasons, the Board concludes that service connection for left ankle osteoarthritis is warranted. The disputed issue is whether the claimed left ankle disability is related to service. As to the lay evidence, ankle pain is readily observable, and the Veteran is competent to report about ankle pain as well as its history. Jandreau, 492 F.3d at 1377, n. 4. He reports having an altered gait due to low back pain that caused him to fall. His reports about an altered gait are supported by medical records. He does not assert continuous left ankle symptoms since service. The Board considers his reports about current left ankle pain and falls from an altered gait associated with low back pain credible. As to the medical evidence, Dr. Z furnished a positive medical opinion. He corroborated the Veteran's reports about left ankle pain with an underlying diagnosis of left ankle osteoarthritis. He explained how the lumbar spine disability would affect the Veteran's ability to ambulate. He found that it likely caused the Veteran to fall and injure his left ankle. The Board attaches probative value to Dr. Z's May 2020 medical opinion since it includes a clear rationale. Nieves-Rodriguez, 22 Vet. App. at 301. There is no conflicting medical opinion. For the foregoing reasons, the evidence as to a secondary relationship, on a causation basis, to the service-connected lumbar spine disability is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a left ankle osteoarthritis as secondary to service-connected lumbar spine disability, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Since service connection is being granted, further discussion of alternative theories of entitlement is not required. Bilateral knee disorder STRs do not show any complaints or treatment for a knee condition. A January 2000 physical examination and report of medical history do not include any pertinent findings. September 2018 private medical records show that the Veteran was treated for chronic right knee pain. Contemporaneous X-rays were normal. March 2019 private medical records include complaints about right knee pain developing over the past week. No history of trauma was indicated. An X-ray was taken and returned normal. In May 2020, Dr. Z, who is qualified as a chiropractor, issued a medical opinion based upon review the Veteran's service records and past medical history. He stated that the Veteran's lumbar spine disability resulted in the Veteran ambulating with an altered gait. He stated that an altered gait would stress the knee joints. Consequently, he opined that the Veteran's chronic knee pain was secondary to the service-connected lumbar spine disability. For the following reasons, the Board concludes that service connection for bilateral knee pain is warranted. The disputed issue is whether the claimed bilateral knee disability is related to the service-connected lumbar spine disability. As to the lay evidence, knee pain is readily observable, and the Veteran is competent to report about it. Jandreau, 492 F.3d at 1377, n. 4. He reports having an altered gait due to low back pain and developing knee pain. His reports about an altered gait and chronic right knee pain are supported by medical records. He does not assert continuous knee pain symptoms since service. The Board considers his reports about current knee pain and altered gait associated with low back pain credible. As to the medical evidence, Dr. Z furnished a positive medical opinion. He corroborated the Veteran's reports about chronic knee pain. He explained how the effects of the lumbar spine disability through gait abnormalities or imbalance can result in additional knee disability. The Board attaches probative value to Dr. Z's May 2020 medical opinion since it includes a clear rationale. Nieves-Rodriguez, 22 Vet. App. at 301. There is no conflicting medical opinion. The Board notes that a specific diagnosis for either knee has not been reported in medical records and Dr. Z's report leaves some ambiguity as whether both knees are affected. As to diagnosis, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that pain alone resulting in functional impairment of earning capacity can satisfy the current disability requirement for service connection. Saunders, 886 F. 3d at 1367-68. The symptoms of knee pain imply occupational functional impairment as contemplated in Saunders, supra. since it affects the Veteran's ability to move. Then, as to Dr. Z's May 2020 opinion, he characterized the disability as chronic knee pain without specification. The Board finds that the May 2020 medical opinion may reasonably be interpreted as including the left knee and notes that at the May 2020 hearing, the representative requested service connection for both knees. For the foregoing reasons, the evidence as to a secondary relationship, on a causation basis, to the service-connected lumbar spine disability is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a bilateral knee disorder as secondary to service-connected lumbar spine disability, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. III. Earlier effective dates The Veteran is currently in receipt of a November 30, 2015 effective date for service connection for his lumbar spine disability and right and left femoral radiculopathy. The effective date is based on the date a formal claim was filed for reopening a previously denied service connection claim for a low back condition. In general, decisions of the RO that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1103. Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date of an award of disability compensation shall be the day following separation from service or the date entitlement arose if the claim is received within one year of separation, otherwise the date of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400(b)(2). When there is a final denial of a claim, and new and material evidence is subsequently received, the effective date of the award of compensation is the date of receipt of the new claim or date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(q)(2). The Veteran's original application for compensation for a low back disability was received on March 26, 2001. On May 3, 2001, a VA Compensation & Pension (C&P) Examination Request Worksheet was created. It requested a general medical examination for the spine. It listed the Veteran's address and phone number found in the March 26, 2001 compensation claim as the contact information for the Veteran. A June 25, 2001 memorandum confirmed that the Veteran's spine VA examination was cancelled. It stated that the Veteran failed to report for the scheduled examination and did not respond to a "no show" letter. In August 2001, the RO mailed the Veteran a notification letter with a copy of the July 2001 rating decision. The listed address on the notification letter matched the one found in the March 2001 compensation claim. The notification letter informed the Veteran about his appeal rights. The Veteran did not appeal, nor was new and material evidence received to include constructive receipt of VA treatment records, within one year of notification of such decision. Absent a showing of clear and unmistakable error, which has not been shown or alleged here, this decision is final. 38 U.S.C. § 7105 (1996); 38 C.F.R. §§ 3.104, 20.200 (2001). On August 29, 2013, the Veteran filed a service connection claim for a low back disability, characterized as back strain. He provided his mailing address and phone number. In March 2014, the RO mailed the Veteran a notification letter with a copy of the March 2014 rating decision. The listed address on the notification letter matched the one found in the August 2013 compensation claim. The notification letter informed him about his appeal rights. The Veteran did not appeal, nor was new and material evidence received to include constructive receipt of VA treatment records, within one year of notification of such decision. Absent a showing of clear and unmistakable error, which has not been shown or alleged here, this decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.200 (2014). On August 6, 2015, a RO reported that it received the Veteran's intent to file claim the day before. It advised him that if a completed application was received within one year from the date of the intent to file form was received, compensation may be payable from the date the intent to file form was received. It enclosed a formal claims form and instructed him to complete it. On November 30, 2015, the Veteran electronically filed claims, including an application to reopen a previously denied claim for low back disability, then characterized as mechanical low back strain. In May 2016, the RO issued a rating decision granting service connection for lumbar strain with lumbar arthritis and associated right and left radiculopathy with effective dates of November 30, 2015, the date the formal claim was filed. In the September 2016 notice of disagreement, the Veteran requested earlier effective dates for service connection for these disabilities. At the May 2017 RO hearing, the representative asserted that the Veteran filed a previous claim sometime in 2013 and did not receive a rating decision in response. At the May 2020 Board hearing, the representative reported that the Veteran had submitted previous service connection claims for his low back disability. The RO informed him that an examination would be scheduled for his claim. However, the RO did not do so and simply denied the low back disability claim. She cited August 29, 2013 as the date of the previous service connection claim and then also noted a 2001 service connection claim for a low back disability. She indicated that the 2001 claim was the instance where the Veteran did not receive notice about a scheduled VA examination. She reported that there were multiple notification irregularities by VA with the instant appeal. She asserted that the effective date should extend to the day after separation since the Veteran was not notified about the scheduled VA examination in connection with his original March 2001 low back disability claim. For the following reasons, the Board finds that an August 5, 2015 effective date, but no earlier, is warranted for service-connected lumbar spine disability and right and left femoral radiculopathy. The Veteran and his representative have made two arguments asserting that the prior August 2001 and March 2014 rating decisions for a low back disability should be non-final. The Board will focus the below discussion on these arguments. Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009). As to the first argument, at the May 2017 RO hearing, the representative asserted that the Veteran was not notified about the March 2014 rating decision. There is a presumption of regularity under which it is presumed that government officials "have properly discharged their official duties." Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (VA need only mail notice to the last address of record for the presumption to attach). This presumption of regularity in the administrative process may be rebutted by "clear evidence to the contrary." Schoolman v. West, 12 Vet. App. 307, 310 (1999). Generally, an allegation of non-receipt, by itself, is insufficient to rebut the presumption of regularity. Id. Rather, a claimant bears the burden of producing clear evidence that VA did not follow its regular mailing practices or that its practices were not regular. Clarke v. Nicholson, 21 Vet. App. 130 (2006). Once the presumption of regularity has been rebutted, the burden shifts to VA to show that regular mailing practices were followed in mailing the document in question in accordance with applicable laws and regulations, or that the claimant actually received the notice. Crain v. Principi, 17 Vet. App. 182, 186 (2003); Romero v. Tran, 33 Vet. App. 252 (2021) (rebuttal of the presumption of regularity requires clear evidence that VA failed to properly discharge its duty, but such evidence need not be claimant specific). Applying this presumption to the instant case, the Board must conclude that the Veteran received the March 2014 rating decision. As noted above, the notification was sent to his address of record. It was not returned as undeliverable. Neither the representative, nor the Veteran provide any additional report or evidence to suggest non-receipt or mailing irregularity that is specific to mailing the March 2014 rating decision. Although the representative and the Veteran report mailing irregularities in connection with the instant appeal at the May 2020 Board hearing, their reports do not include a specific mailing irregularity for the March 2014 rating decision. None is otherwise identified by the Board. In sum, the Board does not find that the presumption of regularity has been rebutted since there is no clear evidence to the contrary that the March 2014 notification letter was not properly mailed to the Veteran's address record. Schoolman, 12 Vet. App. at 310. Accordingly, the Board finds that the Veteran was appropriately notified about the March 2014 rating decision. As to the second argument, the Board has considered whether any irregularity about scheduling the VA spine examination could vitiate finality of the August 2001 rating decision as asserted at the May 2020 Board hearing. The Veteran reports that he did not receive notice of the scheduled VA spine examination in connection with his March 2001 claim. His non-finality assertion for the August 2001 rating decision is akin to an assertion that a grave procedural error occurred and rendered the July 2001 rating decision non-final. In general, a grave procedural error does not vitiate finality of an otherwise final rating decision. Cook v. Principi, 318 F.3d 1334, 1336 (Fed. Cir. 2002) (explaining that the statutory scheme provides only two exceptions to finalityreopening and CUE and overruling Hayre v. West, 188 F.3d 1327 (1999), which created another exception based upon grave procedural error such as a breach of the duty to assist). The only exception is a procedural error that results in extinguishing the Veteran's ability to appeal a decision, such as failure to correctly mail the decision or furnish a statement of the case. See Cook, 318 F.3d at 1340-41 (distinguishing cases involving the straightforward application of the statutes concerning mailing and filing an appeal and the failure to comply with the procedural requirements had the effect of extinguishing the claimant's right to appeal). In this case, the August 2001 notification letter, including a copy of the July 2001 rating decision, was mailed to the Veteran. The listed address matches the one found in the March 2001 compensation claim. He was notified about his appeal rights with respect to the July 2001 rating decision. The Board finds that a procedural error affecting the Veteran's ability to appeal the decision did not occur. Thus, under Cook, supra., the Veteran's assertion that inadequate or no notification about the scheduled VA spine examination in connection with his March 2001 claim should vitiate finality for the July 2001 rating decision is without merit. Id. at 1336. Next, the Board has considered RO correspondence dated August 6, 2015 referring to an intent to file a claim as a possible way to substantiate the claim. The underlying document for an intent to file a claim is not of record. However, by applying the presumption of regularity in VA's intake and processing of claim, the August 6, 2015 correspondence is sufficient evidence that an appropriate intent to file a claim was filed on this date. Mindenhall, 7 Vet. App. at 274. VA recognizes "an intent to file a claim," which may be submitted electronically, on a prescribed intent-to-file-a-claim form, or through an oral communication to certain VA employees that is later recorded in writing. 38 C.F.R. §§ 3.155(b)(1)(i)-(iii). If VA receives a complete application form as defined in 38 C.F.R. § 3.160(a) within one year of receipt of an intent to file, VA will consider the complete claim filed as of the date the intent to file was received. 38 C.F.R. § 3.155(b). In this case, the evidence shows an intent to file claim was received on August 5, 2015 with a formal claim for lumbar spine disability received on November 30, 2015. Thus, an effective date of August 5, 2015 is warranted for service-connected lumbar spine disability and right and left femoral radiculopathy. Id. The Board is sympathetic to the Veteran and representative's assertions about mailing problems and inadequate notice with scheduling an examination in connection with the March 2001 claim and the instant appeal. However, the Board is bound by the laws and regulations that apply to veterans claims. 38 U.S.C. § 7104(c); 38 C.F.R. §§ 19.5, 20.101(a). The legal authority governing effective dates is clear and specific, and the Board is bound by such authority. In this specific case, an effective date of August 5, 2015, but no earlier, for the award of service connection lumbar spine disability and right and left femoral radiculopathy is warranted. IV. Higher initial ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where, as here, an award of service connection for a disability has been granted and the assignment of an initial rating for that disability is disputed, separate rating may be assigned for separate periods of time based on the facts found. In other words, the ratings may be staged. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. (a) Lumbar spine disability The Veteran has an initial 10 percent rating for service-connected lumbar spine disability under DC 5242. 38 C.F.R. § 4.71a, DC 5242. DC 5242 provides ratings under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Id. Under the General Rating Formula for lumbar spine disability, such disability is evaluated 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. Id. As relevant, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted where forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. The only higher schedular evaluations under the General Rating Formula are 50 percent for unfavorable ankylosis of the entire thoracolumbar spine and 100 percent for ankylosis of the entire spine. Id. Any associated neurological abnormalities are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula, 38 C.F.R. § 4.71a. The Board notes the alternative Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, DC 5243. However, the May 2017 reference to bed rest is from the Veteran's own report. The voluminous private treatment records do not indicate physician direct bed rest is a part of his medical treatment regimen for low back pain. The May 2020 DBQ completed by Dr. Z did not reference incapacitating IVDS episodes. Thus, the alternative rating criteria will not be considered further. See Robinson, supra. The Board also notes the recent amendment to the rating schedule. 85 Fed. Reg. 76453 (November 30, 2020); 85 Fed. Reg. 85523 (Dec. 29, 2020). However, these amendments do not raise any reasonable possibility of substantiating higher ratings than those awarded herein, and they will not be considered further. See Robinson, supra. On January 2, 2016, the Veteran had VA back conditions examination. The clinician diagnosed lumbar strain and lumbar arthritis. The Veteran reported experiencing constant back pain. He took narcotic strength medication for pain management. He denied flare-ups but reported functional impairment of decreased motion, pain and weakness. Range of motion (ROM) for the lumbar spine was flexion to 70 degrees, extension to 20 degrees, and bilateral lateral flexion and rotation all to 30 degrees. Pain was noted on examination and deemed to cause functional loss. Tenderness was found at L3-S1. Repetitive use testing did not show additional motion loss. Repeated use over time was not found to significantly limit functional ability. Guarding and tenderness did not result in an abnormal gait or spinal contour. Moderate lower extremity radiculopathy was indicated for both legs. No other associated neurological abnormalities were found. MRI study showed lumbar disc herniation. Functional impact was reported as difficulty staying in one position due to low back muscle fatigue. From 2016 through 2020, the Veteran submitted voluminous private treatment records in connection with this claim. They report that the Veteran had multiple lumbar spine surgeries without success and had a narcotic strength medication regimen for low back pain management. As relevant, April 2018 private medical records showed that lumbar flexion was to 20 degrees, while a July 2018 note found lumbar flexion to 45 degrees. Another November 2019 note reported severely reduced lumbar spine ROM. In May 2020, Dr. Z, a chiropractor, completed a lumbar spine DBQ. He diagnosed lumbar spine DDD, spondylolysis and radiculopathy. Lumbar spine flexion was to 30 degrees and the additional planes of motion were to 10 degrees. He reported that pain would contribute to additional functional loss. Tenderness, muscle spasm and guarding were noted and associated with an abnormal gait. Multiple contributing factors of disability were reported, notably increased pain and motion loss. Severe radiculopathy was reported for both lower extremities. The Veteran used a cane as an ambulatory aid on a constant basis. Dr. Z noted the imaging studies. He described the functional impact as an inability to perform prolonged standing, walking, and lifting due to back pain. The Veteran had to rest several hours per day and would be unable to complete a standard workday, even with sedentary job responsibilities. For the following reasons, the Board finds that an initial disability rating of 40 percent, but no higher, from August 5, 2015 is warranted for the service-connected lumbar spine disability. The voluminous medical evidence and May 2020 DBQ support a 40 percent initial rating from August 5, 2015. They document severe low back disability with motion loss more closely akin to the 40 percent rating criteria when considering functional loss. The Board notes the January 2016 VA examination report shows greater lumbar spine motion. However, the clinician did not properly account for additional motion from low back pain, which in this case is severe, as documented by the voluminous private medical records. Ratings in excess of 40 percent for the lumbar spine disability are limited to unfavorable ankylosis of the thoracolumbar spine or the entire spine. The evidence simply does not indicate that the Veteran's entire thoracolumbar spine has ever been fixed in flexion or extension in an unfavorable position. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). The Board notes that the Court held in Chavis v. McDonough, No. 18-2928 (April 16, 2021) that flare-ups resulting in symptoms more nearly approximating ankylosis can warrant a higher rating under the general rating formula. However, evidence with specific consideration to the Veteran's reports, private medical records, and May 2020 DBQ, do not in any way suggest that unfavorable ankylosis of the entire thoracolumbar spine is present with consideration to functional loss during periods of flare-ups or repeated use over time. Thompson, 815 F.3d at 785. Again, the Veteran's functional impairment reports concern severe low back pain and limited motion. His reports, nor does any additional evidence, suggest that his spine becomes fixed in an unusual or unfavorable position during periods of repeated use over time or flare-ups. Id. For the foregoing reasons, an initial rating of 40 percent, but no higher, from August 5, 2015, for lumbar spine disability is warranted. The preponderance of the evidence reflects the symptoms of the Veteran's lumbar spine disability do not more nearly approximate the criteria for a rating higher than 40 percent at any time during the appeal period. Thus, the benefit of the doubt doctrine is not for application, and a rating greater than 40 percent is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Lower extremity radiculopathy The Veteran is service connected for right and left lower extremity femoral radiculopathy with 20 percent ratings for each extremity under DC 8626. 38 C.F.R. § 4.124a, DC 8626. To maximize the Veteran's benefits, the Board finds that ratings under DC 8520 for sciatic nerve impairment must be considered since the May 2020 DBQ, as discussed below, shows sciatic nerve involvement. Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (applying the more deferential "arbitrary, capricious" standard, rather than de novo review, to the Board's determination of the appropriate diagnostic code); 38 C.F.R. § 4.124a, DCs 8520, 8626. The sciatic nerve impairment rating criteria (DC 8520) provide greater ratings than the currently assigned femoral nerve impairment rating criteria (DC 8626). Id. The representative requested separate rating for sciatic and femoral nerve impairment at the May 2020 Board hearing. However, in this particular case, the symptoms of pain, numbness and muscle weakness attributable to the sciatic and femoral nerve impairment substantially overlap. 38 C.F.R. § 4.14. The record does not raise the issue of muscle atrophy, paralysis or other functional loss for which the impairment from the femoral and sciatic nerve may be distinguished. Thus, the analysis will consider sciatic nerve ratings and attribute all neurological symptomatology to sciatic nerve impairment to afford the Veteran the greatest benefit. Id. Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. Paralysis of the sciatic nerve, such as that caused by sciatica, is rated under DC 8520. Under DC 8520, a maximum schedular rating of 80 percent is awarded for complete paralysis of the sciatic nerve. With complete paralysis, the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. When there is incomplete paralysis, a 60 percent rating is in order for severe disability with marked muscular atrophy. Moderately severe incomplete paralysis warrants a 40 percent evaluation, and moderate incomplete paralysis warrants a 20 percent rating. See 38 C.F.R. § 4.124a, DC 8520. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. The Board will consider the following degree of impairment definitions in the analysis. Id. Moderate - symptoms will likely be described by the claimants and medically graded as significantly disabling. In such cases a larger area in the nerve distribution may be affected by sensory symptoms. Other sign/symptom combinations that may fall into the moderate category include combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. Moderately Severe - motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability is expected. Atrophy may be present. Severe - motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. For the sciatic nerve (38 C.F.R. § 4.124a, DC 8520) marked muscular atrophy is expected. Even though severe incomplete paralysis cases should show findings substantially less than representative findings for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs/symptoms resembling some of those expected in cases of complete paralysis of the nerve. In January 2016, the Veteran had a VA back conditions examination. In pertinent part, muscle strength testing was complete (5/5) for both legs. No muscle atrophy was found. Knee reflexes were hyperactive and ankle reflexes were hypoactive. Light touch sensation was normal. Straight leg raise (SLR) test was positive. Moderate pain and paresthesias and dysesthesias were found. The clinician identified the femoral nerve root as involved and assessed moderate radiculopathy. He reported that the Veteran did not use an ambulatory aid. February 2016 private medical records reported that the Veteran had good strength, normal sensation to light touch and a negative SLR test. He was able to ambulate without assistance. No calf swelling was found. In March 2016, the Veteran had preoperative physical examination. Muscle strength and SLR testing was normal each leg. However, paresthesia was noted for each leg. On March 29, 2016, the Veteran underwent lumbar fusion surgery. The evidence following surgery shows that the Veteran lumbar and radiculopathy symptoms worsened within a few weeks of this surgery and never improved. At the May 2017 RO hearing, the representative asserted that severe radiculopathy was shown in the private medical records. In May 2020, Dr. Z completed a lumbar spine DBQ. He reported 3/5 muscle strength in both legs as attributable to the lumbar spine disability. No muscle atrophy was found. He reported decreased light touch sensation throughout both legs. Position sense was decreased in both legs. SLR was positive for both legs. He reported severe constant pain, dull pain, paresthesias and numbness for both lower extremities. He assessed the radiculopathy as severe for each leg and reported both femoral and sciatic nerve involvement. For the following reasons, the Board finds that 40 percent ratings, but no higher, from March 29, 2016 are warranted for right and left lower extremity radiculopathy. From August 5, 2015 until March 29, 2016, the evidence shows sensory and reflex impairment for both lower extremities. Although the VA clinician's characterization of moderate is by no means controlling, it is consistent with private medical records from February and March 2016 that do not show impairments in muscle strength, muscle atrophy or include otherwise include reports of additional neurological disturbances as compared to the January 2016 VA examination report. Again, the Board considers the following definition for "moderately severe" as motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability is expected. Atrophy may be present. In this case, the Veteran's neurological symptoms in either lower extremity, which include reflex and sensory disorders, are not reported to interfere with ambulation or substantially affect daily activities as to constitute a high level of limitation or disability. He did not use an ambulatory aid at the time of the January 2016 VA examination. February 2016 private orthopedic records characterize the Veteran as having independent ambulation without assistive devices. For these reasons, the next higher moderately severe incomplete paralysis is not more nearly approximated for either lower extremity. From March 29, 2016, the Veteran had lumbar fusion surgery on March 29, 2016 and his back disability symptomatology greatly worsened following this surgery. The evidence during this period more nearly moderately severe incomplete paralysis of the sciatic nerve. At the May 2017 RO hearing and May 2020 Board hearing, the Veteran attested to having significant pain and concomitant impairment affecting both legs. Private medical records document continuing radiculopathy symptoms without improvement and the Veteran started using ambulatory aids. The May 2020 DBQ confirmed decreased muscle strength without muscle atrophy and severe pain in both legs. These findings more nearly approximate the above noted "moderately severe" definition of incomplete paralysis since observable muscle weakness and high level of functional impairment is reported without muscle atrophy or indication of periods of complete nerve paralysis. The Board has considered that the representative and Dr. Z assert that the Veteran has severe nerve impairment in both lower extremities. However, DC 8520 specifically contemplates marked muscle atrophy for severe incomplete paralysis. The private medical records do not suggest notable muscle atrophy affecting either leg, and the May 2020 DBQ reported that muscle atrophy was not present in either leg. Thus, the evidence does not more nearly approximate severe incomplete paralysis of the sciatic nerve under DC 8520. For the foregoing reasons, a rating of 40 percent, but no higher, from March 29, 2016 for right and left lower extremity radiculopathy is warranted. In all other respects the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Entitlement to a TDIU TDIU may be assigned when a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16. The Veteran is currently service connected for the following disabilities: major depression disorder with a 50 percent rating from January 19, 2016, now right and left sciatic radiculopathy with a 20 percent rating from August 5, 2015 until March 29, 2016, and 40 percent thereafter for each extremity and lumbar spine disability with a 40 percent rating from August 5, 2015. The Board notes the above newly service connected disabilities have yet to be assigned initial ratings. However, there is no prejudice by proceeding without initial ratings for these disabilities given the fully favorable TDIU disposition. The Veteran's currently established combined rating meets the schedular TDIU rating criteria from August 5, 2015 as the lumbar spine and associated radiculopathy are considered one disability for TDIU minimum rating purposes. Id. Although there is a formal claim for a TDIU, the issue of entitlement to a TDIU is part and parcel of the claim for a higher initial rating for lumbar spine disability and therefore the relevant date of claim is now August 5, 2015. Harper v. Wilkie, 30 Vet. App. 356, 361-62 (2018) (confirming that when the issue of entitlement to a TDIU is raised as part and parcel of a rating claim, it should be treated separately from a formal claim for TDIU in all aspects of the appeal). As explained below, the Veteran was gainfully employed until March 15, 2016, and further consideration of TDIU prior to March 15, 2016 is not warranted since the Veteran does not meet the threshold eligibility criteria of unemployment. Robinson, 557 F.3d at 1361; 38 C.F.R. § 4.16. In analyzing TDIU claims, the central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" as having two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: The Veteran's history, education, skill, and training; whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Veteran submitted numerous private medical records spanning from June 2015 through the present that reflect a severe lumbar spine disability with radiculopathy affecting both lower extremities. The Board has summarized the private medical records below. In January 2016, the Veteran had a VA lumbar spine examination with a physician. He complained about back pain starting in service that became constant. He had been under treatment for it for the past three years. He had difficulty with daily activities and pain in both legs. Clinical findings were detailed. The physician reported functional impact of difficulty staying in one position due to low back muscle fatigue. February 2016 private orthopedic records showed that the Veteran had a series of conservative treatments for low back pain over the past several years that did not provide lasting pain relief. He currently had low back pain with numbness in both legs. Physical examination was notable for nonspecific back pain. Neurological findings showed good strength and normal sensation to light touch. The Veteran ambulated independently. Imaging studies were reviewed. The orthopedist acknowledged that the Veteran had significant back pain but was hesitant about surgical intervention. He indicated a sacroiliac joint (SI) dysfunction may explain the pain. March 2016 private medical records showed that the Veteran had chronic back pain that had failed multiple conservative treatment modalities. Physical findings were remarkable for pain in all planes of motion. Imaging studies were reviewed. The physician issued a surgical plan. July 2016 private medical records included reports from the Veteran that the symptoms 7-8 weeks following the back surgery were worse than those prior to surgery. In November 2016, the Veteran had a VA-contract Mental Disorder examination. The clinician assessed major depression consistent with occupation and social impairment with occasional decreased in work efficiency and intermittent periods of inability to perform occupational tasks. Symptoms included depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, suicide ideation and obsessional rituals. At the January 2017 RO hearing, the Veteran reported that he left work on March 15, 2016. March 2017 private medical records showed that the Veteran had a lumbar spine fusion surgery about a year ago. He did not experience any improvement with the surgery and believed his leg pain had worsened following it. He then had laminotomies in the months following the surgery without any benefit. He continued to have debilitating back pain on a daily basis and bilateral leg pain. He was under pain management therapy. Physical examination showed the Veteran to exhibit an antalgic gait and left lower extremity weakness. Imaging studies were reviewed. The orthopedist assessed back pain and leg pain after multiple spine procedures. In June 2017, the Veteran submitted VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability (TDIU claim). He reported being unable to work due to his service-connected back and radiculopathy disorders. He reported March 15, 2016 as the date that his service-connected disabilities affected full time employment and he was too disabled to work. He reported July 15, 2016 as the date he last worked full time. He explained that he returned to work following back surgery in June 2016 but was unable to continue working. He had a high school diploma and occupational experience as a lead technician at a financial firm. In October 2017, the Veteran's representative submitted a recent Social Security Administration (SSA) decision notification letter stating that the Veteran had been awarded disability benefits beginning in September 2016. November 2019 and April 2020 private medical records showed that the Veteran continued to be under pain management for severe back pain and lower extremity radiculopathy. He had severely reduced motion in his lumbar spine. At the May 2020 Board hearing, the Veteran reported that he last worked in March 2016. He was awarded SSA disability benefits for his lumbar spine disability. He reported that he tried to return to work in June 2016 but was unable to stay because of severe back pain and radiculopathy. For the following reasons, the Board finds that from March 15, 2016, but no earlier, a TDIU is warranted. The Veteran's highest educational attainment is a high school diploma. He has occupational experience as a lead technician with several private firms, most recently a financial firm. The evidence shows that the Veteran was gainfully employed until March 15, 2016. As noted above, the threshold TDIU criteria of unemployability are not met prior to this date. 38 C.F.R. § 4.16. From March 15, 2016, as to the non-economic TDIU component of physical capability in Ray, supra, the functional impairment from the service-connected lumbar spine disability, associated radiculopathy and major depressive disorder shows occupational impairment affecting a wide variety of physical occupational tasks. It shows that the Veteran had severe low back pain and radiculopathy that was unresponsive to surgical intervention and conservative treatment modalities. The movement limitations from back and leg pain would interfere with the Veteran's ability to perform nearly any physical occupational task, such as manual labor inherent to technical type work. Ray, 31 Vet. App. at 73. Given the above, the Board finds that from March 15, 2016, the Veteran has severe physical limitations associated with service-connected lumbar spine disability and bilateral lower extremity radiculopathy From March 15, 2016, as to the non-economic mental capability in Ray, supra., the Veteran's depressed mood and impaired concentration attributable to his service-connected depressive disorder pose mental impairment in completing a wide variety of occupational tasks associated with general labor or administrative work. It would interfere with his ability to complete occupational tasks in a timely manner and work with his others. Ray, 31 Vet. App. at 73. When considering the Veteran's work and education history and physical and mental impairments due to various service-connected disabilities, the evidence is at least in a state of relative equipoise as to whether the Veteran is unable to secure and follow a substantially gainful occupation within the meaning of the applicable regulation. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"); 38 C.F.R. § 4.16. For the foregoing reasons, the evidence is thus at least evenly balanced as to whether the Veteran's service-connected disabilities from March 15, 2016 precluded him from securing or following a substantially gainful occupation. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU from March 15, 2016 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a right ankle disorder, to include as secondary to service-connected disabilities, is remanded. The representative requested consideration of service connection for pain affecting the ankle and elbow and did not specific one side. The Veteran has not been afforded an examination in connection with these claims. The medical evidence confirms that the Veteran has severe lumbar spine disability with numerous complications, most notably gait imbalance and history of falls. Such complications raise the possibility of a secondary relationship to pain affecting additional joints, including the right elbow and right ankle. The record does not contain sufficient information to adjudicate these claims. The issue of secondary relationship is a complex medical question. Dr. Z's May 2020 medical opinion does not address these specific joints. With these considerations, the Veteran should be afforded an appropriate examination upon remand to assess the nature of his claimed right elbow disorder and right ankle disorder and appropriate medical opinions should be obtained as to whether these disabilities are caused or aggravated by service-connected disabilities. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). These matters are REMANDED for the following action: Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the Veteran's claimed right elbow and right knee disorders. The claims file and a copy of this remand must be made available to the clinician for review, and he or she must specifically acknowledge receipt and review of these materials in any reports generated. The clinician must opine whether any right elbow or right knee disorder experienced by the Veteran since approximately August 2015 is at least as likely as not is (a) caused by service-connected lumbar spine disability with radiculopathy, cervical spine disability with radiculopathy or any other service-connected disability or (b) aggravated by service-connected lumbar spine disability with radiculopathy, cervical spine disability with radiculopathy or any other service-connected disability. The medical opinion must clearly address both causation and aggravation elements for these claims. The clinician is advised that any report of joint pain causing functional impairment is sufficient to establish a current disability. The clinician must provide reasons for each opinion given. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. D. Simpson, 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.