Citation Nr: 21028875 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 09-44 194 DATE: May 12, 2021 ORDER Entitlement to service connection for acquired psychiatric disorder, diagnosed as depressive disorder, is granted. Entitlement to service connection for left knee arthralgia associated with sarcoidosis is granted. Entitlement to service connection for right knee arthralgia associated with sarcoidosis is granted. Entitlement to an increased disability rating in excess of 10 percent for lumbar spine strain prior to February 10, 2020 and in excess of 20 percent from that date is denied. Entitlement to increased disability rating in excess of 10 percent for radiculopathy of the right lower extremity prior to January 24, 2020 and in excess of 20 percent from that date is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a left shoulder condition is remanded. Entitlement to service connection for cervical spine disability to include as secondary to lumbar spine disability is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, the diagnosed depressive disorder is secondary to the Veteran's other service-connected disabilities. 2. Resolving reasonable doubt in favor of the Veteran, the noted left and right knee arthralgia in service persisted as arthralgia noted in medical records during the current appeal period. 3. The Veteran's lumbar strain with spinal stenosis did not manifest in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or a combined range of motion not greater than 120 degrees; or guarding or muscle spasm severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis prior to February 10, 2020, and did not manifest in forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine from that date. The medical evidence of record does not support that the Veteran has IVDS that has resulted in incapacitating episodes with prescribed bed rest and treatment by a physician. 4. The Veteran's radiculopathy of the right lower extremity did not manifest by any more than mild incomplete paralysis of the sciatic nerve prior to January 24, 2020, and not more than moderate incomplete paralysis from that date. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for depressive disorder on a secondary basis have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.310. 2. The criteria for entitlement to service connection for left knee arthralgia associated with sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for entitlement to service connection for right knee arthralgia associated with sarcoidosis have been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to an increased rating in excess of 10 percent for lumbar spine strain prior to February 10, 2020 and in excess of 20 percent from that date have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 5. The criteria for entitlement to increased disability rating in excess of 10 percent for radiculopathy of the right lower extremity prior to January 24, 2020 and in excess of 20 percent from that date have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code (DC) 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1968 to February 1978. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). In general, service connection requires (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 382 F.3d 1163, 1167 (Fed. Cir. 2004).). Secondary service connection is granted for a "disability which is proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310(a). 1. Entitlement to service connection for acquired psychiatric disorder The Veteran contends that he has severe depression and posttraumatic stress disorder (PTSD) as a result of service. After a thorough review of the evidence and resolving any reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection is warranted for the diagnosed depressive disorder but is not warranted for PTSD. The Board notes that pursuant to Clemson v. Shinseki, 23 Vet. App. 1 (2009), the Veteran's claim has been characterized to include any psychiatric disorder, including PTSD. Service connection for PTSD requires the following three elements: (1) a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor in accordance with 38 C.F.R. 4.125 (a)), (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. 3.304(f). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. 1154 (a); 38 C.F.R. 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether the veteran "engaged in combat with the enemy." Id. The Veteran's service treatment records (STRs) do not mention psychiatric treatment or reports of psychiatric complaints. A December 2012 psychiatric assessment notes that the Veteran has a diagnosis of major depressive disorder, severe with psychotic features. This note is referenced within the April 2013 VA psychiatric examination where the examiner also diagnosed depressive disorder but stated that the Veteran did not meet the diagnostic criteria for PTSD. The examiner opined that the Veteran's depressive disorder was due to bereavement, marital discord, and chronic medical conditions. The Board notes that the Veteran has several service-connected disabilities and since 1983 has had service connection for sarcoidosis which was the basis for his medical retirement from active service in 1978. A February 25, 2013 CAPRI psychiatric outpatient note records that the Veteran was "stressed out over things he can't control, things like his medical problems." The Veteran reported never having been on antidepressant medication. The medical provider diagnosed depression and anxiety and noted a previous diagnosis of pain disorder with general medical problem and psychological factors. The record shows that by June 2013, the Veteran had been prescribed medication for depression and anxiety. An April 2016 CAPRI note states that the Veteran has been followed since 2013 for anxiety/depression due to general medical condition. The medical provider confirmed a diagnosis of depression related to general medical condition. A January 2017 CAPRI note records that the Veteran admitted to periodic bouts of depression without trigger. The examiner continued to note a diagnosis of depressive disorder due to general medical conditions. The Veteran was currently already prescribed medication for depression. An October 1, 2018 CAPRI note reflects a positive PTSD screening. The Veteran was treated at a Florida veterans center from 2016 to 2019. These records reflect a March 2018 note that the Veteran exhibited symptoms of PTSD but needed a thorough psychiatric evaluation to confirm it. In a January 2020 series of VA medical opinions, a medical provider opines that the Veteran does not have PTSD as that was an erroneous diagnosis previously, and that his diagnosis from VA examination is adjustment disorder with depressed mood and is not aggravated beyond natural state by service-connected disabilities. The examiner opined that the Veteran's adjustment disorder with depressed mood was a separate entity and related to adjustment to primary stresses in life associated with three failed marriages, no children, retirement on disability, grief, and other non-service-related matters. The Board here notes that the Veteran was in fact medically retired from active service in 1978, as well as from his civilian job in 2012 and placed on Social Security disability. In the remarks of the related January 2020 VA examination, the examiner recorded that when asked about psychological difficulties, the Veteran commented that he has so many medications he is "overwhelmed," and mentioned being "on prednisone since 75." The Board notes that prednisone was the medication prescribed for the Veteran's service-connected sarcoidosis. In the remarks, the examiner opined that the Veteran's diagnosed adjustment disorder was not associated with military service or to service-connected disease or injury. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's currently diagnosed depressive disorder is proximately due to or aggravated beyond its natural progression by his service-connected disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for acquired psychiatric disorder, diagnosed as depressive disorder, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. 2. Entitlement to service connection for left knee arthralgia associated with sarcoidosis 3. Entitlement to service connection for right knee arthralgia associated with sarcoidosis The Veteran contends that he has had knee pain since active service. After a thorough review of the evidence and resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection for arthralgia of the left and right knees is warranted. The Board notes that the Veteran has various medical diagnosis related to the knee. In this decision, the Board finds that knee pain categorized as arthralgia, which is mentioned in medical records as related to the Veteran's service-connected sarcoidosis, was incurred during active service, and, resolving reasonable doubt, has continued intermittently since service. The Board notes that the Veteran has also had diagnoses of degenerative joint disease (DJD) in both knees and has undergone surgical procedures in each knee but finds that these conditions are not related to active service or secondary to service-connected disabilities. The Veteran's STRs note right knee pain in July and September 1975. The Veteran underwent procedures to diagnose sarcoidosis in September 1975. In December 1976, bilateral knee pain is noted as arthralgia, additionally with swelling in the left knee. In May 1977, there is a note of bilateral knee arthralgia. The Veteran was medically retired due to sarcoidosis and lower back issues in February 1978. A January 1979 note states that the Veteran has a positive McMurray test in the left knee and presumed Baker's cyst. It also notes bilateral knee arthralgias. The examiner noted that an old meniscus injury could not be ruled out but that the Veteran had imaging done of the knees that were negative. A May 1979 note states that the Veteran's ongoing bilateral knee pain had onset in May 1975 and continued as undiagnosed with current crepitus. The June 1979 physical evaluation board found that the Veteran had sarcoidosis with pulmonary and joint manifestations. A February 20, 2003 CAPRI note shows the medical provider diagnosed right knee arthritis with pain and that the Veteran reported pain for over 20 years with no known trauma. A March 2003 CAPRI note records that the medical provider diagnosed right knee arthralgia with a recent normal X-ray. The Veteran complained of knee pain for several years. A May 29, 2003 CAPRI note shows the medical provider diagnosed acute arthritis in the left knee with effusion using X-ray. The Veteran reported swelling in the left knee for six days and it is recorded that there was no history of left knee pain and swelling per the Veteran. A June 2003 CAPRI note records the medical provider diagnosed effusion in the left knee and noted it "may be" associated with sarcoidosis. The Veteran said the right knee was not bothering him as it had been a few months earlier. The Board notes that "knee arthralgia" is listed as an ongoing current medical problem in the Veteran's medical records for multiple years, for example in May 2010 or April 2016. There are also notes of knee pain related to arthritis, for example in a September 17, 2015 CAPRI note. The Veteran had a VA examination for joints in June 2010, but the examiner did not include the Veteran's knees in the examination since the Veteran stated his knees were not bothering him at the time. The Board notes that the Veteran was granted entitlement to service connection for bilateral hip trochanteric bursitis with an effective date in March 2010 as MRI findings in 2010 showed sarcoid lesions in the related bones. Imaging of the knees in the medical record have not shown sarcoid involvement per the medical providers. The Veteran underwent right knee arthroscopy in 2011 and left knee arthroscopy in 2015. The March 2013 VA examination notes a diagnosis of DJD in both knees with the left diagnosed by X-ray in 2003 and the right by X-ray in 2011. A February 2003 X-ray of the right knee was normal. The Veteran reported that his knees had always hurt, the left being worse than the right. The examiner opined that the Veteran's bilateral DJD knee conditions were not at least as likely as not related to active service. The examiner stated that the right knee status post arthroscopy partial medial meniscectomy and chondroplasty is not caused by or a result of knee pains in active service. The knee pains in service were associated with acute pulmonary sarcoidosis, the examiner noted that "acute arthralgias commonly occur along with active pulmonary sarcoidosis." However, there was no objective evidence for onset of DJD in active service or within two years of service as DJD was most commonly associated with aging. "Recent rheumatology visit notes indicate a diagnosis of osteoarthritis and no active sarcoidosis to explain current symptoms." The right knee meniscal tear occurred 30 years after service and was not related to arthralgia reported in service. In the June 2019 decision, the Board found the related opinion inadequate for not including reference to the Veteran's lay statements about ongoing pain since service. A VA medical addendum opinion in January 2020 opines that the Veteran's left knee pain was acute and started in 2003 and was not chronic as the Veteran claimed. As for the right knee, the examiner opined that it also was not chronic pain as claimed by the Veteran and was not sarcoid arthritis but resulted from a torn meniscus that was addressed in 2011. The examiner updated the January 2020 opinion regarding the left knee in October 2020. The examiner had previously stated that the Baker's cyst mentioned in the STRs would be connected to service as it was noted in 1979. After informing the examiner that the Veteran was finished with active service in February 1978, he stated the Baker's cyst, if present, would not be related to service. Nonetheless, the current medical records do not support that the Veteran has been currently diagnosed with Baker's cyst of the left knee. In Saunders v. Wilkie, the Federal Circuit determined that "pain is an impairment because it diminishes the body's ability to function, and that pain need not be diagnosed as connected to a current underlying condition to function as an impairment." Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018). The Court went on to explain that "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain to establish a disability, the veteran's pain must amount to a functional impairment. To establish the presence of a disability, a veteran will need to show that her pain reaches the level of a functional impairment of earning capacity." Id. at 1367-68. In the present case, the Veteran has multiple diagnosed conditions of the bilateral knees with varying symptoms, some of which are shared among other medical diagnoses, including pain. Medical providers throughout the Veteran's medical record attribute pain at times as "arthralgia" in the bilateral knees, from active service and continuing into records of the appeal time period. The medical providers have noted that arthralgia is associated with sarcoidosis. "Arthralgia" is defined as pain in the joint. See Dorland's Illustrated Medical Dictionary 150 (32nd ed. 2012). At the same time, the medical providers have diagnosed the Veteran with DJD in both knees as well as meniscal problems leading to arthroscopy in both knees at different times. DJD was diagnosed by X-ray many years after the Veteran separated from active service. Of note, the Veteran had previous X-rays of the right knee in 2003 showing no DJD. And there were negative imaging studies of the bilateral knees done in active service. In the March 21, 2013 VA examination report, the examiner notes that there was functional loss due to pain, less movement than normal, and swelling. The symptoms or diagnosis at that examination included general pain. The impact on work reported was that the Veteran reported difficulty with prolonged standing. The examiner wrote that "knee issues preclude physically strenuous labor, frequent stair climbing, squatting, etc." The Board notes that a February 6, 2013 CAPRI note includes knee arthralgia as an ongoing medical condition. The January 2020 VA medical opinion stated, "As of sarcoid remission, no specialist has made a conclusive connection to veteran's currently diagnosed orthopedic conditions and pulmonary sarcoidosis." The Board notes that a May 2019 VA examination recorded sarcoidosis as a current ongoing diagnosis for which the Veteran took prescription medication. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's bilateral knee pain, referenced as arthralgia in the medical record, is proximately due to or aggravated beyond its natural progression by his service-connected sarcoidosis. The medical record shows that over the years, knee pain has been attributed at times to sarcoidosis and at times to non-sarcoid arthritis or other conditions. Knee arthralgia was noted in service as a condition related to sarcoidosis. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left and right knee disability, categorized as arthralgia, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. Increased Rating 4. Entitlement to an increased disability rating in excess of 10 percent for lumbar spine strain prior to February 10, 2020 and in excess of 20 percent from that date The Veteran contends that his service-connected lumbar spine disability is worse than the currently assigned 10 percent rating prior to February 10, 2020 and 20 percent from that date. After a thorough review of the evidence of record, the Board finds that an increased disability rating is not warranted. The Veteran submitted a claim for increased disability rating for the lumbar spine in November 2010. In an April 2013 rating decision, the AOJ continued the assigned 10 percent disability rating. The Veteran perfected an appeal in September 2016. Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the Veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran's lumbar spine degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. At the March 2013 VA examination, the Veteran exhibited forward flexion of the thoracolumbar spine to 80 degrees with painful movement and a total range of motion of 225 degrees. The Veteran did not exhibit guarding or muscle spasm. There was no ankylosis noted. The examiner noted IVDS of the spine that did not result in bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran regularly used lumbar support. At the July 2014 VA examination, the Veteran exhibited forward flexion of the lumbar spine to 80 degrees and a total range of motion of 230 degrees. The Veteran did not exhibit guarding or muscle spasm. The Veteran mentioned he had a spinal stimulator implanted in 2013. There was no ankylosis. The Veteran did not have IVDS. The Veteran reported occasional use of a brace and walker. The Veteran reported the brace was a corset for the back, but the walker was for his feet and ankles as prescribed by the podiatrist. In a January 2017 Board hearing, the Veteran stated that he had 15 days per month on which he was unable to get out of bed due to back pain. He stated that the spinal cord stimulator was unable to be removed. The Board notes that the Veteran has since been granted entitlement to TDIU. At the January 24, 2020 VA examination, the Veteran reported that his back pain had been increasing for the past 18 months. The Veteran had a spinal stimulator implanted several years prior but stated that it had stopped working and the clinic wanted to remove the device but was unable to do so. The Veteran reported that "half of the time he is unable to get out of bed." The forward flexion of the spine measured to 80 degrees and a total range of motion of 205 degrees. There was pain on all directions of motion and with weight bearing. Range of motion for repeated use over time was estimated at 70 degrees of forward flexion and a total range of motion of 145 degrees. The Veteran had guarding and muscle spasm but not resulting in abnormal gait or spinal contour. There was not ankylosis of the spine. The examiner noted IVDS of the spine that did not result in bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran used a brace regularly and walker occasionally. At the February 10, 2020 VA examination, the Veteran reported that his back pain flares up when he has been standing too long or walking sometimes. The functional loss included pain from bending or getting up from a sitting position. The forward flexion of the spine measured to 76 degrees and a total range of motion of 183 degrees. There was pain on all directions of motion and with weight bearing. Range of motion for repeated use over time was estimated at 70 degrees of forward flexion and a total range of motion of 160 degrees with the same estimate for range of motion during flare-ups. The Veteran had guarding and muscle spasm resulting in abnormal gait or spinal contour, described as Veteran must take a break and bend over when spasm happens. There was not ankylosis of the spine. The examiner noted no IVDS of the spine. The Veteran reported use of a brace and walker constantly. This examination was 16 days after the prior one. This examiner diagnosed spinal stenosis as a progression of the Veteran's lumbar strain. The Board finds that the Veteran's lumbar spine symptoms do not meet the functional equivalent of ankylosis. 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). For a rating of 40 percent for the thoracolumbar spine, the Veteran must exhibit forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The medical evidence of record shows that the Veteran experiences pain but he is able to bend his lumbar spine, even if it is at less than full range of motion. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for lumbar spine strain and spinal stenosis prior to February 10, 2020 or in excess of 20 percent from that date. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to increased disability rating in excess of 10 percent for radiculopathy of the right lower prior to January 24, 2020 and in excess of 20 percent from that date The Veteran contends that his service-connected right lower extremity radiculopathy is worse than contemplated by the currently assigned 10 percent rating prior to January 24, 2020 and 20 percent from that date. After a thorough review of the evidence of record, the Board finds that an increased disability rating is not warranted. The Veteran's radiculopathy of the right lower extremity is rated under Diagnostic Code 8520 based on incomplete paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve, 20 percent for moderate incomplete paralysis, 40 percent for moderately severe incomplete paralysis, 60 percent for severe incomplete paralysis, and 80 percent for complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. The words "mild," "moderate," "moderately severe," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. At the March 2013 VA examination, the Veteran exhibited mild paresthesias related to right lower extremity radiculopathy and severe intermittent pain. The examiner evaluated the overall severity of the Veteran's right lower extremity radiculopathy as mild. At the July 2014 VA examination, the examiner noted that there was no objective evidence of lower extremity radiculopathy. The Board remanded for a more recent examination in June 2019. On the January 24, 2020 VA medical examination, the examiner noted moderate severity for symptoms of intermittent pain, paresthesias or dysesthesias, and numbness on the right lower extremity radiculopathy related to the sciatic nerve. At the February 10, 2020 VA examination, 16 days after the prior VA examination, the examiner noted that the Veteran reported subjective symptoms of paresthesia, pain, and numbness but there were no objective findings for a diagnosis of the claimed radiculopathy. The Board notes that the Veteran has been afforded multiple VA examinations for his right lower extremity radiculopathy. At one examination, the examiner noted there were not objective indicators to diagnose lower extremity radiculopathy. However, at the January 24, 2020 VA examination, the examiner noted moderate radiculopathy in the right lower extremity. Prior to January 24, 2020, the evidence supports that the Veteran had mild right lower extremity incomplete paralysis. There was no evidence of muscle atrophy or of the foot dangling and dropping. In sum, the preponderance of the evidence is against increased ratings in excess of 10 percent prior to January 24, 2020 or in excess of 20 percent from that date for right lower extremity radiculopathy. Therefore, the appeal is denied, and increase are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran claims sleep apnea due to service, including a report of trouble sleep during service. The VA medical opinion from January 2020 opined that the Veteran's sleep apnea was likely due to the "excess weight and nearly 100 pound weight gain" since service. The examiner noted that obesity was a risk factor for sleep apnea. The examiner noted that in 2011, when the Veteran was diagnosed with sleep apnea, he weighed 245 pounds, but during active service, noted in 1976, the Veteran weighed 147 pounds. At the Veteran's height and a weight of 245 pounds, the Veteran would have a BMI at the entry level to obesity. A May 1979 medical note described the Veteran as a "somewhat underweight malnourished man," and diagnosed "borderline malnutrition." The Board notes that, while obesity cannot be service-connected on a direct basis, and obesity cannot qualify as an in-service event for service connection purposes, obesity may indeed serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOGCPREC 1-2017. In such a case, the evidence would need to reflect that (1) a service-connected disability or disabilities caused the Veteran to become obese, (2) the obesity was a substantial factor in causing another disability, and (3) the disability would not have occurred but for the obesity caused by the Veteran's service-connected disability or disabilities. Id. Here, the Veteran is service-connected for sarcoidosis since 1983 and has been on steroidal medication intermittently since 1975. The Veteran is also service-connected for diabetes mellitus, lumbar strain, and bilateral hip disabilities, among others. The AOJ should obtain an addendum medical opinion on the Veteran's weight gain, obesity, and if it is related to service-connected disabilities. 2. Entitlement to service connection for left shoulder condition is remanded. The Veteran contends that he has a left shoulder condition that is related to active service or to a service-connected disability. The May 1977 note in the STR records complaint of left shoulder pain as arthralgia. A December 1976 note shows complaint of left shoulder pain as arthralgia. A May 1979 note lists arthritis secondary to sarcoidosis without articular destruction as a diagnosis. This is after separation from service in February 1978. The Veteran had a VA examination for joints in June 2010. The examiner opined that the Veteran's left shoulder pain was not related to the arthralgia mentioned in the STRs, but that the pain was more likely related to musculoskeletal conditions unrelated to sarcoidosis. The examiner diagnosed left shoulder rotator cuff syndrome. The Veteran underwent a VA examination in March 2013 and the examiner diagnosed left rotator cuff tear status post repair. In the June 2019 decision, the Board found the related opinion inadequate for not including reference to the Veteran's lay statements about ongoing pain since service. In a January 2020 addendum opinion, the VA examiner opined that the Veteran's left shoulder condition had no nexus to the knees because the shoulder is not anatomically dependent on the knees. The examiner also noted that the Veteran's lay statements regarding pain were not supported by documentation, that is the evidence shows that left shoulder pain developed in 2006. In a June 2019 decision, the Board remanded the issue of service connection for left shoulder condition. In the remand directive, the Board stated that the addendum opinion "must address the May 1979 diagnosis of arthritis." The January 2020 VA addendum opinion does not include reference to that. Accordingly, the Board must remand again to obtain an addendum opinion that complies with the prior Board remand. 3. Entitlement to service connection for cervical spine disability to include as secondary to lumbar spine disability is remanded. In a June 2019 decision, the Board remanded the cervical spine issue to obtain an addendum medical opinion. In the subsequent December 24, 2020 VA medical opinion, the examiner wrote, "There is no evidence of neck pain while in service." On the contrary, the Board notes that a September 22, 1975 service record notes, "neck pain." Accordingly, as there is a material error in the December 2020 VA medical opinion, the Board must remand for a new medical opinion on the cervical spine issue. The matters are remanded for the following action: 1. Obtain an addendum medical opinion regarding sleep apnea. The examiner should address (a) whether a service-connected disability or disabilities caused the Veteran to gain significant weight or become obese or aggravated the Veteran's weight gain, and if so, (b) whether any weight gain, obesity or aggravation of such resulting from service-connected disability was a substantial factor in causing sleep apnea such that the sleep apnea would not have occurred but for the weight gain or obesity caused or aggravated by service-connected disability. 2. Obtain an addendum medical opinion for the Veteran's left shoulder condition. The examiner must reference the note in the service treatment record from May 1979 (bearing in mind that the Veteran was separated from service in February 1978) noting a diagnosis of arthritis secondary to sarcoidosis without articular destruction. The examiner must address a) is it as least as likely as not that the Veteran's left shoulder condition is related to an event, injury, or disease in active service and b) is it as least as likely as not that the Veteran's left shoulder condition is caused or aggravated by a service-connected disability. The examiner must take into account the medical evidence of record and the Veteran's lay statements when forming these opinions. 3. Obtain a new medical opinion regarding service connection for the Veteran's diagnosed cervical spine condition. The examiner must address the following a) is it as least as likely as not that the Veteran's cervical spine condition is related to an event, injury, or disease in active service and b) is it as least as likely as not that the Veteran's cervical spine condition is caused or aggravated by a service-connected disability. The examiner must take into account the medical evidence of record and the Veteran's lay statements when forming these opinions. The examiner must specifically reference the following: the September 22, 1975 complaint of neck pain; the May 1979 diagnosis of arthritis secondary to sarcoidosis. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.