Citation Nr: 21028928 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-03 522 DATE: May 12, 2021 ORDER A 30 percent rating is granted for posttraumatic stress disorder (PTSD) for the entire period on appeal prior to January 15, 2020, subject to the law and regulations governing the award of monetary benefits. A rating in excess of 70 percent for PTSD from January 15, 2020 is denied. A 10 percent rating is granted for left upper extremity cervical radiculopathy for the entire period on appeal prior to February 19, 2020, subject to the law and regulations governing the award of monetary benefits. A rating in excess of 10 percent for left upper extremity cervical radiculopathy is denied. REMANDED Entitlement to service connection for a left leg disability is remanded. FINDINGS OF FACT 1. Prior to January 15, 2020 the Veteran's PTSD more nearly approximated than not the criteria of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Although there were findings of flattened affect and irritability prior to January 15, 2020, the Veteran's PTSD was not then manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as: circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood, other than depressed mood; and/or difficulty in establishing and maintaining effective work and social relationships. 3. From January 15, 2020 the Veteran's PTSD has not been manifested by total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. 4. Prior to February 19, 2020 the Veteran's left upper extremity radiculopathy more nearly approximated than not the criteria of mild incomplete paralysis of the affected nerve. 5. The Veteran's left upper extremity radiculopathy has not been manifested by moderate incomplete paralysis at any time during the period on appeal. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for a rating of no more than 30 percent for PTSD have been met for the entire period on appeal prior to January 15, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 2. The criteria for a rating in excess of 70 percent for PTSD from January 15, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 3. Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent rating for left upper extremity cervical radiculopathy prior to February 19, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8715. 4. The criteria for a rating in excess of 10 percent for left upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8715. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from April 1988 to May 1995 and from September 1999 to February 2013. His decorations include the Southwest Asia Service Medal and Combat Action Ribbon. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The RO, in pertinent part, denied service connection for a left leg disability; granted service connection and a 10 percent rating for PTSD, effective March 1, 2013; and granted service connection and a 0 (zero) percent (noncompensable) rating for left upper extremity cervical radiculopathy, effective March 1, 2013. In March 2019, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. In July 2019, the Board remanded the issues on appeal to the agency of original jurisdiction (AOJ) for additional development. In October 2020, after taking further action, the AOJ increased the rating for PTSD to 70 percent, effective January 15, 2020, and increased the rating for left upper extremity cervical radiculopathy to 10 percent, effective February 19, 2020. The prior denials were otherwise confirmed and continued, and the case was returned to the Board. The Board finds that there has been at least substantial compliance with its remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). However, and although the Board regrets the additional delay, for the reasons detailed below, further development is still required regarding the left leg claim. As a final preliminary matter, the Board notes that the issues on appeal previously included the issue of entitlement to service connection for dysphagia as secondary to a service-connected disability of the cervical spine. However, in October 2020, while the case was in remand status, the AOJ granted service connection for that disability. As such, that matter is no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where service connection is granted during the pendency of an appeal, a second notice of disagreement must thereafter be timely filed in order to initiate appellate review of "downstream" issues, such as the compensation level assigned for the disability or the effective date of the award of service connection). Higher Ratings Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). 1. Entitlement to a rating in excess of 10 percent for PTSD prior to January 15, 2020 PTSD is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders, pursuant to 38 C.F.R. § 4.130. When a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, a noncompensable (zero percent) evaluation is warranted. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or if symptoms are controlled by continuous medication. A 30 percent rating is in order when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for Veterans Claims (Court) has held that the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Here, the Board finds the Veteran is entitled to a rating of no more than 30 percent for the period on appeal prior to January 15, 2020. In pertinent part, a VA examination conducted in March 2013 noted symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; and mild memory loss such as forgetting names, directions, or recent events. Such symptomatology is generally associated with the criteria for a 30 percent rating. The Board further notes that such symptoms are demonstrated by other evidence pertaining to that period. For example, in his October 2013 notice of disagreement (NOD), the Veteran noted sleep problems and poor short-term memory. Various treatment records from 2016 also note sleep problems associated with PTSD, including night sweats and insomnia. At the March 2019 hearing, the Veteran reported symptoms of anxiety, crowd avoidance, weekly panic attacks, and memory problems such that he had to write a lot of things down. He denied thoughts of suicide. See transcript pp. 8-10. The Board acknowledges that the March 2013 VA examiner found that the Veteran's level of occupational and social impairment was best summarized as mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. That is consistent with the current 10 percent rating. However, a review of the other evidence of record reflects that his disability has more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. For example, while he indicated that he had a close relationship with his wife and children at the March 2013 VA examination, he also reported that he and his wife had had "a few difficult periods." He further reported that his wife and children informed him that he was "unbearable" following his return from deployment in Iraq; that psychotherapy had helped reduce his symptoms; and that improving his coping skills had helped improve his relationship with his wife and children. In addition, the Veteran testified at the March 2019 hearing that he would describe his impairment from PTSD as moderate. He also reported that both of his managers at his current job had talked to him about being aggressive; and that he experienced on and off work conflicts that he attributed to his PTSD. Further, he described his relations with family and friends as strained, standoffish, and not as close as they used to be; and testified that he tended to isolate himself from the public. See transcript pp. 6-8. In light of the foregoing, and resolving reasonable doubt in favor of the Veteran regarding the degree of disability, the Board finds that his psychiatric manifestations more nearly approximated than not the criteria for a 30 percent rating throughout the period on appeal prior to January 15, 2020. The Board further finds, however, that a rating in excess of 30 percent is not warranted for the period prior to January 15, 2020, to include on the basis of additional "staged" ratings. The Board acknowledges that the record reflects the presence of some symptoms that are associated with a higher rating. In pertinent part, the March 2013 VA examination report noted symptoms such as flattened affect, irritability and outbursts of anger, hypervigilance, and exaggerated startle response. However, the Veteran also denied any history of violent behavioral problems, and the record does not otherwise demonstrate the type of impaired impulse control with periods of violence associated with a 70 percent rating. Further, the record does not demonstrate that the Veteran was found during that time frame to exhibit symptoms such as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood, other than depressed mood; and/or difficulty in establishing and maintaining effective work and social relationships. There were no findings of such on the March 2013 VA examination, or in the medical treatment records for that period, and the Veteran did not report the presence of such symptoms at the March 2019 Board hearing. The Board also notes that multiple treatment records dated in 2019 indicate that he was oriented to time, place, person; that he was in no acute distress; and that he was interactive and professional. In sum, the record does not demonstrate that he suffered occupational and social impairment to the extent as to constitute at least the type of reduced reliability and productivity that would warrant a rating in excess of 30 percent. For all these reasons, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for PTSD prior to January 15, 2020. To that extent, the appeal with respect to that period is denied. 2. Entitlement to a rating in excess of 70 percent for PTSD from January 15, 2020 Regarding the period from January 15, 2020, the Board notes that the Veteran's representative summarized the criteria for a 100 percent rating in a January 2021 brief; which implicitly suggests that he is entitled to such a rating. However, the representative did not identify any evidence that supports such a finding. The representative noted evidence demonstrating that the Veteran experiences nightmares, for example, which affect sleep and mood; however, as noted previously, symptoms of chronic sleep impairment are generally associated with a 30 percent rating. None of the evidence of record, including the report of a January 2020 VA examination, demonstrates that the Veteran has experienced symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, his own occupation, or his own name. Further, the record does not demonstrate that the Veteran's PTSD has resulted in total occupational and social impairment. The January 2020 VA examiner found that the Veteran's PTSD had resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Such a finding is inconsistent with total occupational and social impairment. Moreover, the examiner noted the fact that the Veteran was employed and provided details thereof, including the fact that he worked regular hours. He remained married, although he described the relationship as " pretty strained." He also had a support system of other veterans. In light of the foregoing, the Board finds that the Veteran has not met or more nearly approximated the criteria for a rating in excess of 70 percent during any portion of the period on appeal from January 15, 2020. As the preponderance of the evidence is against the assignment of a higher rating, the appeal with respect to this period must be denied. 3. Entitlement to a compensable rating for left upper extremity radiculopathy prior to February 19, 2020 Under the laws administered by VA, a distinction is made between major (dominant) and minor (non-dominant) upper extremities for rating purposes. In the instant case, the Veteran is left-hand dominant; i.e., his left upper extremity is considered the "major" extremity. The Veteran's left upper extremity radiculopathy is evaluated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8715, for impairment of the median nerve. Under that diagnostic code, mild incomplete paralysis of the median nerve warrants a 10 percent evaluation for both the major and minor side. Moderate incomplete paralysis warrants a 20 percent evaluation on the minor side and a 30 percent evaluation on the major side. Severe incomplete paralysis of the minor side warrants a 40 percent rating, and a 50 percent rating on the major side. Complete paralysis of the median nervewith the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand, pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, index and middle fingers remain extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm, flexion of wrist weakened, and pain with trophic disturbanceswarrants a 60 percent evaluation on the minor side and a 70 percent evaluation on the major side. The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All of the evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes, that the definitions for "mild" include not very severe. WEBSTER'S II NEW COLLEGE DICTIONARY at 694 (1995). In addition, a synonym for "mild" is "slight" and definitions for "slight" include small in size, degree, or amount. Id at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions for "severe" include extremely intense. Id. at 1012. The Board also acknowledges that VA's Adjudication Manual, M21-1, III.iv.4.N.4.c (November 16, 2017) discusses the terminology in 38 C.F.R. § 4.124a, DCs 8510-8730. The Manual indicates with regard to "mild": As this is the lowest level of evaluation for each nerve this is the default assigned based on the symptoms, however slight, as long as they were sufficient to support a diagnosis of the peripheral nerve impairment for service connection purposes. In general, look for a disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis. The Manual indicates with regard to "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. The Manual indicates with regard to "severe": In general, expect 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. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve (38 C.F.R. § 4.123). Prior to November 2017 revisions, VA's Adjudication Procedures Manual M21-1, Part III, Subpart iv, Chapter 4, § G(4)) defined "mild" incomplete paralysis as demonstrating subjective symptoms or diminished sensation; "moderate" incomplete paralysis as featuring the absence of sensation confirmed by objective findings; and "severe" incomplete paralysis as featuring more than sensory findings (such as atrophy, weakness, and diminished reflexes). In June 2016, VA amended the M21-1 adjudication manual "to further clarify the intent of VA's policy," and the relevant portion of the M21-1 manual included the following: Important: This provision does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength. Further, the Court held in Miller v. Shulkin, 28 Vet. App. 376, 380 (2017), that "[a]lthough the note preceding § 4.124a directs the claims adjudicator to award no more than a 20% disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level." The Adjudication Manual is not binding on the Board. DAV v. Sec'y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) ("The M21-1 Manual is binding on neither the agency nor tribunals"). Nevertheless, it does provide useful guidance in defining these terms, particularly if the Veteran demonstrates impairment consistent with higher rating(s) than currently in effect. Stated another way, the Board will look to see if there are findings that would warrant a higher rating under the M2-1 provisions, but will not deny the benefit sought on appeal if those provisions are not satisfied. As noted, Diagnostic Code 8715 does not explicitly provide for a noncompensable rating. In every instance where the schedule does not provide a zero percent rating for a Diagnostic Code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The Board notes that the objective record pertaining to the period on appeal prior to February 19, 2020, including the report of a May 2013 VA peripheral nerves examination, reflects little or no functional impairment of the left upper extremity. However, the Veteran has consistently reported pertinent symptomatology throughout the pendency of his claim. For example, at the May 2013 VA examination he reported that following the in-service neck injury he experienced left arm pain, tingling and weakness; and that he continued to experience occasional tingling in the left arm, and that left-hand weakness remained. It was also noted that he reported moderate paresthesias and/or dysesthesias of the left upper extremity; even though he denied numbness and constant or intermittent pain. At the March 2019 Board hearing, the Veteran indicated that he experienced pain from the neck which radiated into his left arm. In addition, he reported left hand pain which he stated was a constant "5" on a scale of 1 to 10. He also testified that when he engaged in activities that involved lifting or climbing or his arms above his shoulders, his left hand would go numb. Further, he described problems with fine motor coordination, to include writing. See Transcript pp. 10-15. In light of the Veteran's account of his symptomatology, it appears that there have been periods where he has experienced nerve-related impairment of the left upper extremity, including prior to February 19, 2020. Further, he testified that he used medication to treat his symptoms, and the rating criteria do not explicitly contemplate the use of medication to ameliorate symptoms. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Board also takes note of the fact that the M21-1 provisions, discussed above, provide that the criteria of mild incomplete paralysis is the default assigned based on symptoms, however slight, as long as the symptoms are sufficient to support a diagnosis of peripheral nerve impairment for service connection purposes. In light of the foregoing, and resolving reasonable doubt in the Veteran's favor, the Board finds that he is entitled to a 10 percent rating for service-connected left upper extremity radiculopathy for the period prior to February 19, 2020. To that extent, the appeal of this issue is granted. 4. Entitlement to a rating in excess of 10 percent for left upper extremity radiculopathy, to include from February 19, 2020 The Board finds that a rating in excess of 10 percent is not warranted for left upper extremity radiculopathy for any portion of the period on appeal. A thorough review of the record throughout the appeal period reflects little or no objective, nerve-related functional impairment of the left upper extremity. The 2013 VA peripheral nerves examiner found that the Veteran had left upper extremity paresthesias (residual radiculopathy) without objective clinical evidence at the time of the examination. That finding is consistent with the fact that the examination itself revealed muscle strength testing was 5/5 (normal) for left elbow flexion and extension, wrist flexion and extension, grip, and pinch. Reflexes were 2+ (normal) for the left biceps, triceps, and brachioradialis. In addition, sensation testing for light touch was normal in the left shoulder area, inner/outer forearm, and hand/fingers. The Board acknowledges that the Veteran described the severity of his left upper extremity radiculopathy symptoms as moderate at his March 2019 hearing. However, the more recent February 2020 VA examiner found him to have mild incomplete paralysis. The Board is not bound by either of these descriptions, although it is evidence for consideration. On the whole, the Board finds that the February 2020 VA examination findings are consistent with the other evidence of record and are consistent with a finding of no more than mild incomplete paralysis of the left upper extremity. At that examination, the Veteran reported that he did not experience constant or intermittent pain of the left upper extremity; but did experience mild paresthesias and/or dysesthesias, and mild numbness. Muscle strength testing was 5/5 (normal) for left elbow flexion and extension, and wrist flexion and extension. The left grip and pinch were 4/5 (active movement against some resistance). Reflexes were 2+ (normal) for the left biceps, triceps, and brachioradialis. Sensation testing for light touch was normal in the left shoulder area, and inner/outer forearm; and was decreased but not absent in the hand/fingers. In light of the foregoing, the Board finds the record, including the VA examination reports and the Veteran's hearing testimony, reflects impairment that is consistent with no more than mild incomplete paralysis; and that he has not met or more nearly approximated the criteria of moderate incomplete paralysis at any time during the pendency of his claim. Stated another way, the impairment attributable to the left upper extremity radiculopathy is small in size, degree, or amount, and not very severe; and is not of average or medium quantity, quality, or extent. He does not have findings that would warrant consideration of moderate incomplete paralysis pursuant to the M21-1 provisions, noted above. Nor does the record demonstrate he would have such impairment but for the use of medication. The preponderance of the evidence is against the assignment of a rating in excess of 10 percent for any portion of the period on appeal, to include on the basis of "staged" ratings. To that extent, the appeal of this issue is denied. REASONS FOR REMAND Entitlement to service connection for a left leg disability is remanded. The Veteran has indicated that he experiences recurrent left leg pain secondary to his service-connected lumbar spine disability. He testified at the hearing that his symptoms were similar to those he had in his left upper extremity. Under applicable law, disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). 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 or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In addition, Note (1) of the General Rating Formula for Diseases and Injuries of the Spine provides for a separate rating for associated neurologic impairment of a service-connected spine disorder. See 38 C.F.R. § 4.71a. Here, the Board notes that medical treatment records, including in July 2009 and January 2013, include findings of sciatica of the left lower extremity associated with the lumbar spine disability. However, VA examiners in 2013 concluded that there was no pathology to render a diagnosis for the Veteran's reported left leg pain, and that there was no associated neurologic impairment of the lumbar spine. The June 2013 rating decision denied the claim for lack of a current diagnosed disability. That said, the Board cannot ignore the fact the Veteran has continued to report recurrent left leg symptoms, including pain. The Board further notes that the Federal Circuit has held that pain alone may constitute a disability when it results in functional impairment of earning capacity, even in the absence of a diagnosis. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); cf. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). It is unclear from the record whether the Veteran currently has a left leg disability, and, if so, whether it is etiologically related to service and/or is secondary to the service-connected disability of his lumbar spine. A remand is required to afford the Veteran an examination and opinion that addresses the matter. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). This matter is REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issue remaining on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for an examination of his left leg. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has had a current disability of the left leg at any time since his separation from service in February 2013. In so doing, the examiner should comment on the significance, if any, of the Veteran's account of recurrent left leg pain. For any left leg disability found to be present, the examiner should express an opinion as to whether it is at least as likely as not that it was incurred in, or is otherwise related to, service. If it is the examiner's opinion that it is unlikely that an identified left leg disability had its onset in, or is otherwise attributable to, service, the examiner should offer a further opinion as to whether it is at least as likely as not that such disability has been (a) caused or (b) aggravated (i.e., worsened beyond natural progression) by the Veteran's service-connected lumbar spine disability. A complete rationale for all opinions expressed must be provided. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue remaining on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board John Kitlas, 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.