Citation Nr: 21031119 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 14-41 126A DATE: May 20, 2021 REMANDED Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to exposure to environmental hazards in the Gulf War, is remanded. Entitlement to service connection for a gastrointestinal disorder, other than irritable bowel syndrome (IBS), to include gastroesophageal reflux disease (GERD), and as due to exposure to environmental hazards in the Gulf War, is remanded. Entitlement to service connection for right hand numbness, to include as due to exposure to environmental hazards in the Gulf War, is remanded. Entitlement to service connection for left hand numbness, to include as due to exposure to environmental hazards in the Gulf War, is remanded. Entitlement to a rating in excess of 20 percent for degenerative disc disease with intervertebral disc syndrome (previously lumbar disc disease) is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy associated with degenerative disc disease with intervertebral disc syndrome is remanded. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy of the sciatic nerve associated with degenerative disc disease with intervertebral disc syndrome is remanded. Entitlement a separate rating prior to September 15, 2020, a rating in excess of 10 percent from September 15, 2020, and a compensable rating thereafter for right lower extremity radiculopathy of the femoral nerve associated with degenerative disc disease with intervertebral disc syndrome is remanded. Entitlement to a separate rating for involuntary urination associated with degenerative disc disease with intervertebral disc syndrome prior to September 15, 2020, and a compensable rating thereafter is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) for the appeal period prior to December 8, 2011, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1976 to June 1980 and from March 1990 to September 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In February 2019, the Board remanded these matters to the RO for further development. As an initial matter, the Board notes that in a December 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for sleep apnea and service connection for IBS, claimed as Crohn's disease. As the grant of service connection for sleep apnea is considered a full grant of the issue sought on appeal, this issue is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Although the AOJ granted service connection for IBS, claimed as Crohn's disease, and noted that this was a full grant of the benefits sought on appeal, the Board finds it more appropriate to recharacterize the Veteran's initial claim for service connection for Crohn's disease, abdominal pain, and diarrhea, as service connection for IBS and service connection for a gastrointestinal disorder, other than IBS, to include GERD, as the evidence shows the Veteran has more than one disability related to this claim. Therefore, to reflect the evidence of record most accurately, the Board has bifurcated the Veteran's claim into two separate issues of entitlement to service connection. See Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011) (bifurcation of a claim generally is within VA's discretion). Accordingly, as the AOJ's grant of service connection for IBS is a full grant of that disability, it is no longer before the Board in this decision; however, the issue of entitlement to service connection for a gastrointestinal disorder, other than IBS, to include GERD, remains on appeal before the Board. Additionally, the Board notes that in the December 2020 rating decision, the AOJ granted service connection for radiculopathy of the right lower extremity femoral nerve as associated with the Veteran's service-connected lumbar spine disability and assigned a 10 percent rating effective September 15, 2020, and also granted service connection for involuntary urination associated with his service-connected lumbar spine disability and assigned a noncompensable (0 percent) rating from September 15, 2020. Thereafter, in a March 2021 rating decision, the AOJ decreased the Veteran's rating for his right lower extremity radiculopathy of the femoral nerve to noncompensable from February 10, 2021. Although the Veteran has not specifically disagreed with these ratings, the Board finds that radiculopathy of the upper and lower extremities and involuntary urination are part and parcel of the increased rating claim for the Veteran's lumbar spine disability. See 38 C.F.R. § 4.71a, General Rating Formula, Note 1. Moreover, as noted in the February 2019 Board decision, when the Veteran appealed the rating assigned for his lumbar spine disability, his appeal encompassed ratings for all manifestations of the condition. As such, the issues on appeal have been recharacterized as listed on the title page of this decision. However, the Veteran did not appeal the rating reduction for his right lower extremity radiculopathy of the femoral nerve nor expressed disagreement with the March 2021 reduction. Rating reduction claims are separate from increased rating claims. Dofflemeyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992). As such, the propriety of the reduction is not included in the increased rating claim currently before the Board but as the decision is not final, the Veteran may still appeal the reduction in the March 2021 rating decision. The Board further notes that as the appeal for an increased rating for his right lower extremity radiculopathy of the femoral nerve includes the time period during which the rating has been reduced to noncompensable, the issue has been recharacterized in the title page of this decision to recognize that period. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim. In this regard, since issuance of the last Supplemental Statement of the Case (SSOC) in December 2020, additional evidence, relevant to all the issues on appeal, have been associated with the Veteran's claims file. Specifically, Social Security Administration (SSA) records were added to the claims file after the December 2020 SSOC but were not considered by the AOJ before the Veteran's appeal was transferred to the Board. The Board notes that applicable VA regulations require that pertinent evidence received by the RO prior to the transfer of the matter to the Board must be referred to the appropriate rating or authorization activity for review and preparation of an SSOC. 38 C.F.R. § 19.37. Accordingly, as the record does not show that the AOJ has readjudicated the claim with consideration of the additional, relevant evidence of record received prior to transfer of the record to the Board, a remand is required for the issuance of an SSOC. 38 C.F.R. § 19.31, 19.37. The Board also notes that additional relevant VA medical treatment records and examinations were added to the claims file after issuance of the December 2020 rating decision and after transfer of the appeal to the Board. Although the record does not contain a waiver of initial AOJ review of this evidence, upon remand the AOJ will review this new evidence in the first instance during readjudication of the claim. 1. Entitlement to service connection for CFS, to include as due to exposure to environmental hazards in the Gulf War In addition to the reasons discussed above, the Board also finds that a remand is warranted for the Veteran's claim as there has not been substantial compliance with the February 2019 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, in the February 2019 Board remand, the Board instructed the VA examiner to provide an opinion as to whether the Veteran's claimed fatigue constitutes and undiagnosed illness or a medically unexplained chronic multi symptom illness as defined under 38 C.F.R. § 3.317. The Board also instructed the VA examiner to clarify whether the Veteran's fatigue is a chronic disability or whether it is a symptom or manifestation of another chronic disability. Although the August 2019 VA examiner found that the Veteran did not have nor ever had CFS, the examiner specifically did not clarify whether the Veteran's fatigue is a symptom or manifestation of another chronic disability or if it constitutes an undiagnosed illness or medically unexplained chronic multi-symptom illness as instructed to do so in the February 2019 Board decision. Accordingly, the Board finds that a remand is warranted to obtain an addendum opinion that addresses the nature and origin of the Veteran's fatigue. 2. Entitlement to service connection for a gastrointestinal disorder, other than IBS, to include GERD, and as due to exposure to environmental hazards in the Gulf War In addition to the reasons discussed above, the Board also finds that a remand is warranted for the Veteran's claim. In light of the potential multiple disabilities related to the Veteran's initial service connection claim for Crohn's disease, abdominal pain, and diarrhea, the February 2019 Board decision remanded the claim for a VA examination in order for a VA examiner to identify the Veteran's diagnosed gastrointestinal disorders and opine whether such were related to service. As such, the Veteran underwent a Gulf War examination in August 2019 where the examiner diagnosed the Veteran with IBS and GERD. The examiner opined that the Veteran's GERD was not related to environmental exposures during the Persian Gulf War because the Veteran's GERD was not manifest until approximately 2000. However, the VA examiner did not provide an opinion as to whether the Veteran's GERD is otherwise related to his active duty service, to include the service treatment records (STRs) from the late 1970s showing digestive conditions including gastroenteritis and right lower quadrant abdominal pain as well as the Veteran's testimony during the April 2018 Board hearing of abdominal pain approximate to his service in the Persian Gulf. Therefore, a remand is warranted for an addendum opinion to determine the nature and origin of the Veteran's GERD, to include whether such is secondary to his service-connected IBS. Additionally, although the August 2019 VA examiner did not diagnose the Veteran with Crohn's disease, the examiner did not otherwise clarify whether the Veteran has or had Crohn's disease during the pendency of the appeal. In light of the conflicting evidence of record concerning whether the Veteran has Crohn's disease and given that SSA records addressing the Veteran's history of Crohn's disease were added to the claims file, on remand, the VA examiner should specifically provide an opinion concerning whether the Veteran had or has Crohn's disease during the pendency of his appeal. 3. Entitlement to service connection for right-hand and left-hand numbness, to include as due to exposure to environmental hazards in the Gulf War In addition to the reasons discussed above, the Board also finds that a remand is warranted for further development regarding the Veteran's claims for right- and left-hand numbness. In this regard, although the August 2019 VA examiner found that the Veteran's hand symptoms were related to his bilateral carpal tunnel diagnosis, and that his carpal tunnel syndrome was not related to any exposures during service in Southwest Asia, the VA examiner did not explain why the Veteran's carpal tunnel syndrome was not related to such exposure. The Board notes that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Additionally, the VA examiner did not address the Veteran's contention that his bilateral hand numbness constitutes an undiagnosed illness because even though the numbness in his hands was diagnosed as carpal tunnel syndrome, after his carpal tunnel surgery, he continued to experience these symptoms with no difference. In light of these deficiencies, the Board finds that a remand is warranted for an addendum VA opinion. 4. Entitlement to a rating in excess of 20 percent for degenerative disc disease with intervertebral disc syndrome (previously lumbar disc disease) In addition to the reasons for remand discussed above, the Board also, unfortunately, finds that a remand is warranted for another VA examination. The Board acknowledges that the Veteran recently underwent VA back examinations in September 2020 and February 2021; however, due to inconsistencies and inadequacies among these examinations, the Board finds that another examination is necessary in order to adequately assess the severity of the Veteran's disability. In this regard, the Board finds that neither the September 2020 nor February 2021 VA examinations complied with all the findings required by Correia v. McDonald, 28 Vet. App. 158 (2016). Specifically, in Correia, the United States Court of Appeals for Veterans Claims (Court) concluded that 38 C.F.R. § 4.59 requires VA examinations, whenever possible, to include joint testing for pain on both active and passive range of motion, as well as with weightbearing and non-weightbearing, and that if an examiner is unable to conduct the required testing or concludes that such is unnecessary, he or she should clearly explain why that it so. 28 Vet. App. at 158. Here, although the September 2020 VA examiner found evidence of pain on non-weightbearing and with weight-bearing as well as pain during initial range of motion testing, the VA examiner did not record such range of motion measurements, to include where pain began, nor provided a reason for the failure to do so. Likewise, the February 2021 VA examiner found that the Veteran exhibited pain with active range of motion but failed to provide measurements where pain began and failed to indicate (i.e., did not check any relevant box) whether pain caused functional loss. Moreover, the Board finds that the February 2021 VA examination does not sufficiently address the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this regard, the VA examiner noted that the Veteran was being examined immediately after repeated use over time, provided the same range of motion measurements as initially recorded, and estimated that after repetitive use over time, the Veteran would have difficulty keeping the same range of motion as noted on examination. This finding is internally inconsistent as the examiner indicted both that the Veteran was being examined after repeated use over time and that his range of motion measurements may be different after repeated use over time. Thus, this finding is insufficient under Sharp as it is unclear what the Veteran's range of motion measurements are, or would be estimated as, after repeated use over time. Thus, as the last VA examination does not fully satisfy the requirements of Correia, Sharp, and 38 C.F.R. § 4.59, a new VA examination is necessary. Additionally, while the September 2020 VA examination reflects that the Veteran had radiculopathy, muscle atrophy, and a urinary problem associated with his lumbar spine disability, the February 2021 VA examination, just a few months later, reflects that the Veteran does not have radicular pain or signs and symptoms or radiculopathy, muscle atrophy, nor other neurologic abnormalities such as bladder or bowel problems. Accordingly, and as discussed in further detail below, a remand is also warranted to adequately assess the neurological impairments and manifestations of the Veteran's lumbar spine disability. Finally, because during the September 2020 VA examination the Veteran reported that his lumbar spine disability impacts his activities of daily living and because the February 2021 VA examination reflects that the Veteran's disability limits his activities, the Board is requesting that, on remand, the VA examiner discuss the effects of the Veteran's disability on his activities of daily living to assess the overall functional impairment of his back disability. 5. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy; entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy of the sciatic nerve; and entitlement a separate rating prior to September 15, 2020, a rating in excess of 10 percent from September 15, 2020, and a compensable rating thereafter for right lower extremity radiculopathy of the femoral nerve The Veteran's increased rating claims for his left and right lower extremity radiculopathy disabilities are intertwined with his lumbar spine disability rating claim as that development may provide relevant evidence as to the Veteran's radiculopathy claims. See AB, 6 Vet. App. at 39 (providing that a veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). As such, a remand of these claims is required. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Additionally, with respect to the Veteran's service-connected left lower extremity radiculopathy, the evidence is conflicting regarding the presence and severity of any muscle atrophy. For example, although a March 2011 SSA physical residual capacity assessment reflects the Veteran has left leg atrophy, the subsequent February 2012 VA back examination reflects that the Veteran had no muscle atrophy and the November 2012 opinion also reflects the Veteran had no muscle atrophy. However, during the April 2018 Board hearing, the Veteran testified that he had muscle atrophy and that is left leg is smaller than his right leg while his spouse also testified that he had severe muscle loss in one leg. See April 2018 Board hearing transcript. pp. 16-17. Likewise, the September 2020 VA examiner found that the Veteran had muscle atrophy in his left lower extremity below the patella and that the atrophied side was measured as 41 centimeters (cm) while the normal side was measured as 45 cm. On the other hand, the February 2021 VA back examiner found no atrophy at all while the associated February 2021 peripheral nerves examination reflects both that the Veteran's current symptoms include muscle atrophy but that the Veteran also does not have muscle atrophy. As the presence and severity of any muscle atrophy could affect the overall severity of his radiculopathy and, thus, the rating assigned, a VA examination is required on remand in order to more completely evaluate the severity of the Veteran's left lower extremity radiculopathy, specifically by addressing the presence and severity of any muscular atrophy. With respect to the Veteran's service-connected right lower extremity radiculopathy of the femoral nerve, the September 2020 VA back examiner found that the Veteran had right lower extremity femoral nerve involvement associated with his service-connected lumbar spine disability and found that the Veteran's right sided radiculopathy was mild in nature. This was the basis for the AOJ's grant of service connection for right lower extremity radiculopathy of the femoral nerve and assignment of a 10 percent rating from September 15, 2020, in the December 2020 rating decision. Thereafter, however, the February 2021 VA back examiner found that the Veteran did not have any radicular pain or signs and symptoms of radiculopathy while the associated peripheral nerves examination, that month, reflects that the Veteran had peripheral neuropathy affecting the left external cutaneous nerve of the thigh while the section of the examination addressing the femoral nerve was not filled out. Given these examination inconsistencies, a remand is warranted for an updated VA examination to determine the severity of the Veteran's right lower extremity radiculopathy of the femoral nerve. Moreover, the May 2012 VA back examination reflects that the Veteran had right femoral nerve radiculopathy. As such, on remand, the VA examiner should clarify whether the Veteran had right lower extremity radiculopathy of the femoral nerve prior to September 15, 2020, for which a separate rating may be warranted, and, if so, should provide an opinion as to the severity of that disability. 6. Entitlement to a separate rating for involuntary urination associated with degenerative disc disease with intervertebral disc syndrome prior to September 15, 2020, and a compensable rating thereafter The Veteran is currently in receipt of a noncompensable rating for involuntary urination from September 15, 2020, based upon a September 2020 VA examination finding that the Veteran has involuntary urination associated with severe pain caused by his degenerative disc disease. The September 2020 VA examiner also noted that while the Veteran's current symptoms include the feeling of needing to urinate, there is no actual incontinence. Since the September 2020 VA examination, VA treatment records reflect that the Veteran may be experiencing increased urinary symptoms associated with his lumbar spine disability. For example, an October 2020 VA treatment record reflects that the Veteran reported loss of bladder when lifting objects and that he has bladder incontinence when lifting five to ten pounds while a March 2021 VA treatment record reflects that the Veteran has experienced one or two episodes of urinary incontinence, in particular while lifting anything of significance. As such, the Board finds that an updated VA examination is warranted to assess the severity of the Veteran's disability. In addition, as the Veteran testified at the April 2018 Board hearing that he experienced some bladder control issues if he lifts something heavy, on remand, the examiner should clarify whether the Veteran had a bladder impairment disability related to his lumbar spine disability prior to September 15, 2020, and, if so, at what point during the appeal period did this manifest. See April 2018 Board hearing transcript, pp. 17-20. 7. Entitlement to a TDIU for the appeal period prior to December 8, 2011 At the outset, the Board notes that in a March 2021 rating decision, the AOJ granted entitlement to a TDIU from December 28, 2020. Thereafter, in another March 2021 rating decision, the AOJ granted entitlement to a TDIU from December 8, 2011, the date the AOJ determined that VA received the Veteran's claims leading to the grant of a TDIU and the earliest date in which the Veteran met the schedular criteria for a grant of TDIU. However, as the issue of entitlement to a TDIU arose as part and parcel of an increased rating claim for the Veteran's lumbar spine disability received on December 8, 2011, the period on appeal includes the one-year period prior to December 8, 2011, which is the same period on appeal as the original claim for the increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, the rating period for consideration of a TDIU is from one year prior to receipt of the claim and that period is still for consideration and on appeal before the Board. Here, although for the period prior to December 8, 2011, the Veteran does not currently meet the schedular requirements for a TDIU rating, as the Veteran's increased rating claim for his lumbar spine disability is also being remanded, and could impact a decision on the issue of entitlement to a TDIU for this period of time, the claims are inextricably intertwined. Harris, 1 Vet. App. at 183. Therefore, this issue must also be remanded. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated March 2021. 2. Provide the Veteran with another opportunity to identify and/or submit any outstanding private treatment records relevant to his claims. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. 3. Then, obtain an addendum VA opinion from an appropriate medical professional to address the Veteran's claim for service connection for fatigue, to include as due to environmental hazards from service in the Gulf War. The claims file, to include a copy of this Remand, must be made available to and be thoroughly reviewed by the VA examiner. The VA examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's claimed fatigue constitutes an undiagnosed illness or a medically unexplained chronic multi symptom illness as defined under 38 C.F.R. § 3.317. In providing the above opinion, the examiner should address/clarify whether the Veteran's fatigue is a chronic disability or whether it is a symptom or manifestation of another chronic disability. The examiner should also address the April 2018 medical letter from Dr. D.S. that the Veteran's fatigue is at least as likely as not an undiagnosed symptom. (b) If the examiner finds that the Veteran's fatigue is a chronic disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such had an onset in service or is otherwise related to service, to include as due to exposure to environmental hazards from service in the Gulf War and/or the Veteran's report of experiencing fatigue since approximately 1992? A complete rationale must be provided for all opinions. A discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. 4. Obtain an addendum VA opinion from an appropriate medical professional to address the Veteran's claim for service connection for a gastrointestinal disorder, other than IBS, to include GERD, and to include as due to environmental hazards from service in the Gulf War. The claims file, to include a copy of this Remand, must be made available to and be thoroughly reviewed by the VA examiner. The VA examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has or had a diagnosis of Crohn's disease during the pendency of the appeal (i.e. from December 2011). Why or why not? (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's GERD, and Crohn's disease only if the VA examiner finds the Veteran has a diagnosis of Crohn's disease during the appeal period: (1) had an onset during service; (2) is otherwise related to service, to include as due to environmental exposures during Gulf War service in Southwest Asia; OR (3) is caused by OR aggravated by the Veteran's service-connected IBS, to include any incremental increase or non-permanent aggravation of the condition? In rendering his or her opinion, the examiner should address BOTH the causation and aggravation questions in his or her rationale. If aggravation is found, the examiner should quantify the degree of aggravation, if possible and state whether there was an increase in disability regardless of permanence, but medically ascertainable. The examiner should also ADDRESS (1) the STRs from the late 1970s showing digestive conditions including gastroenteritis and right lower quadrant abdominal pain and (2) the Veteran's testimony during the April 2018 Board hearing of abdominal pain approximate to his service in the Persian Gulf. The examiner should provide a complete rationale for all opinions and the rationale for a negative opinion must not be based solely on the lack of a relevant in-service diagnosis or clinical finding. 5. Obtain an addendum VA opinion from an appropriate medical professional to address the Veteran's claim for bilateral hand numbness, to include as due to environmental hazards from service in the Gulf War. The claims file, to include a copy of this Remand, must be made available to and be thoroughly reviewed by the VA examiner. The VA examiner is asked to respond to the following: (a) Clarify whether the Veteran's bilateral hand numbness is a chronic disability or whether it is a symptom or manifestation of another chronic disability, to include carpal tunnel syndrome and/or diabetic neuropathy. Why or why not? In providing this clarification opinion, the VA examiner should ADDRESS the Veteran's contention that his bilateral hand numbness constitutes an undiagnosed illness because even though the numbness in his hands was diagnosed at carpal tunnel syndrome, after his carpal tunnel surgery, he continued to experience these symptoms with no difference. (b) If the examiner finds that the Veteran's bilateral hand numbness is a chronic disability, or is a symptom of another chronic disability, to include his carpal tunnel syndrome and/or diabetic neuropathy, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such (1) had an onset during service or (2) is otherwise related to service to include exposure to environmental hazards while serving in Southwest Asia? (c) If the examiner finds that the Veteran's bilateral hand numbness is NOT a chronic disability or is NOT a symptom of another chronic disability, to include carpal tunnel syndrome and/or diabetic neuropathy, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the symptoms constitute an undiagnosed illness or a medically unexplained chronic multi symptom illness as defined under 38 C.F.R. § 3.317. A complete rationale must be provided for all opinions. A discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. 6. Then, schedule the Veteran for an updated VA examination to determine the severity of his service-connected lumbar spine disability and associated neurologic disabilities. The claims file, including a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated testing should be accomplished and all symptomatology associated with the lumbar spine disability should be identified. The examiner should respond to the following: (a) The examiner must test the Veteran's range of motion on active and passive motion, on weight-bearing and non-weight-bearing, if possible, and record the range of motion measurements. (b) If there is evidence of pain on motion, the examiner must indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination results in any loss of range of motion. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (c) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use due to the Veteran's disability. The examiner should state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups, if any, he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment she experiences during a flare-up of his back and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion ESTIMATING any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. (d) If it is not feasible to determine the extent to which the Veteran experiences additional functional loss on repeated use over time or during flare-ups without resorting to speculation, the examiner must provide an explanation for why that is so. The examiner is further advised that the inability to provide an opinion without resorting to speculation must be based on the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner. (e) In addition to the above, the VA examiner should clearly indicate all orthopedic and any neurologic manifestations of the Veteran's service-connected lumbar spine disability. The Board notes the Veteran is service-connected for left lower extremity radiculopathy of the sciatic nerve associated with the Veteran's lumbar spine disability, right lower extremity radiculopathy of the sciatic nerve associated with the Veteran's lumbar spine disability, right lower extremity radiculopathy of the femoral nerve associated with the Veteran's lumbar spine disability, and involuntary urination associated with the Veteran's lumbar spine disability. (f) Finally, the examiner must, to the extent possible, DISCUSS the effect of the Veteran's lumbar spine disability on his activities of daily living and any associated functional impairment. A complete rationale must be provided for all opinions expressed. 7. Schedule the Veteran for an updated VA examination to determine the severity of his service-connected left lower extremity and right lower extremity radiculopathy. The claims file, including a copy of this Remand, must be made available to and be reviewed by the examiner. All indicated testing should be accomplished and all symptomatology should be identified. The examiner should respond to the following: (a) Evaluate the current severity of the Veteran's service-connected left lower extremity radiculopathy stating whether there is complete or incomplete paralysis. If there is incomplete paralysis, describe whether it is mild, moderate, moderately severe, or severe with marked muscular atrophy. (b) The examiner should clarify whether the Veteran has muscular atrophy, specifically of the left lower extremity, and, if so, provide the measurements of both the atrophied side as well as the normal side. In so doing, the examiner should specifically review the prior VA examinations of record and Board testimony, including the March 2011 SSA physical residual capacity assessment noting left leg atrophy and the September 2020 VA finding of muscle atrophy in the left lower extremity radiculopathy. (c) Evaluate the current severity of the Veteran's service-connected right lower extremity radiculopathy of the sciatic and femoral nerves stating whether there is complete or incomplete paralysis. If there is incomplete paralysis, describe whether it is mild, moderate, moderately severe, or severe with marked muscular atrophy. (d) The examiner should clarify whether it is at least as likely as not (50 percent probability or greater) that the Veteran had right lower extremity radiculopathy of the femoral nerve prior to September 15, 2020, and, if so, at what point during the appeal period (i.e., at what point does the evidence show the Veteran has right lower extremity radiculopathy of the femoral nerve) and, if possible, provide an opinion estimating the severity of the radiculopathy from that date ( i.e., mild, moderate, moderately severe, or severe with marked muscular atrophy). In providing this opinion, the VA examiner must address the May 2012 VA back examination finding that the Veteran had right lower extremity radiculopathy of the femoral nerve. A complete rationale must be provided for all opinions. If it is not feasible to provide any of the requested opinions without resorting to speculation, the examiner must provide an explanation for why that is so. 8. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the current severity of his involuntary urination disability. The claims file, including a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran had involuntary urination, or any bladder impairment related to his service-connected lumbar spine disability for the period prior to September 15, 2020? Why or why not? If so, at what point during the appeal period did the Veteran's bladder disability manifest? A complete rationale must be provided for all opinions expressed. If it is not feasible to provide any of the requested opinions without resorting to speculation, the examiner must provide an explanation for why that is so. 9. Readjudicate the claims on appeal based on the entirety of the evidence, including the issue of entitlement to TDIU for the appeal period prior to December 8, 2011. If any benefit sought remains denied, issue a SSOC and allow the Veteran an appropriate period of time to respond. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, Associate 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.