Citation Nr: 21041185 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 09-27 744A DATE: July 8, 2021 ORDER Entitlement to service connection for migraine headaches, to include as secondary to service-connected cervical spine injury, is granted. Entitlement to service connection for chronic constipation is granted. Entitlement to a 20 percent disability rating for hemorrhoids is granted. REMANDED Entitlement to service connection for a prostate disability is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to a disability rating in excess of 40 percent for lumbar spine injury with degenerative joint and disc disease is remanded. Entitlement to a disability rating in excess of 20 percent for cervical spine injury with degenerative joint and disc disease is remanded. Entitlement to a disability rating in excess of 10 percent prior to March 14, 2013 and in excess of 20 percent thereafter for right shoulder dislocation with degenerative joint disease is remanded. Entitlement to an initial disability rating in excess of 20 percent for right leg radiculopathy is remanded. Entitlement to a compensable disability rating for left corneal abrasion with recurrent erosions is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to January 28, 2009 is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's migraine headache disability is secondary to his service-connected cervical spine injury. 2. The weight of the evidence establishes that the Veteran's chronic constipation is secondary to medications used to treat his service-connected cervical and lumbar spine disabilities. 3. The Veteran's hemorrhoids have manifested with persistent bleeding and secondary anemia throughout the period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for service connection for migraine headaches, to include as secondary to service-connected cervical spine injury, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for service connection for chronic constipation, to include as secondary to service-connected cervical and lumbar spine injuries, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for a maximum 20 percent disability rating for hemorrhoids have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Army from January 1966 to July 1989. He is a recipient of the Army Commendation Medal and Army Achievement Medal, among other decorations and awards. The Board notes that the Veteran has had two appeals in appellate status during the period on appeal. The attorney listed at the top of this document represents the Veteran in the issues listed above, and he has specifically limited his representation to the issues addressed in this decision. A Veterans Service Organization represents the Veteran in the other issues on appeal, which were addressed in a separate decision. This case was most recently before the Board in October 2020, at which time the issues were remanded for issuance of a supplemental statement of the case (SSOC). The RO issued an SSOC in November 2020, and the case has since returned to the Board for appellate consideration. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, in order to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may also be 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). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. 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 caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 1. Entitlement to service connection for migraine headaches The Veteran seeks service connection for migraine headaches, either on a direct basis or as secondary to a service-connected disability, including a cervical spine disability. Turning to the evidence, the Board observes that service treatment records (STRs) show the Veteran complained of headaches during active service, in 1970 and in the mid-1980s, following a motor vehicle accident. However, the Veteran's April 1989 retirement examination is silent for reports of a chronic headache condition. The Veteran submitted a headaches disability benefits questionnaire (DBQ) completed by private physician S.B. in August 2018. Dr. S.B. wrote that he personally reviewed current treatment records confirming diagnosis and treatment of chronic migraine headaches; and based on his review, he opined that the Veteran's current chronic migraine headache disability was more likely than not due to the severe interval progression of his service-connected cervical spine degenerative disk disease and degenerative joint disease. In support of his opinion, Dr. S.B. cited to medical literature indicating that cervical spondylosis is a well-known cause of nerve impingement. He noted that VA treatment records showed "severe narrowing of the C2-3 neuroforamen on the right and slight on the left" and "severe narrowing bilaterally" at the C3-C4 level. Dr. S.B. explained that this was "definitive anatomic proof" of the origin of the Veteran's migraine headaches, which he described as "cervicogenic . . . (i.e. migraine headaches that originate from pinched nerves in the cervical spine)." Dr. S.B. cited to a nationwide retrospective cohort study demonstrating the anatomic basis for migraine headaches to support his findings. The Veteran was afforded a VA headaches examination in February 2020. He reported that he started having headaches during active service in the 1970s in Germany. He stated that he was seen by a doctor, was given a painkiller, and was told he had a migraine. He reported that he continued to have migraine episodes on a daily basis. The examiner diagnosed migraine headaches. In the remarks section, the examiner wrote that "[a]ccording to Veteran's VBMS STR's, DOD & VA record there is evidence of chronic ongoing 'migraine headache' since service. There are files in service from 1970 and ongoing records in VA[.]" However, in an accompanying opinion, the examiner determined that the Veteran's migraine headaches were less likely than not related to service, and less likely than not secondary to a service-connected disability, including a cervical spine disability. The examiner explained that there was "no evidence" that his headache condition was secondary to his cervical spine disability and that, "[a]t this time there is no nexus found in the current medical literature reviewed that cervical spine DDD & DJD causes the anatomical condition responsible for migraine." The examiner did not further explain his conclusions, nor did he address the private DBQ and opinion submitted by the Veteran in August 2018. Overall, after careful review of the record, the Board finds that the evidence is, at the very least, in equipoise on the question of whether the Veteran's current migraine headaches are etiologically related to service or a service-connected disability. In reaching this conclusion, the Board acknowledges the February 2020 VA examiner's negative nexus opinion concerning the relationship between the Veteran's current migraine headaches and his cervical spine disability. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the expert's knowledge and skill in analyzing the data, and the medical conclusion the expert reaches. While probative, the examiner did not address the private positive nexus opinion submitted by the Veteran in August 2018, which included citation to a nationwide retrospective cohort study that showed an association between cervical spondylosis and migraine headaches. Further, the examiner noted in his report that there was evidence of chronic, ongoing migraine headaches since service. In this regard, the Board notes that STRs show the Veteran complained of and was treated for headaches during service. Finally, the Board notes that the Veteran is competent to report the onset and chronicity of his headache symptoms, and he has consistently reported that his headaches started during service and have continued ever since. As is true with any piece of evidence, the credibility and weight to be attached to medical opinions and observations are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Ultimately, the Board finds that the medical evidence of record is, at the very least, in equipoise. Under such circumstances and granting the Veteran the benefit of the doubt in this matter, the Board concludes that service connection for migraine headaches is warranted. 2. Entitlement to service connection for constipation The Veteran seeks service connection for migraine constipation, either on a direct basis or as secondary to a service-connected disability, including a cervical spine disability. Turning to the evidence, the Board notes that the Veteran submitted an intestinal conditions DBQ completed by private physician S.B. in August 2018. In an accompanying opinion, Dr. S.B. wrote that he personally reviewed the Veteran's medical treatment records, which showed he had been prescribed non-steroidal anti-inflammatory drugs (NSAIDS) during the years since discharge from service, and based on his review, he opined that the Veteran's current chronic constipation was more likely than not due to chronic NSAID use for his service-connected cervical and lumbar spine disabilities. In support of his opinion, Dr. S.B. cited to medical literature indicating that constipation is a side effect of NSAID use. The Veteran was afforded a VA examination in connection with his claim in February 2020, during which he reported that he started having constipation during active service, and that he still has constipation daily. The examiner diagnosed chronic constipation. In an accompanying opinion, the examiner determined that the Veteran's constipation was less likely than not proximately due to or the result of his service-connected condition, but then proceeded to provide a rationale that linked the Veteran's constipation to treatment given for his cervical and lumbar disabilities. Specifically, the examiner wrote, "[t]here is evidence that his constipation is secondary to the treatment given for his cervical and lumbar disabilities using opioid analgesics." The examiner explained that the Veteran's records showed that he developed chronic, persistent constipation from 2010 to 2019, and that he was treated with laxatives continuously during those years with psyllium and docusate. The examiner also wrote that there was documented evidence that the Veteran was taking opioid narcotic analgesics during that period of time, and that "it is well known in the medical literature that opioid analgesics is a major cause of chronic-persistent constipation." The examiner further wrote that the Veteran was not treated with narcotic analgesics during service and, consequently, there were no records of constipation during that time. Based on the foregoing, the Board finds that the weight of the evidence establishes that the Veteran's current chronic constipation is etiologically related to the medications used to treat his service-connected cervical and lumbar spine disabilities. The August 2018 private positive nexus opinion relates the Veteran's constipation to his well-documented NSAID use, and the February 2020 VA examiner attributed constipation to opioid analgesicsall of which the Veteran has used to treat his service-connected cervical and lumbar spine disabilities. As the weight of the evidence shows that the medications used to treat his service-connected disabilities have caused his chronic constipation, the Veteran's claim for service connection for constipation is granted. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. 3. Entitlement to increased ratings for hemorrhoids The Veteran seeks higher ratings for hemorrhoids, currently rated noncompensable prior to March 14, 2013 and 10 percent disabling from March 14, 2013 under 38 C.F.R. § 4.114, Diagnostic Code 7336. Under Diagnostic Code 7336, mild or moderate hemorrhoids warrant a non-compensable (zero percent) disability rating. A 10 percent disability rating is assigned for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, and evidencing frequent occurrences. A 20 percent disability rating is warranted for hemorrhoids that are manifested by persistent bleeding and with secondary anemia or with fissures. Turning to the evidence, the Board notes that the Veteran was afforded a VA examination in connection with his claim in April 2008. He reported symptoms of anal itching, diarrhea, pain, tenesmus, swelling, and perianal discharge. He also reported constant itching with burning pain and bleeding about once weekly. He reported using suppositories to relieve his pain. The Veteran was afforded another VA examination in March 2013. The Veteran reported getting treatment for his hemorrhoids when they flared up, approximately every two months. He reported taking a daily stool softener and metamucil. The examiner noted external hemorrhoids of mild to moderate severity that were presently inflamed with current bleeding. Examination of the rectal area showed large external hemorrhoids and irreducible external hemorrhoids. The examiner provided the results of CBC laboratory testing but did not explain the results. The examiner determined that the Veteran's hemorrhoids did not impact his ability to work. The Veteran was afforded another VA examination in January 2018. He reported that he continued to have pain, swelling, rectal bleeding, and itching associated with his hemorrhoids. He reported that inflammation of his hemorrhoids felt like a hot burning pain, like his anus was tearing apart. He reported continued rectal bleeding, with blood on the toilet paper every day and blood in the toilet bowl every three weeks. The examiner noted that the Veteran was evaluated by gastroenterology for rectal bleeding and had a colonoscopy in October 2010. He was also referred to gastroenterology for anemia in October 2011. The Veteran reported taking a daily stool softener and iron pills for anemia. He reported previous use of suppositories. The examiner noted that the Veteran's treatment plan included taking continuous medication for the diagnosed conditionsdocusate for hemorrhoids and ferrous sulfate for anemia. The examiner found that the Veteran's hemorrhoids were of mild or moderate severity with secondary anemia. Physical examination revealed large external hemorrhoids, irreducible external hemorrhoids, and excessive redundant tissue. The examiner provided CBC laboratory results but did not explain the significance of the values. The Veteran's hemorrhoids did not impact his ability to work. In the remarks section of her report, the examiner wrote that review of the Veteran's medical records showed that he had mild anemia from January 2010 to November 2013. The Veteran was evaluated by gastroenterology for rectal bleeding in 2010. He completed a colonoscopy that was normal, except for external hemorrhoids in October 2010. He was also referred to gastroenterology for anemia in 2011 and completed an esophagogastroduodenoscopy (EGD) in October 2011, the results of which were normal. The examiner noted that there was no evidence of a GI bleed or other explanation for his anemia; therefore, his anemia was at least as likely as not related to his hemorrhoids. She noted that his hemorrhoids were controlled with iron replacement therapy. The Veteran most recently underwent a VA examination in February 2020. He reported recurrent hemorrhoid symptoms of irritation and some bleeding and burning pain, which occur daily. He reported using cream, suppositories, and a daily stool softener for treatment. He reported that his hemorrhoids did not impact his ability to do daily activities. The examiner noted that the Veteran was required to continuously take docusate, a daily stool softener. The examiner found that the Veteran's hemorrhoids were of mild to moderate severity and caused recurrent irritation and minimal bleeding. Physical examination revealed small or moderate external hemorrhoids. CBC laboratory results were provided, but the examiner did not explain the significance of the values. The Veteran's hemorrhoids did not impact his ability to work. VA and Tricare medical treatment records show the Veteran was treated for hemorrhoids throughout the period on appeal. An August 2008 note indicated that laboratory testing showed "mild anemia." A March 2010 VA treatment record noted that the Veteran had anemia. The Veteran was still experiencing active bleeding in June 2010. A July 2010 gastroenterology consultation noted that the Veteran had been experiencing intermittent rectal bleeding for about a month. The Veteran was evaluated for anemia in October 2011. In January 2013, the Veteran complained that his hemorrhoids were getting worse, and that they "[bled] all the time." Overall, after careful review of the record, the Board finds that the evidence weighs in favor of assigning a 20 percent disability rating for hemorrhoids for the entire period on appeal. As previously discussed, the evidence shows the Veteran had persistent bleeding and suffered from anemia throughout the period on appeal. The January 2018 VA examiner determined that his anemia was at least as likely as not related to his hemorrhoids. Therefore, as persistent bleeding and anemia have been documented throughout the period on appeal, and as a VA examiner has attributed anemia to the Veteran's hemorrhoids, the Board finds that the Veteran's symptoms more closely approximate a 20 percent disability rating under Diagnostic Code 7336. Therefore, the Veteran's claim is granted. REASONS FOR REMAND For the reasons discussed below, the remaining issues on appeal must be remanded for further development. 1. Entitlement to service connection for a prostate disability is remanded. In its November 2019 remand, the Board noted that a February 2018 VA opinion was inadequate because the examiner relied solely on information contained in the medical records and treatise evidence but did not refer to the Veteran's lay statements regarding symptomology. The Board noted that in these statements, the Veteran indicated experiencing additional symptomology not noted in the medical records. In this regard, the Board notes that in December 2010, the Veteran submitted a questionnaire in which he indicated he experienced symptoms of pain or burning when urinating; difficulty urinating; frequent urination (particularly at night); urgent need to urinate; pain in the abdomen, groin, or back; and pain in the area between the penis and rectum. He indicated that the symptoms had continued since service, and that they had always been present and never seemed to go away. STRs show the Veteran complained of difficulty urinating, painful urination, increased frequency of urination, and discharge. The Veteran underwent another VA examination in connection with his claim in February 2020, during which the examiner diagnosed benign prostatic hyperplasia. In an accompanying opinion, the examiner determined that the Veteran's prostate condition was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner explained that there was no evidence of the condition in service, and the Veteran was not diagnosed until 25 years after discharge. Unfortunately, however, the examiner again relied solely on STRs and post-service treatment records and did not address the Veteran's lay statements, submitted in December 2010, concerning chronicity of symptoms since service. Therefore, remand is warranted to obtain an addendum opinion that considers the Veteran's competent and credible lay statements concerning chronicity of symptoms since service. 2. Entitlement to service connection for sleep apnea is remanded. In August 2018, the Veteran submitted a sleep apnea DBQ completed by private physician S.B. In an accompanying statement, Dr. S.B. wrote that the Veteran's obstructive sleep apnea was more likely than not due to "severe interval progression of service connected cervical DDD & DJD." Dr. S.B. referenced medical literature showing that the two most common risk factors for obstructive sleep apnea included obesity and neck circumference, but he noted that the Veteran did not fit the legal definition of obesity. Dr. S.B. also referenced an article suggesting that pathologies of the cervical spine present "significant additional etiologies for producing obstructive sleep apnea in select patient populations" but did not connect the article to the Veteran's case, in particular, or otherwise explain why the article supported his opinion that the Veteran's sleep apnea was due to his cervical spine disability; he merely noted that cervical spondylosis was an "uncommon cause of obstructive sleep apnea." The Veteran was most recently afforded a VA examination in connection with his claim in February 2020. The examiner diagnosed obstructive sleep apnea. In an accompanying opinion, the examiner determined that the Veteran's sleep apnea was less likely than not incurred in or caused by an in-service injury, event, or illness, noting that the Veteran was not diagnosed with sleep apnea until 20 years after discharge from active service. The examiner concluded that because Veteran did not have the most well-established risk factors for sleep apnea (including obesity, significant airway abnormalities, smoking, and alcoholism), and since the only positive risk factors he had were gender and large neck circumference, his sleep apnea was due to "family genetic predisposition to [obstructive sleep apnea (OSA)] with a structural craniofacial phenotype associated with heritable OSA." The examiner acknowledged Dr. S.B.'s August 2018 opinion but disagreed, explaining that, "according to recent literature reviewed there is no nexus found that cervical DDD, DJD or spondylosis causes OSA." Overall, the Board finds that the February 2020 VA opinion is inadequate because the examiner did not adequately address the question of whether the Veteran's current sleep apnea was proximately due to or aggravated by a service-connected disability or disabilities, to include his cervical spine disability, as requested by the Board in its November 2019 remand instructions. The examiner's opinion focused mainly on direct service connection and touched on the Veteran's contentions regarding secondary service connection only to express disagreement with the August 2018 private positive nexus opinion. The Board likewise finds that Dr. S.B.'s August 2018 opinion is inadequate for awarding service connection. Dr. S.B. noted that the Veteran had severe cervical spondylosis but stated only that such a condition was "uncommon cause of obstructive sleep apnea." He did not effectively link the medical literature he referenced in his opinion to the Veteran's case, in particular. Therefore, based on the foregoing, the Board finds that the claim of entitlement to service connection for obstructive sleep apnea must be remanded for another addendum opinion. 3. Entitlement to increased ratings for lumbar spine, cervical spine, and right shoulder disabilities In accordance with the Board's November 2019 remand instructions, the Veteran was afforded VA examinations to determine the current severity of his service-connected right shoulder, lumbar, and cervical spine disabilities. The Veteran was afforded new examinations in February 2020. Unfortunately, the Board finds that they are inadequate for rating purposes. First, the Board notes that the lumbar and cervical spine examinations did not include range of motion testing, "for pain on both active and passive motion [and] in weight-bearing and nonweight-bearing." See Correia v. McDonald, 28 Vet. App. 158 (2016). Further, the shoulder examination did not provide range of motion findings for the "opposite undamaged joint." Id. Finally, in none of the examinations did the examiner address functional loss after repeated use. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). For these reasons, the Board finds the February 2020 examinations to be inadequate, and remand for new examinations that adequately address functional loss is necessary. In this regard, the Board acknowledges the Veteran's attorney's assertions that the examiner's findings that the Veteran did not experience flare-ups of his lumbar, cervical, or right shoulder disabilities are inconsistent with the evidence of record. On remand, the examiner should specifically ask the Veteran if he experiences flare-ups of his disabilities and to attempt to elicit information regarding the severity, frequency, and duration of any such flare-ups. Additionally, the Board calls attention to recent holding by the United States Court of Appeals for Veterans Claims (Court) in Chavis v. McDonough, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660 at * 2 (Apr. 16, 2021). In that case, the Court clarified that for the purpose of rating spinal disabilities, the criteria for ankylosis can be met by evidence of the functional equivalent of ankylosis during a flare-up. Ankylosis is a medical term meaning fixation or immobility of a joint, or "in essence, a complete limitation of motion," and it is an objective finding. Id. 4. Entitlement to a disability rating in excess of 20 percent for right leg radiculopathy The Veteran was provided VA examinations to determine the severity of his right leg radiculopathy in May 2014 and February 2020. During the May 2014 examination, the Veteran was found to have moderate incomplete paralysis of the sciatic nerve and mild incomplete paralysis of the external popliteal (common peroneal) nerve. During the February 2020 examination, the Veteran was found to have moderate incomplete paralysis of the sciatic nerve only, with no other nerve involvement. It is unclear if the mild incomplete paralysis of the external popliteal nerve documented during the May 2014 examination resolved. The Board finds that remand is warranted to afford the Veteran a VA peripheral nerves examination to ascertain the extent of any external popliteal nerve involvement during the period on appeal (to include ascertaining whether it has resolved), which is necessary to determine whether separate ratings are warranted. 5. Entitlement to a compensable disability rating for left corneal abrasion with recurrent erosions In accordance with the Board's November 2019 remand instructions, the Veteran was afforded a VA eye examination in February 2020 to determine the current severity of his left corneal abrasion with recurrent erosions. The examiner determined that the Veteran's specified condition of recurrent corneal erosion "was either [erroneous] or has resolved." The examiner explained that the Veteran had no corneal abrasion, which "typically resolve without residuals, as in this case." The examiner noted that the present examination found no visual disability or functional impairment. However, in an October 2020 statement, the Veteran wrote that his eye condition had not resolved, that he still has recurrent corneal erosions, that the most recent erosion occurred about two weeks prior to his statement, and that he sees his doctor every six months for checkups and once a year for prescriptions. He reported putting liquid eye drops in his eyes four times per day. In a November 2020 brief, the Veteran's attorney acknowledged that the Veteran's vision is not always impaired by his service-connected condition but cited to evidence of record indicating that his condition has resulted in incapacitating episodes several times per year, such that a higher disability rating is warranted. If a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA may be required to provide a medical examination during the period of recurrence in order to provide a proper disability rating. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In Ardison, the Court found that an examination conducted during the remission phase of the condition did not "accurately reflect the elements of the present disability." In this case, the evidence of record suggests that the Veteran's service-connected left corneal abrasion with recurrent erosions undergoes periods of remission and recurrence, and that the February 2020 examination was conducted during a period of remission. There is no information as to how flare-ups manifest, the severity of the Veteran's symptoms and extent of any medical treatment required during flare-ups, or the duration or frequency of flare-ups. Given that the most recent examination does not appear to have been conducted during a period of flare-up, and given the lack of information concerning the frequency, duration, characteristics, and severity of flare-ups, the Board finds the February 2020 VA eye examination inadequate. A remand is required to obtain an adequate examination that more fully depicts the Veteran's eye disability, including during a flare-up. 6. Entitlement to a TDIU on an extraschedular basis prior to January 28, 2009 The Veteran's claim for a TDIU prior to January 28, 2009 is part and parcel of his claims for increased ratings. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, as a decision on the increased rating claims remanded herein could significantly impact a decision on the issue of entitlement to a TDIU prior to January 28, 2009, the issues are inextricably intertwined. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Obtain an addendum opinion concerning the etiology of the Veteran's currently diagnosed benign prostatic hyperplasia. The examiner must review the clams file, to include STRs, post-service treatment records, the Veteran's lay statements, and any treatise evidence submitted by the Veteran. The examiner must opine as to whether any diagnosed prostate disability is at least as likely as not (50 percent or greater probability) related to any event, injury, or disease during service. In doing so, the examiner should specifically address the questionnaire, submitted in December 2010, in which the Veteran indicated he experienced symptoms of pain or burning when urinating; difficulty urinating; frequent urination (particularly at night); urgent need to urinate; pain in the abdomen, groin, or back; and pain in the area between the penis and rectum; that these symptoms had continued since service, and that they had always been present and never seemed to go away. A complete rationale must be provided for any opinion rendered. 2. Obtain an addendum opinion, preferably from a VA examiner with experience treating sleep disabilities, to determine the etiology of the Veteran's sleep apnea. The examiner must review the clams file, to include STRs, post-service treatment records, the Veteran's lay statements, and the August 2018 private medical opinion and accompanying treatise evidence. The examiner must opine whether the Veteran's currently diagnosed sleep apnea disability is at least as likely as not (50 percent or greater probability) related to an any event, injury, or disease during service. The examiner should also opine as to whether the Veteran's diagnosed sleep apnea is at least as likely as not (50 percent or greater probability) (1) proximately due to a service-connected disability or disabilities, to specifically include a cervical spine disability; or (2) aggravated by a service-connected disability or disabilities, to include a cervical spine disability. The examiner is advised that the term "aggravation" in this context does not require that there be "permanent" worsening of the nonservice connected disability. Ward v. Wilkie, 31 Vet. App. 233 (2019). The examiner must provide separate findings and rationales relating to causation and aggravation. A complete rationale must be provided for any opinion rendered. 3. Schedule the Veteran for a VA examination to assess the current nature and severity of his service-connected right shoulder, lumbar spine, and cervical spine disabilities. The claims file must be made available to the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail in accordance with the criteria for evaluating spine disabilities. Any indicated special diagnostic tests that are deemed necessary for an accurate assessment must be conducted. The examiner must test and record the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing (if applicable). With regard to the right shoulder, the examiner must also test and record range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. Further, the examiner must also specifically express an opinion concerning whether there would be additional limitation on functional ability on repeated use or during flare-ups, and to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. In this regard, the examiner must specifically ask the Veteran whether he experiences flare-ups. If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran. Regarding the Veteran's cervical and lumbar spine disabilities, the examiner should address whether the lumbar/cervical spine is functionally ankylosed during flare-ups. If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished. Specifically, if the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Schedule the Veteran for a VA peripheral nerves examination by an appropriate clinician to determine the current severity of his service-connected right leg radiculopathy, as well as the specific nerve roots involved. 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. In particular, the examiner should review the May 2014 VA examination report, which documented involvement of both the sciatic and external popliteal (common peroneal) nerves, and the February 2020 examination report, which reflected involvement of only the sciatic nerve, and clarify which specific nerve(s) are affected by the Veteran's bilateral lower extremity radiculopathy, to include the sciatic and external popliteal (common peroneal) nerves, and the symptoms attributed to each. 5. Obtain a new VA examination with an appropriate VA examiner with respect to the severity of the Veteran's service-connected left corneal abrasion with recurrent erosions. The examination should preferably be scheduled during a time when the Veteran's condition is symptomatic or flaring upi.e., during an active erosion. The Veteran's claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. (Continued on the next page) If the examination is not conducted during a flare-up, the examiner should elicit information regarding the frequency, duration, characteristics, and severity of flare-ups of his eye condition. If the requested opinion cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. The examiner should also indicate if the Veteran's reported symptoms are attributable to an eye condition other than left corneal abrasion with recurrent erosions. 6. Then, readjudicate the matters on appeal, including the issue of entitlement to a TDIU prior to January 28, 2009. If applicable, the RO should consider referring the TDIU claim to the Director of Compensation Service for extraschedular consideration, if warranted. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. T. Raftery, 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.