Citation Nr: 25005276 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 17-08 750 DATE: April 17, 2025 ORDER Entitlement to an increased rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy prior to December 16, 2023, is denied. Entitlement to an increased rating in excess of 10 percent for left lower extremity sciatic nerve radiculopathy prior to December 16, 2023, is denied. Entitlement to an increased rating in excess of 10 percent for right lower extremity femoral nerve radiculopathy prior to December 16, 2023, is denied. Entitlement to an increased rating in excess of 10 percent for left lower extremity femoral nerve radiculopathy prior to December 16, 2023, is denied. Entitlement to an increased rating of 40 percent for right lower extremity sciatic nerve radiculopathy from December 16, 2023, to present is granted. Entitlement to an increased rating of 40 percent for left lower extremity sciatic nerve radiculopathy from December 16, 2023, to present is granted. Entitlement to an increased rating of 30 percent for right lower extremity femoral nerve radiculopathy from December 16, 2023, to present is granted. Entitlement to an increased rating of 30 percent for left lower extremity femoral nerve radiculopathy from December 16, 2023, to present is granted. Entitlement to an earlier effective date of December 12, 2019, for the award of a TDIU is granted. REMANDED Entitlement to an increased rating in excess of 40 percent for a lumbar spine disability is remanded. Entitlement to a TDIU on an extraschedular basis from July 28, 2006, to December 11, 2019, is remanded. FINDING OF FACT 1. Prior to December 16, 2023, the Veteran's left lower extremity radiculopathy of the sciatic nerve manifested as mild incomplete paralysis. 2. Prior to December 16, 2023, the Veteran's right lower extremity radiculopathy of the sciatic nerve manifested as mild incomplete paralysis. 3. Prior to December 16, 2023, the Veteran's left lower extremity radiculopathy of the femoral nerve manifested as mild incomplete paralysis. 4. Prior to December 16, 2023, the Veteran's right extremity radiculopathy of the femoral nerve manifested as mild incomplete paralysis. 5. From December 16, 2023, to present the Veteran's left lower extremity radiculopathy of the sciatic nerve manifests as moderately severe incomplete paralysis. 6. From December 16, 2023, to present the Veteran's right lower extremity radiculopathy of the sciatic nerve manifests as moderately severe incomplete paralysis. 7. From December 16, 2023, to present the Veteran's left lower extremity radiculopathy of the femoral nerve manifests as severe incomplete paralysis. 8. From December 16, 2023, to present the Veteran's right lower extremity radiculopathy of the femoral nerve manifests as severe incomplete paralysis. 9. The Veteran's right shoulder disability originated in service and is otherwise etiologically related to service. 10. For the period from December 12, 2019, to December 16, 2023, the Veteran's service-connected disabilities were of sufficient severity to preclude him from obtaining and maintaining substantially gainful employment. CONCLUSION OF LAW 1. The criteria for entitlement to an increased rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy prior to December 16, 2023, has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8520. 2. The criteria for entitlement to an increased rating in excess of 10 percent for left lower extremity sciatic nerve radiculopathy prior to December 16, 2023, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8520. 3. The criteria for entitlement to an increased rating in excess of 10 percent for right lower extremity femoral nerve radiculopathy prior to December 16, 2023, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8526. 4. The criteria for entitlement to an increased rating in excess of 10 percent for left lower extremity femoral nerve radiculopathy prior to December 16, 2023, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8526. 5. The criteria for entitlement to an increased rating of 40 percent for right lower extremity sciatic nerve radiculopathy from December 16, 2023, to present have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8520. 6. The criteria for entitlement to an increased rating of 40 percent for left lower extremity sciatic nerve radiculopathy from December 16, 2023, to present have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8520. 7. The criteria for entitlement to an increased rating of 30 percent for right lower extremity femoral nerve radiculopathy from December 16, 2023, to present have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8526. 8. The criteria for entitlement to an increased rating of 30 percent for right lower extremity femoral nerve radiculopathy from December 16, 2023, to present have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.124, 4.124a; Diagnostic Code 8526. 9. The criteria for entitlement to service connection for a right shoulder disability have been met. 38 U.S.C. §§ 1101, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 10. The criteria for an earlier effective date of December 12, 2019, for TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from May 1969 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) from an October 2014 and October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Previously, the Board denied the Veteran's claims in a September 2023 decision. The Veteran timely appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). The Court issued a Joint Motion for Partial Remand (JMPR) in September 2024. The Veteran's claims have returned to the Board for readjudication pursuant to the JMPR. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are also appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve group, a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve group, a 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve group, a 60 percent rating is assigned for severe incomplete paralysis of the sciatic nerve group, with marked muscular atrophy, and an 80 percent rating is assigned for complete paralysis of the sciatic nerve group (the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of the knee weakened or (very rarely) lost). Under DC 8526, a 10 percent rating is warranted for mild incomplete paralysis of the femoral nerve. A 20 percent rating is warranted when moderate, and a 30 percent rating when severe. Complete paralysis of the quadriceps extensor muscles warrants a maximum evaluation of 40 percent. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of impaired function substantially less than the type of picture for "complete paralysis" given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The words "mild," "moderate," and 'severe" are not defined in the VA Schedule for Rating Disabilities. 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. It should also be noted that use of such terminology by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. Id. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. In this case, the Board considers "mild" to correspond to slight symptoms sufficient to support the diagnosis, generally characterized by less persistent sensory deficits, or those affecting a small area, and or very minimal reflex or motor abnormalities. The Board considers "moderate" to correspond to the maximum evaluation available for sensory-only impairment, characterized by symptoms described by the Veteran and considered significantly disabling medically, and/or involving a larger area in nerve distribution. Additionally, moderate can correspond to combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes with or without sensory impairment, graded as medically moderate. "Moderately severe" is only applicable for involvement of the sciatic nerve and is the maximum rating available for sciatic nerve neuritis not characterized by organic changes specified in 38 C.F.R. § 4.123. It is expected at this level there would be motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability. Finally, "severe" is characterized by 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, marked muscular atrophy is expected. Although severe incomplete paralysis cases should show findings substantially less than those for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contains signs or symptoms that resemble 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. The above definitions are consonant with those of M21-1, Part V, Section 12.A.2.c. Consonant with the Court's admonition to explain why applicable provisions of the M-21 should not apply, the Board finds no better source of a definition for those terms, and as those terms are already in use by the Veterans Benefits Administration, the Board finds it would operate to the prejudice of the Veteran to resort to a separate set of definitions at the appellate stage. 1. Entitlement to an increased rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy prior to December 16, 2023 2. Entitlement to an increased rating in excess of 10 percent for left lower extremity sciatic nerve radiculopathy prior to December 16, 2023 3. Entitlement to an increased rating in excess of 10 percent for right lower extremity femoral nerve radiculopathy prior to December 16, 2023 4. Entitlement to an increased rating in excess of 10 percent for left lower extremity femoral nerve radiculopathy prior to December 16, 2023 Via the September 2024 JMPR, the Court found that the Board erred by not addressing the Veteran's bilateral lower extremity radiculopathy as part of his claim for an increased rating for his service-connected lumbar spine disability. In a September 2021 rating decision, the RO granted service connection for the Veteran's bilateral lower extremity radiculopathy of the sciatic and femoral nerves effective December 12, 2019. Bilateral lower extremity sciatic nerve radiculopathy was rated at 10 percent disabling per leg pursuant to Diagnostic Code 8520. Bilateral lower extremity femoral nerve radiculopathy was rated at 10 percent disabling per leg pursuant to Diagnostic 8526. During the pendency of the appeal, the Veteran's bilateral lower extremity sciatic nerve radiculopathy and femoral nerve radiculopathy were increased to 20 percent effective December 16, 2023. Service treatment notes demonstrated that the Veteran denied numbness in his feet or legs in July 2019. In September 2020, the Veteran complained of left leg/arm numbness. In February 2021, the Veteran denied numbness in his extremities. During a December 2019 VA examination, the examiner diagnosed the Veteran with bilateral lower extremity radiculopathy. The Veteran reported that his legs will go numb once a month for a few hours. The Veteran demonstrated active movement against some resistance bilaterally. The Veteran's deep tendon reflexes were absent bilaterally at the ankle and left knee and hypoactive at the right knee. The sensory examination was normal bilaterally. He was unable to perform the straight leg raising test. The examiner noted bilateral mild intermittent pain, bilateral mild paresthesias/and or dysesthesias, and bilateral mild numbness. The examiner indicated involvement bilaterally of the femoral nerve and sciatic nerve. The examiner reported that the involvement was mild and wholly sensory. Based on a review of the record, the Board finds that the weight of the evidence shows that the Veteran's service-connected bilateral lower extremity radiculopathy of both the sciatic nerve and femoral nerve is productive of no more than mild incomplete paralysis prior to December 16, 2023. The December 2019 examiner indicated that the Veteran's bilateral lower extremity sciatic and femoral nerve was manifested by mild incomplete paralysis. The evidence does not demonstrate moderate incomplete paralysis, muscle atrophy, or severe paralysis of the affected nerves, which would warrant a higher rating. Thus, the Board finds that a rating in excess of 10 percent is not warranted for either the sciatic nerve or femoral nerve bilaterally of the lower extremities prior to December 16, 2023. The Board has considered the December 2019 examination. However, the examination also indicates active movement against some resistance, normal sensation to light touch, and no atrophy. Despite the mostly absent and hypoactive deep tendon reflexes, the examiner stated that the Veteran's bilateral radiculopathy of the sciatic nerve and femoral nerve involvement was wholly sensory. As indicated above, where the involvement is wholly sensory, the rating should be for mild, or at the most, moderate symptomatology. 38 C.F.R. § 4.124a. Here, the VA examination demonstrated that the Veteran's functional impairment was related to his service-connected lumbar spine disability rather than as a result of his service-connected right and left lower extremity radiculopathy of the sciatic and femoral nerves. Therefore, these findings do not support a higher rating consistent with moderate or moderately severe incomplete paralysis. Additionally, the Board has considered the Veteran's medical treatment records and lay statements found within. The Board notes that the Veteran frequently denied numbness in his lower extremities throughout the period on appeal. The only occurrence in which the Veteran reported numbness or pain in his lower extremities was during flareups of his service-connected lumbar spine disability, which lasted a few hours per month. Therefore, the Board finds that the Veteran's lay statements did not suggest a higher rating in excess of 10 percent for his bilateral lower extremity radiculopathy of the sciatic or femoral nerve prior to December 16, 2023. As noted above, the Board finds that the Veteran's bilateral lower extremity sciatic radiculopathy and femoral radiculopathy did not warrant a rating in excess of 10 percent. Thus, for the period prior to December 16, 2023, the Veteran's claim is denied. 5. Entitlement to an increased rating in excess of 20 percent for right lower extremity sciatic nerve radiculopathy from December 16, 2023, to present 6. Entitlement to an increased rating in excess of 20 percent for left lower extremity sciatic nerve radiculopathy from December 16, 2023, to present 7. Entitlement to an increased rating in excess of 20 percent for right lower extremity femoral nerve radiculopathy from December 16, 2023, to present 8. Entitlement to an increased rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy from December 16, 2023, to present During a May 2024 VA examination, the Veteran demonstrated movement against gravity during a muscle strength test. The reflex exam demonstrated bilateral lower extremity hypoactive reflexes. The sensory exam was normal bilaterally, and the straight leg raising test was negative bilaterally. He did not demonstrate trophic changes nor an abnormal gait. The examiner noted bilateral moderate constant pain, no intermittent pain, bilateral moderate paresthesias/and or dysesthesias, and bilateral moderate numbness. The examiner indicated involvement bilaterally of the femoral nerve and sciatic nerves. The examiner reported moderately severe incomplete paralysis of sciatic nerve bilaterally and severe incomplete paralysis of the femoral nerve bilaterally. The examiner noted that the Veteran did not have atrophy. The Veteran was constantly using a wheelchair, cane, and walker. The Veteran was only capable of walking short distances with his walker but was primarily dependent on the wheelchair. From December 16, 2023, to present, the Board finds that the Veteran's bilateral lower extremity sciatic radiculopathy manifested in moderately severe incomplete paralysis. Thus, the Board finds that a 40 percent rating is warranted pursuant to Diagnostic Code 8520. Additionally, the Board finds that the Veteran's bilateral lower extremity femoral radiculopathy manifested in severe incomplete paralysis. Thus, the Board finds that a 30 percent rating is warranted pursuant to Diagnostic Code 8526. Based on a review of the record, the Board finds that the weight of the evidence shows that the Veteran's service-connected bilateral lower extremity radiculopathy of the sciatic nerve is productive of moderately severe incomplete paralysis, and his bilateral lower extremity radiculopathy of the femoral nerve is productive of severe incomplete paralysis since December 16, 2023, as indicated by the May 2024 examination. The evidence does not demonstrate severe incomplete paralysis of the sciatic nerve nor muscle atrophy warranting a higher rating. Thus, the Board finds that a 40 percent rating for bilateral sciatic nerve radiculopathy and a 30 percent rating for bilateral femoral nerve radiculopathy is warranted. The Board has considered the May 2024 examination. However, the examination also indicates active movement against some resistance, normal sensation to light touch, no atrophy, and hypoactive deep tendon reflexes. The examiner noted that the Veteran's bilateral lower extremity radiculopathy was not wholly sensory, which warrants an increased rating. However, the examiner did not find complete paralysis nor muscular atrophy, which would be indicative of a rating in excess of 40 percent for bilateral sciatic nerve radiculopathy or in excess of 30 percent for bilateral femoral nerve radiculopathy. The Board finds the May 2024 examination to be highly probative. Applying the regulations to the period from December 16, 2023, to present, the Board finds that the criteria for a rating higher than 40 percent are not met for bilateral lower extremity sciatic nerve radiculopathy. To merit the assignment of a 60 percent rating, the evidence must show severe incomplete paralysis with marked muscular atrophy. The record during this timeframe shows no evidence of atrophy, paralysis, or drop foot, and the Veteran's use and control of both lower extremities is primarily intact. The record since December 16, 2023, does not demonstrate a disability picture that more closely approximates severe incomplete paralysis or complete paralysis of the sciatic nerve, and a higher rating is not warranted. Additionally, the Board finds that the criteria for a rating higher than 30 percent are not met for bilateral lower extremity femoral nerve radiculopathy. To merit the assignment of a 40 percent rating, the evidence must show complete paralysis of the quadriceps extensor muscles. The record during this timeframe shows no evidence of complete paralysis. The record since December 16, 2023, does not demonstrate a disability picture that more closely approximates complete paralysis of the femoral nerve, and a higher rating is not warranted. The Board has considered all other potentially applicable diagnostic codes; however, there is no evidence of neuritis or neuralgia. Therefore, 38 C.F.R. § 4.124a , DCs 8620 and 8720 are not for application in this case. There is also no evidence showing neurological damage associated with any other peripheral nerves. Therefore, DCs 8521 to 8530, 8621 to 8630, and 8721 to 8730 are not applicable in this case. Accordingly, there is no basis for higher ratings in excess of 40 percent regarding the Veteran's bilateral sciatic nerve radiculopathy or 30 percent for his bilateral femoral nerve radiculopathy. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if it manifests to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). To establish service connection under this provision, there must be evidence of a chronic disease shown as such in service (or within an applicable presumptive period under C.F.R. § 3.307) and subsequent manifestations of the same chronic disease. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, reasonable doubt will be resolved in each such issue in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Gilbert v. Derwinski, 1Vet. App .49 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). 9. Entitlement to service connection for a right shoulder disability The Veteran contends that his right shoulder disability was etiologically related to an in-service injury. Service treatment records demonstrated that the Veteran complained of a left shoulder disability rather than a right shoulder disability. During the Veteran's March 1969 entrance examination, the Veteran self-reported no bone, joint, or other deformity and no painful or trick shoulder or elbow. The clinical evaluation checked "normal" spine and other musculoskeletal. In June 1969, the Veteran complained of neck and shoulder pain. In November 1969, the Veteran complained of a sharp pain in his clavicle and shoulder. The Veteran stated that shoulder was injured by rotating weight on his shoulder. X-rays demonstrated a diagnosis of left shoulder and neck contusion. Post-service treatment records demonstrated complaints of pain in the right shoulder. A 2002 MRI found the shoulder to be normal but suggestive of a degenerative articular surface rent tear. In 2006, the Veteran was diagnosed with right acromioclavicular joint arthritis. In 2014, x-rays demonstrated extreme degenerative joint disease and impingement on the cuff area. In 2015, an MRI demonstrated degenerative joint disease with impingement on cuff and "probable" tears in supraspinatus. In January 2015, the Veteran complained of right shoulder pain, which he stated began when he fell off a truck in service. In May 2015, the Veteran's physician noted that he had fallen off a truck in the 1970s injuring the shoulder but no procedure was done. He further reported deformity of the right shoulder since protrusion of the acromion process. Two weeks later the Veteran underwent a right shoulder surgery. Private treatment records revealed that the Veteran received shoulder injections in March 2018. In September 2015, the Veteran underwent a VA neck examination. The RO requested that the VA examiner provide a medical opinion on the Veteran's shoulder disability without a physical examination. The examiner opined that the Veteran's right shoulder disability was less likely than not caused by service. The examiner noted that there was only "one vague mention" of pain in service, which did not state whether it was the left or right shoulder. The examiner also noted that the Veteran worked in a physical capacity until 1995 and was right hand dominant. The examiner stated that the gap between service and diagnosis made a nexus "etiologically untenable." During a December 2019 VA examination, the examiner noted diagnoses of right shoulder impingement syndrome and right labral tear from 2015. The examiner opined that the Veteran's current right shoulder disability was less likely than not incurred in or caused by active service. The examiner reviewed the November 1969 in-service incident but noted that the specific shoulder was not identified. The examiner noted another seemingly connected treatment record from 1971 in which the clinician noted a left neck and shoulder contusion. Post-service, the examiner noted that a 2002 MRI found the right shoulder to be normal. The examiner noted that the right shoulder arthritis was not diagnosed until 2006, and that the Veteran's right rotator cuff was not diagnosed until 2015. The Veteran submitted a private medical opinion in March 2025. The physician thoroughly reviewed the Veteran's medical record, prior examinations, and lay statements. The physician acknowledged that the Veteran's service treatment records explicitly stated a left neck and shoulder injury. However, the physician stated that falling with a load creates a significant risk for acute trauma to the shoulder girdle, including rotator cuff tears, AC joint injuries, and labral tears. The physician stated that it was plausible that the Veteran experienced a concurrent right shoulder injury, which was overlooked, because the left shoulder was immediately symptomatic. The physician noted that by 2001 the Veteran exhibited atrophy of the deltoid and severe pain with passive range of motion, which was indicative of chronic degenerative changes likely originating from prior structural damage. The physician reported that the 2002 MRI was suggestive of a degenerative articular surface tear indicating a chronic and prior trauma to the shoulder. The physician discredited the theory that the Veteran's right shoulder disability was solely due to post-service occupational activities or aging. Citing relevant medical sources, the physician reported that the Veteran's post-service complaints of pain and deterioration of the shoulder culminated in posttraumatic osteoarthritis. The physician stated that posttraumatic osteoarthritis occurs as a result of a prior injury with a delayed onset; the most common causes were acute injuries, such as sports trauma, vehicular accidents, falls, or combat-related incidents, very similar to the Veteran's fall from a truck in service. In many cases of posttraumatic osteoarthritis, the physician reported that patients may be asymptomatic for years or decades after the original trauma. Considering the Veteran's post-service employment, the physician noted an unrelated April 2009 VA examination in which the Veteran reported managing farm crews rather than engaging in strenuous physical labor. Thus, the physician stated that it was a relevant distinction since he was not regularly performing overhead lifting, heavy carrying, or other physically demanding activities of the right arm. Also, the record did not suggest a specific post-service injury. Therefore, the physician opined that the Veteran's right shoulder disability was likely the result of his in-service fall. The Court, in its September 2024 JMPR, found that the VA's duty to assist was not satisfied as the December 2019 VA examination was inadequate. Specifically, a 2002 MRI results suggested a degenerative articular surface rent tear consistent with shoulder impingement, but the December 2019 examiner stated that his arthritis was not noted until 2006. Additionally, the Veteran's medical record noted a complaint of generalized joint pain increased in the shoulders in April 2000. Therefore, the Court found that the December 2019 VA medical opinion did not consider the Veteran's full medical history. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). Thus, the Board finds the December 2019 VA examination inadequate. However, as the decision below is considered a full grant of the benefit sought, a remand is not required to cure this procedural defect. Based on a review of the record, the Board finds the evidence persuasive in favor of the Veteran's claim of entitlement to service connection for a right shoulder disability. The Veteran possesses a diagnosis of right shoulder impingement syndrome and experienced an in-service injury when he fell off of a truck. Therefore, the remaining issue before the Board is whether the Veteran's right shoulder disability was etiologically caused by his in-service injury. The Board acknowledges that the Veteran, in his lay statements, indicated that he experienced a right shoulder injury in service. Additionally, the Veteran is competent to report symptoms of pain and onset attributable to his right shoulder disability. However, the Veteran is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). To the extent, the Veteran attempts to provide a nexus opinion, the Board finds the private medical opinion to be of greater probative weigh than the Veteran's lay assertions. Moreover, the private physician thoroughly reviewed the Veteran's service treatment records, post-service medical records, lay statements, and relevant medical literature. Therefore, the Board affords the March 2025 private opinion probative value as the physician provided a sound rationale corroborated by the record and supported by available medical literature. As the Court found the December 2019 VA opinion inadequate, the Board acknowledges that the only adequate opinion of record is that of the March 2025 private physician. In sum, the Board finds the evidence of record persuasively in the Veteran's favor. Therefore, service connection for a right shoulder disability warranted, and the Veteran's claim is granted. 10. Earlier effective date for TDIU from December 12, 2019, to December 16, 2023 The Veteran via his attorney contend that an earlier effective date for TDIU is warranted. Specifically, the Veteran contends that the effective date should be July 28, 2006 as it was part and parcel to his continuously pursued claim for an increased rating for his lumbar spine disability. For effective date purposes, an award of TDIU is akin to an award of a higher initial rating or a higher rating. Dalton v. Nicholson, 21 Vet. App. 23, 32-34 (2007); Hurd v. West, 13 Vet. App. 449, 450 (2000). An initial rating is awarded effective as the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. §§ 5110(a), (b)(2); 38 C.F.R. §§ 3.400(b)(2), (o)(1). A higher rating is awarded effective as of the earliest date it is factually ascertainable that an increase in disability occurred if the claim is received within one year of that date. It otherwise is the date of receipt of the claim. 38 U.S.C. § 5110(b)(3); 38 C.F.R. § 3.400(o)(2). When the evidence is in approximate balance, the claimant is afforded the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A TDIU may be granted where a Veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or higher, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or higher, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or higher. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a Veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Substantially gainful employment is employment that is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the employee resides. The term suggests a living wage. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). The ability to work sporadically or to obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment and will be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The December 16, 2023, effective date currently assigned to the Veteran's TDIU corresponds with the date VA received his formal TDIU claim, in which he indicated being unable to work due to his service-connected lumbar spine disability, cervical spine disability, bilateral knee disability, and radiculopathies. Neither he nor his representative has contended that he filed an earlier formal TDIU claim. There also is no indication of such from the claims file. As such, the only way to secure an earlier effective date based on the Veteran's formal TDIU claim is if it is considered akin to a higher rating claim as opposed to a higher initial rating claim and it is factually ascertainable that he became unemployable due to that disability. This means, as argued, that a TDIU is part and parcel to the higher initial rating claim for the Veteran's service-connected lumbar spine disability. Consideration of a TDIU accordingly must extend back to July 28, 2006, when the claim was received. Finally, the Veteran's representative cites additional caselaw holding that the grant of a TDIU for only a portion of the period under consideration means that a TDIU for the rest of that period remains at issue. Harper v. Wilkie, 30 Vet. App. 356, 362 (2018); see also Payne v. Wilkie, 31 Vet. App. 373, 389 (2019). That a TDIU has been granted effective December 16, 2023, does not eliminate the need to adjudicate a TDIU from July 28, 2006, through December 15, 2023, in other words. A May 2009 rating decision granted service connection for lumbar strain with degenerative joint disease with a 40 percent evaluation effective July 28, 2006. In May 2009, the Veteran submitted a statement in support of the claim expressing his desire to continue his appeal. Additionally, in March 2010, the Veteran submitted another statement in support of the claim explicitly requesting an increased rating for his back disability as he was dependent on a walker and wheelchair. With no development other then the association of VA treatment records, the Veteran submitted an application for disability compensation for an increased rating for his back disability. Therefore, the Board finds that the Veteran's claim for an increased rating in excess of 40 percent for his lumbar spine disability has been continuously pursued since July 28, 2006. The remaining issue is whether the Veteran's service-connected lumbar spine disability and cervical spine disability rendered him unable to obtain substantially gainful employment. During the period on appeal prior to December 16, 2023, the Veteran was in receipt of the following disability ratings: a 40 percent rating for lumbar strain with degenerative joint disease; a 40 percent rating for bilateral hearing loss; a 20 percent rating for cervical strain; a 20 percent rating for diabetes mellitus; 10 percent rating for left lower extremity sciatic nerve radiculopathy; a 10 percent rating for right lower extremity sciatic nerve radiculopathy; a 10 percent rating for left lower extremity femoral nerve radiculopathy; a 10 percent rating for right lower extremity femoral nerve radiculopathy; a 10 percent rating for left knee arthritis; a 10 percent rating for right knee arthritis; and a 10 percent rating for tinnitus. For the period between July 28, 2006, to December 11, 2019, the Veteran had one disability rated at 40 percent, but the combined rating was less than 70 percent. Thus, the Veteran did not meet the schedular requirements for a TDIU from July 28, 2006, to December 11, 2019, and will be discussed below. However, from December 12, 2019, to December 15, 2023, the Veteran met the schedular criteria. VA treatment records demonstrated that the Veteran had been taking prescription opioids for pain throughout the period on appeal. The Veteran's wife had left her employment in 2014 to become a full-time caregiver assisting him with activities of daily living. In a private opinion submitted in March 2025, the physician stated that the Veteran's lumbar spine disability, cervical spine disability, and bilateral knee arthritis coupled with chronic opiod use for pain, reliance on assistive devices, limited education, and work history the Veteran would be unable to engage in gainful employment, including sedentary occupations, since 2000. The physician quoted that sedentary work involves primarily sitting but also includes the ability to walk or stand up to 2 hours out of an 8-hour day. The physician reported that the combination of his disabilities prevented prolonged sitting, standing, walking, or the use of his upper extremities for repetitive tasks, which made it "virtually impossible" for the Veteran to sustain competitive employment in any capacity. The severity of his disabilities was evidence by, as noted by the physician, leaving his supervisory position on farms due to physical limitations. Additionally, the physician stated that the Veteran likely required regular aid and attendance from his wife to even assist with the safe completion of activities of daily living since at least July 2003. He physician noted that individuals with severe musculoskeletal impairments, particularly those with frequent falls, often require long-term assistance to prevent further injury and maintain basic quality of life. Thus, the physician stated that the Veteran's history of falls, reliance on assistive devices, chronic pain, and progressive mobility limitations impacted his ability to perform essential daily functions independently. Based on the Veteran's skills and training, the Board finds that his service-connected lumbar spine disability, cervical spine disability, and bilateral knees disability would preclude him from obtaining and maintaining substantially gainful employment. Post-service, the Veteran worked in a supervisory role of farm laborers but left the position due to physical limitations. The Veteran's inability to remain seated or standing for any prolonged period of time coupled with his use of a wheelchair prevented the Veteran from participating in manual labor or easily moving around a farm. Additionally, as the Veteran's wife assisted him with activities of daily living full-time as a caregiver, the Board finds that the Veteran would be unable to safely or effectively maintain gainful employment. In making this finding, the Board finds the March 2025 private opinion to be the most probative evidence of record as the physician provided a sound rationale corroborated by record and medical literature. As for the date TDIU is assigned, the Board finds that he met the schedular criteria for TDIU as of December 12, 2019, and that during this time he was unemployed based on the physical limitations due to his service-connected lumbar spine disability, cervical spine disability, and bilateral knee disability. Accordingly, the Board finds the evidence persuasively in favor of the Veteran. Therefore, a TDIU is warranted for the period from December 12, 2019, to December 15, 2023. As such, the Veteran's claim is granted to this extent. REASONS FOR REMAND 11. Entitlement to an increased rating in excess of 40 percent for a lumbar spine disability The Veteran contends that the severity of his lumbar spine disability is not adequately reflected with a 40 percent disability rating. Throughout the period on appeal, the Veteran has been in receipt of a 40 percent disability rating pursuant to Diagnostic Code 5242-5237. VA treatment records demonstrated that the Veteran had back pain and been prescribed pain medication throughout the period on appeal. In January 2022, the Veteran had a functional assessment. The Veteran received assistance bathing part of his body, such as his back or leg. The Veteran could get his clothes from his drawers and dress himself without assistance with the exception of tying his shoes. The Veteran was also able to move in and out of bed or chair without assistance other than his cane or walker. In September 2023, the Veteran's primary care noted normal curvature of the back and nontender. The Veteran reported that his back pain was well-managed, and he was going for walks as much as he could. In November 2023, the Veteran reported back pain at a 6 out 10 with relief from medication. The Veteran reported using a cane, walker and wheelchair. He reported going for walks around his 10 acre property, Walmart, and the cemetery. As of May 2024, the Veteran was prescribed a pain relief ointment applied twice per day and oral medications. The Veteran reported his back pain at a 6 out 10 but was receiving relief from medications. The Veteran was capable of exercising as tolerated even if using either a cane, walker, or wheelchair. During a September 2015 VA examination, the examiner noted the following initial ranges of motion: forward flexion was 30 degrees; extension was 20 degrees; right lateral flexion was 30 degrees; left lateral flexion was 30 degrees; right lateral rotation was 40 degrees; and left lateral rotation was 40 degrees. Pain was noted during examination but did not cause functional loss. The Veteran was able to perform repetitive testing. The examiner could not state without mere speculation that repeated use would cause additional functional limitations. The Veteran did not report flareups. The examiner noted muscle spasms. The Veteran was regularly using a cane as an assistive device. During a December 2019 VA examination, the examiner noted diagnoses of lumbosacral strain, degenerative arthritis of the spine and bilateral lower extremity radiculopathy. The Veteran reported flare-ups about once per month in which his legs will go numb for a few hours. The Veteran reported that he is unable to dress himself or shower, falls if he does not have his walker, and sleeps in a recliner since he is unable to get up from a flat position. The examiner was unable to perform initial range of motion testing as the Veteran stated that the pain was too bad, and he would need an ambulance afterwards. The examiner noted objective evidence of localized tenderness or pain on palpation as the Veteran reported pain anywhere his back was touched. However, the examiner was unable to relate the Veteran's soft tissue tenderness to his degenerative arthritis of the spine but rather is related to fibromyalgia. The Veteran refused to perform repetitive use testing due to pain. As the initial range of motion testing was not performed, the examiner was unable to estimate range of motion during flareups. The examiner noted functional impact based on the Veteran's back disability. He would be unable to stand or walk for prolonged period of time without a walker. The examiner stated that the Veteran would also need a wheelchair or time rest if he is on his feet too long. The examiner stated that the examination was based largely off of observation and is very limited. The examiner estimated that the Veteran's forward flexion was 50/60 degrees based on watching him sit down and stand up. The examiner noted that the standing up required a little assistance. The Veteran did not exhibit a foot drop. However, the examiner stated that when measuring the Veterans leg/ankle strength there was a degree of giveaway weakness, which made the examination unreliable. The Veteran exhibited moderate localized tenderness of the back, which the examiner stated was likely due to his diagnosed fibromyalgia. The examiner noted no ankylosis of the spine nor any additional factors contributing to the disability, including ankylosis. During a May 2024 VA examination, the examiner noted a diagnosis of lumbar strain with degenerative joint disease of the lumbar spine. The Veteran reported that his back disability has worsened due to pain and stiffness. He reported taking over the counter and prescription medication along with injections. The Veteran denied flareups. The Veteran reported functional loss manifested as decreased range of motion and increased pan with prolonged standing, walking, and bending down. The examiner noted the following active and passive ranges of motion: forward flexion was 25 degrees; extension was 10 degrees; right lateral flexion was 15 degrees; left lateral flexion was 15 degrees; right lateral rotation was 15 degrees; and left lateral rotation was 15 degrees. The examiner observed pain during range of motion The examiner did not observe evidence of localized tenderness or pain on palpation of the joint. The Veteran was unable to perform repetitive use testing due to the fear of pain, but the examiner reported pain, fatigability, and weakness with repetitive use. The examiner did not estimate a decrease in range of motion with repetitive use. The examiner did not observe guarding or muscle spasms. The examiner reported the following additional factors: interference with sitting; interference with standing; disturbance of locomotion; and less movement than normal. The Veteran did not have atrophy or ankylosis of the spine. The examiner reported that the Veteran did not have IVDS. In a March 2025 private opinion, the physician noted that the Veteran had been taking opioid pain medication for his musculoskeletal injuries since, at least, 2006. The physician stated that opioids were generally reserved for cases of chronic pain where other treatments were insufficient. Additionally, the Veteran had supplemented with over the counter pain medication. The Board acknowledges that the relevant diagnostic codes for the Veteran's lumbar spine disability did not contemplate the use of medications, and, therefore, the Board must discount any ameliorative effects that the Veteran's medications might provide when assigning a rating for his musculoskeletal disabilities under those diagnostic codes. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); see also McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc) (concluding that "if [the applicable Diagnostic Code] does not specifically contemplate the effects of medication, the Board is required pursuant to Jones to discount the ameliorative effects of medication when evaluating the [disability]"). As noted above, the Veteran has been prescribed a regiment of medication, which provided some relief to his symptoms, including opioids, injections, topical ointments, and over the counter medications. Since he received some relief with treatment, the Board finds that ameliorative effects must be considered in deciding whether an increased rating is warranted. See Ingram v. Collins, No. 23-1798 (Vet. App. Mar. 12, 2025) (providing that a remand is warranted if the Veteran finds relief from symptoms with the use of medication). Thus, the Board finds that a remand is necessary to determine the implications of the Veteran's treatment on his lumbar spine disability. 12. Entitlement to a TDIU on an extraschedular basis prior to December 12, 2019 Where the percentage requirements for a schedular TDIU are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rating boards will refer to the Director of the Compensation Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The Board's sole initial inquiry is whether referral for extraschedular consideration is warranted in light of the evidence. If the Board finds "sufficient evidence" to substantiate a "reasonable possibility" that a veteran may be unemployable because of service-connected disabilities, then the proper course of action is to remand the claim for referral to the Director of Compensation Service for an advisory opinion for extraschedular consideration. See 38 C.F.R. § 4.16(b); Ray v. Wilkie, 31 Vet. App. 58, 66 (2019). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a Veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the Court in directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Regarding the physical limitations factor, the Court stated that relevant considerations include, but are not limited to, the Veteran's limitations with respect to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations. Id. Regarding the mental ability factor, the Court stated that relevant considerations include, but are not limited to, the Veteran's limitations with respect to memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. In determining whether unemployability exists, consideration may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In contrast, if the Board determines that a referral is not appropriate, a different analysis must be made. In particular, the Court in Snider held that if the Board denies a referral, it must make two determinations: (1) that a referral for extraschedular TDIU consideration is not warranted because there is insufficient evidence to substantiate a reasonable possibility that a veteran is unemployable because of service-connected disabilities; and (2) that TDIU benefits are not warranted because service-connected disabilities did not render the veteran unemployable. Snider v. McDonough, No. 19-6707 (CAVC November 19, 2021). The first inquiry, the question of the referral, is a factual finding based on a lower evidentiary threshold than for a grant of an extraschedular TDIU. See Ray v. Wilkie, 31 Vet. App. 58.VA treatment records demonstrated that the Veteran's wife left her full-time employment to become his caregiver in 2014. Therefore, between July 28, 2006, and December 11, 2019, the Board will consider first whether referral is appropriate, and, if not, whether TDIU benefits are warranted. Regarding the economic component, the Veteran has a high school education. The Veteran's DD214 shows he completed training as a light vehicle driver, and his specialty was as a heavy vehicle driver. In a February 2007 private orthopedic consultation, the Veteran complained of back, neck, and bilateral knee pain. The Veteran described the pain as sharp, throbbing, burning, and a dull ache causing weakness, stiffness, and swelling. On a scale from 1 to 10, the Veteran reported his pain at 10 at rest, and after repetitive use, the Veteran described his pain as 10 plus with fatigue, weakness, and lack of endurance. The Veteran reported pain radiating into his bilateral lower extremities. The Veteran reported that sitting, standing, bending, stooping, pushing, pulling, lifting, overhead work, kneeling, crawling, squatting and walking could cause flareups lasting for several hours to several days. The pain was only reduced with medication and lying down. The physician noted that Veteran used a cane, corrective shoes, and a walker for ambulation. He reported that he could walk up to three blocks or for 30 to 40 minutes until his pain increased. The physician noted that the Veteran had been unable to work for over 12 to 15 years due to physical disabilities and did not participate in recreational activities. Additionally, the Veteran reported that he was unable to drive for long periods of time due to pain. During a July 2014 VA examination for a bilateral knee disability, the examiner noted that the Veteran used a wheelchair for his back disability but was able to "move well" once he entered the examination room. The examiner stated that the Veteran's bilateral knee disability did not impact his ability to work. Specifically, the examiner noted that the Veteran's bilateral range of motion demonstrated no loss of functional abilities. During a July 2014 VA examination for a back disability, the examiner noted that the Veteran's disability to contributed to less movement than normal. The examiner noted that the Veteran's symptoms relative to range of motion and pain were due to fibromyalgia rather than his back disability. The Board notes that, for a Veteran to prevail on a claim for TDIU on an extraschedular basis, it is necessary that the record reflect some factor which places the case in a different category than other Veterans with an equal rating of disability. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The pertinent question is whether the Veteran can perform the physical and mental acts required by employment, not whether the Veteran can find employment. Id. This is because a disability rating is recognition that the impairment makes it difficult to obtain or keep employment. The Board finds that the evidence above is sufficient to substantiate a "reasonable possibility" that a veteran may be unemployable because of service-connected lumbar spine disability, cervical spine disability, and bilateral knee disability. As such, the Board finds that referral for consideration of a TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b) is warranted. By this remand, no determination, express or implied, is being made as to the credibility of any statements on file. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination from an examiner with the appropriate expertise to determine the severity of the Veteran's lumbar spine disability. The electronic claims file should be made accessible and be reviewed by the examiner. The examiner should detail all findings. (a.) The examiner should produce the findings as to the current nature, extent, and severity of the Veteran's lumbar spine disability. The examiner should disregard any ameliorative effects of medications, to include oral, topical, or injections, and include a statement to that effect. (b.) Additionally, the examiner should provide a statement determining whether the Veteran's lumbar spine is functionally ankylosed. (c.) A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a specific measurement without resorting to mere speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Thereafter, the AOJ should readjudicate the issue on appeal. Then, issue the Veteran and his representative an SSOC and allow them an appropriate opportunity to respond. 3. Obtain a VA opinion regarding the Veteran's employability from an appropriate VA examiner. After reviewing the claims folder, the examiner is asked to do the following: (a.) Address the combined effect of the Veteran's service-connected lumbar strain with degenerative joint disease, cervical strain, left knee arthritis, and right knee arthritis on his ability to maintain substantially gainful employment, to include sedentary employment, from July 28, 2006, to December 15, 2019. 4. The RO shall refer the case to the Director, Compensation Service for a determination as to whether the Veteran is entitled to a total disability rating based on individual unemployability due to service-connected disabilities prior to December 12, 2019, in accordance with the provisions of 38 C.F.R. § 4.16(b). 5. The AOJ should then prepare a new rating decision and readjudicate the issue of entitlement to a TDIU on an extraschedular basis. 6. If the benefit sought on appeal is not granted in full the AOJ must issue a supplemental statement of the case and provide the appellant and his representative an opportunity to respond. Thereafter, if appropriate, return the case to the Board. (a.) The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this appeal as a result of this action. This case must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B , 7112. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Clevenger, Gordanna A. 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.