Source: https://va-claim.com/2018/10/22/right-left-upper-extremity-radiculopathy-denied-degenerative-disc-disease-of-cervical-spine-lumbar-spine-denied-right-lower-extremity-radiculopathy-granted-citation-nr-18900004/
Timestamp: 2019-04-19 09:14:52+00:00

Document:
Entitlement to service connection for right upper extremity radiculopathy is denied.
Entitlement to service connection for left upper extremity radiculopathy is denied.
Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine is denied.
Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine is denied.
Entitlement to a separate 20 percent rating for right lower extremity radiculopathy, claimed as sciatica, is granted from September 11, 2017 to November 9, 2017.
Entitlement to service connection for temporomandibular condition (TMJ) is remanded.
Entitlement to service connection for a left shoulder disability is remanded.
1. The preponderance of the evidence of record is against finding that the Veteran had, at any point during the period on appeal, a right upper extremity radiculopathy related to his cervical spine disability.
2. The preponderance of the evidence of record is against finding that the Veteran had, at any point during the period on appeal, a left upper extremity radiculopathy related to his cervical spine disability.
3. The Veteran experienced moderate neurologic disability of the right lower extremity from September 11, 2017 to November 9, 2017.
4. For the entire period on appeal, the Veteran’s service-connected cervical spine degenerative disc disease is manifested by limitation of motion to no worse than 45 degrees of flexions and a combined range of motion to 270 degrees with pain; there is no ankylosis of the cervical spine.
5. For the entire period on appeal, the Veteran’s service-connected lumbar spine degenerative disc disease is manifested by no worse than limitation of motion to 90 degrees of flexion and a combined range of motion to 225 degrees with pain; there is no ankylosis of the lumbar spine.
1. The criteria for service connection for right upper extremity radiculopathy are not met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).
2. The criteria for entitlement to service connection for left upper extremity radiculopathy are not met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).
3. The criteria for an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237.
4. The criteria for an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237.
5. The criteria for a separate 20 percent rating for right lower extremity radiculopathy, claimed as sciatica, are met from September 11, 2017 to November 9, 2017.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).
The Veteran served on active duty from May 1992 to September 2013.
On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. The Veteran chose to participate in BEAAM, the Board of Veterans’ Appeals (Board) Early Applicability of Appeals Modernization research program. This decision has been written consistent with the new AMA framework.
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131.  To establish service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).  The absence of any one element will result in denial of service connection.  Coburn v. Nicholson, 19 Vet. App. 427 (2006).
1. Entitlement to service connection for right upper extremity radiculopathy.
2. Entitlement to service connection for left upper extremity radiculopathy.
The Veteran contends that he has right and left upper extremity radiculopathies that are due to his service-connected cervical spine disability.
As the 2015 EMG testing, November 2017 VA examination, and November 2017 private treatment note all reflect diagnoses of carpal tunnel syndrome, and the 2017 VA examiner explained that diagnosis was not related to the Veteran’s cervical spine disability, the Board determines that service connection is not warranted for upper extremity radiculopathies.  The Board lends significant probative value to the November 2017 opinion, which assesses the nature of the Veteran’s diagnosed conditions against current medical standards.  See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that the probative value of a medical opinion comes from the “factually accurate, fully articulated, sound reasoning for the conclusion”).  This opinion is supported by the additional evidence of record, to include the October 2013 and May 2017VA examination results and the November 2017 private diagnosis of carpal/cubital tunnel symptoms.
While the Veteran believes he has a current diagnosis of upper extremity radiculopathies, and has reported arm numbness, he is not competent to provide a diagnosis in this case.  Here, the issue is medically complex, as it requires specialized medical education and knowledge of the interaction between multiple organ systems in the body and the ability to interpret complicated diagnostic medical testing.  Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  Service connection for radiculopathies of the bilateral upper extremities is denied.
3. Entitlement to service connection for right lower extremity sciatica.
Although the November 2017 VA examiner also noted no diagnosis of any lower extremity radiculopathy or sciatica, the Board observes that a September 2017 private treatment record reflects a diagnosis of lumbar radiculopathy and an observation of decreased strength in the right lower extremity.  That private treatment note is concurrent with private radiographic evidence of disk herniation with nerve impingement; the record reflects that the Veteran underwent surgery to correct that herniation later in September 2017.  Although the November 2017 VA examination report reflects that, at the time of that examination, the Veteran no longer had symptoms of lumbar radiculopathy, the private treatment evidence of record reflects that he did experience such disability during the appeal period.  McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (requirement of current disability is satisfied when claimant has disability at time claim filed or during pendency of that claim, even if it resolves prior to adjudication of claim).  As those symptoms were attributed to his service-connected lumbar spine disability, the Board herein grants service connection for a right lower extremity radiculopathy, claimed as sciatica.  As this disability represents a neurologic abnormality associated with the Veteran’s service-connected lumbar spine disability, the evaluation will be discussed below, under an appropriate diagnostic code, in accordance with note (1) to the General Rating Formula for Diseases and Injuries of the Spine.  38 C.F.R. § 4.71a.
Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  Separate rating codes identify the various disabilities.  38 C.F.R. Part 4. The determination of whether an increased rating is warranted is based on review of the evidentiary record on appeal and the application of all pertinent regulations.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.
The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal.  Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App.  505 (2007).
When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal exertion, strength, speed, coordination and endurance.  The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion.  Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled.  DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59.  In that regard, painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint.  38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011).  Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded.  Mitchell v. Shinseki, 25 Vet. App. 32 (2011).
Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases (General Rating Formula) or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes.  38 C.F.R. § 4.71a.
The General Rating Formula provides a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.
A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.
A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine.
A 40 percent rating is warranted for Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine.
A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine.
A 100 percent rating is warranted for unfavorable ankylosis of the entire spine.  The criteria of the General Rating Formula are applied with and without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.  38 C.F.R. § 4.71a.
Associated objective neurologic abnormalities are to be rated separately.  The combined range of motion refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation.  The normal range of motion of the thoracolumbar spine encompasses flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees.  38 C.F.R. § 4.71a, Plate V.  The normal combined normal range of motion of the thoracolumbar spine is 240 degrees and of the cervical spine is 340 degrees.  38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine.
Intervertebral disc syndrome is rated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25.  38 C.F.R. § 4.71a, Diagnostic Code 5243.
4. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine.
The Veteran contends that his cervical spine degenerative disc disease symptoms and functional limitations are more severe than the current 10 disability rating reflects. The Veteran’s cervical spine disability is rated under Diagnostic Code 5237, which contemplates cervical strain.  38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5237.
Based on the above criteria, the Veteran’s cervical spine degenerative disc disease did not warrant a disability rating in excess of 10 percent.  He did not demonstrate forward flexion greater than 15 degrees but not greater than 30 degrees or less or have favorable ankylosis of the entire cervical spine.  At most, he demonstrated forward flexion limited to 45 degrees, with a combined range of motion of 270 degrees.  Further, he did not have favorable or unfavorable ankylosis of the entire cervical spine or unfavorable ankylosis of the entire spine.
In an August 2014 rating decision, the Veteran was granted service connection for DDD of the cervical spine and assigned a 10 percent rating based a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees on 38 C.F.R. § 4.59 which allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint.
During the appeal period the Veteran underwent VA examinations in October 2013, May 2017, and November 2017.  Range of motion testing was performed and showed, at worst, forward flexion to 45 degrees and a combined range of motion no less than 270 degrees.  During examination the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use.  No report suggests that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements.
The Veteran is competent to report his observed functional impairment and pain on movement, and his reports are credible and entitled to probative weight, as his symptoms of pain are lay-observable.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).  Although he had pain on movement, he did not have additional limitation of motion, functional loss, or functional impairment even on repetitive-motion testing during VA examinations that would warrant a higher disability rating.  The Veteran is not competent to provide a finding that his range of motion was limited to a specific degree or extent, as there is no suggestion that he obtained range-of-motion measurements via objective testing using a goniometer.  38 C.F.R. § 4.46.
Based on this record, the Board finds that the cervical spine disability is appropriately rated as 10 percent disabling throughout the period on appeal.  The Board reaches the same conclusion even when considering functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995).  On review, the Veteran’s functional loss was identified as pain.  Such manifestations are considered in the currently assigned rating.
The Board considered assigning a disability rating under another diagnostic code.  Other applicable diagnostic codes are 5003 and 5243.  Diagnostic Code 5003, however, ultimately requires evaluation based on limitation of motion using identical criteria.  A higher disability rating is not available under Diagnostic Code 5243, as the record does not show the Veteran has intervertebral disc syndrome that resulted in associated incapacitating episodes lasting at least 4 weeks within a 12-month period.
Consideration has been given to assigning a separate compensable rating for neurological impairment related to the cervical disability.  However, there is no indication from the record that the Veteran had complaints of neurological impairment other than addressed above in this decision.
Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for a cervical spine disability, and the claim is denied.
5. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine.
The Veteran contends that his lumbar spine degenerative disc disease symptoms and functional limitations are more severe than the current 10 disability rating reflects. The Veteran’s lumbar spine disability is rated under Diagnostic Code 5237, which contemplates lumbosacral strain.  38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5237.
Based on the above criteria, the Veteran’s lumbar spine degenerative disc disease did not warrant a disability rating in excess of 10 percent.  He did not demonstrate forward flexion of greater than 30 degrees but not greater than 60 degrees or have favorable ankylosis of the entire lumbar spine.  At most, he demonstrated forward flexion limited to 90 degrees, with a combined range of motion of 225 degrees with pain.  Further, he did not have favorable or unfavorable ankylosis of the entire lumbar spine.
In an August 2014 rating decision, the Veteran was granted service connection for DDD of the lumbar spine and assigned a 10 percent rating based on 38 C.F.R. § 4.59 which allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint.
During the appeal period the Veteran underwent VA examinations in October 2013, May 2017, and November 2017.  Range of motion testing was performed and showed, at worst, forward flexion to 90 degrees and a combined range of motion no less than 225 degrees.  During examination the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use.  No report suggests that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements.
The Veteran is competent to report his observed functional impairment and pain on movement, and his reports are credible and entitled to probative weight, as his symptoms of pain are lay-observable.  Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).  Although he had pain on movement, he did not have additional limitation of motion, functional loss, or functional impairment even on repetitive-motion testing during VA examinations that would warrant a higher disability rating.  The Veteran is not competent to provide a finding that his range of motion was limited to a specific degree or extent, as there is no suggestion that he obtained range-of-motion measurements via objective testing using a goniometer.  38 C.F.R. § 4.46.
Based on this record, the Board finds that the lumbar spine disability is appropriately rated as 10 percent disabling throughout the period on appeal.  The Board reaches the same conclusion even when considering functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995).  On review, the Veteran’s functional loss was identified as pain.  Such manifestations are considered in the currently assigned rating.
Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for a lumbar spine disability, and the claim is denied.
Consideration has been given to assigning a separate compensable rating for neurological impairment related to the lumbar spine disability.  As noted above, the Board herein determined that the Veteran experienced right lower extremity radiculopathy as a result of his lumbar spine disability.  An October 2013 VA examination reflects that the Veteran had no neurologic abnormalities associated with his lumbar spine disability and this finding is repeated in a May 2017 VA examination.  However, a private treatment note dated September 11, 2017 reflects diagnosis of right lower extremity radiculopathy and documents decreased sensation.  Other private treatment notes dated in September 2017 reflect the Veteran’s report of right lower extremity pain and observe decreased strength in that extremity.  A September 21, 2017 note observes decreased (4/5) motor function.  Private treatment notes reflect that the Veteran subsequently, in September 2017, underwent surgical treatment and, at the time of the November 2017 VA examination, the VA examiner found no neurologic abnormalities associated with the lumbar spine disability. In sum, the evidence in this case indicates that the Veteran experienced an additional neurological manifestation, from September to November 2017, that relates to his lumbar spine disability.
The diagnostic codes for disability of the sciatic nerve are 8520-paralysis, 8620-neuritis, and 8720-neuralgia. These diagnostic codes employ the use of words such as mild, moderate, severe, and incomplete paralysis. The Board notes that words “mild,” “moderate,” and “severe” are not defined in the 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 evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating.  38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6.  The term “incomplete paralysis” with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. 38 C.F.R. § 4.124 (a).  Based on the private practitioner’s observation of some decreased motor function, the Board determines that the Veteran’s right lower extremity warrants a moderate, or 20 percent disability rating from the date of diagnosis – September 11, 2017 – to November 9, 2017, the date of the subsequent examination observing no such disability.  However, as the record does not reflect any observation or complaint of symptoms of paralysis of the right lower extremity, a higher rating is not warranted.
6. Entitlement to service connection for a TMJ condition is remanded.
In regard to the service connection claim for TMJ, the Agency of Original Jurisdiction (AOJ) did not obtain a VA examination prior to the January 2018 rating decision on appeal.  However, based on the evidence associated with the claims file prior to the January 2018 rating decision, the Board finds that a VA examination is required to determine whether TMJ is related to service.  Accordingly, the issue of service connection for TMJ is remanded.
7. Entitlement to service connection for a left shoulder disability is remanded.
The issue of entitlement to a left shoulder disability is remanded to correct a prior error by VA.  The AOJ obtained a May 2017 medical opinion prior to the January 2018 rating decision on appeal.  However, this medical opinion does not provide a nexus statement or rationale regarding whether the Veteran’s left shoulder disability had its onset in service or is caused or aggravated by his service-connected cervical spine degenerative disc disability.
1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any temporomandibular condition.  The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including teeth grinding.
(a.) whether it is at least as likely as not related to an in-service injury, event, or disease.
(c.) whether it is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability, including the cervical spine disability.

References: § 4
 § 4
 v. 
 v. 
 v. 
 v. 
 v. 
 v. 
 § 4
 § 1155
 v. 
 § 4
 v. 
 v. 
 § 5107
 v. 
 v. 
 § 4
 v. 
 v. 
 § 4
 § 4
 § 4
 V. 
 § 4
 § 4
 § 4
 § 4
 v. 
 § 4
 v. 
 § 4
 v. 
 § 4
 v. 
 § 4
 § 7104
 § 4