Source: https://va-claim.com/2017/12/16/lumbosacral-strain-peripheral-neuropathy-of-the-right-left-lower-extremity-residuals-of-status-post-hemorrhoid-surgery-and-individual-unemployability-tdiu-denied-citation-nr-1749066/
Timestamp: 2019-04-20 18:38:18+00:00

Document:
1.  Entitlement to a disability rating in excess of 20 percent for lumbosacral strain.
2.  Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity.
3.  Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity.
4.  Entitlement to a disability rating in excess of 20 percent for residuals of status-post hemorrhoid surgery.
5.  Entitlement to a total disability rating based on individual unemployability (TDIU).
The Veteran served on active duty from April 1959 to January 1961.
These matters come to the Board of Veterans' Appeals (Board) on appeal from decisions of VA's Appeals Management Office (AMO) and the RO in July 2014 and in January 2015 that, in pertinent part, granted service connection for lumbosacral strain evaluated as 20 percent disabling effective February 13, 2003; granted service connection for peripheral neuropathy of the right lower extremity and of the left lower extremity-each evaluated as 10 percent disabling effective February 13, 2003; denied a disability rating in excess of 20 percent for service-connected residuals of status-post hemorrhoid surgery; and denied a TDIU.  The Veteran timely appealed.  These are the only issues that have been perfected on appeal.
In June 2017, the Board remanded the Veteran's claims.  The Veteran's VA claims folder has been returned to the Board for further appellate proceedings.
1.  Residuals of status-post hemorrhoid surgery is assigned the maximum schedular rating authorized by regulation.
2.  Lumbosacral strain is manifested by pain and limited motion.  Remaining functional flexion is better that 30 degrees.
3.  Peripheral neuropathy of the right lower extremity is productive of no more than mild neuropathy.
4.  Peripheral neuropathy of the left lower extremity is productive of no more than mild neuropathy.
5.  The Veteran has been granted service connection for lumbosacral strain (rated as 20 percent disabling), status post hemorrhoid surgery (rated as 20 percent disabling), peripheral neuropathy of the right lower extremity (rated as 10 percent disabling), peripheral neuropathy of the left lower extremity (rated as 10 percent disabling), and tinnitus (rated as 10 percent disabling); his combined rating is 50 percent.
6.  The Veteran's service-connected disabilities do not prevent him from obtaining or retaining substantially gainful employment.
1.  The criteria for the assignment of a rating in excess of 20 percent for residuals of status-post hemorrhoid surgery have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2016).
2.  The criteria for a disability rating in excess of 20 percent for lumbosacral strain have not been met.  38 U.S.C.A. § 1155 (West 2002 and 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013); 4.71a, Diagnostic Codes 5292, 5295 (effective prior to September 26, 2003), Diagnostic Code 5293 (effective from September 23, 2002 to September 25, 2003), Diagnostic Code 5237 (effective from September 26, 2003).
3.  The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8521 (2016).
4.  The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8521 (2016).
5.  The criteria for TDIU are not met.  38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2016).
The Veteran seeks entitlement to entitlement to increased disability ratings for lumbosacral strain, peripheral neuropathy of the right and left lower extremities, and hemorrhoids as well as entitlement to TDIU.
The Board previously remanded these claims in June 2017 order for the agency of original jurisdiction (AOJ) to review recent evidence that was associated with the record and readjudicate the Veteran's claims.  Pursuant to the Board's remand instructions, the AOJ reviewed the recently associated evidence and readjudicated the Veteran's claims in an August 2017 supplemental statement of the case (SSOC).  Accordingly, the Board's remand instructions have been complied with regarding the claims on appeal.  See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance].
VA has a duty to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim.  This notice must specifically inform the claimant of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant.  See 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2016).  In a letter mailed to the Veteran in September 2013, prior to the initial adjudication of his claims, VA satisfied this duty.
The Board notes that the claims for initial increased disability ratings for lumbosacral strain and peripheral neuropathy of the right and left lower extremities are downstream issues from the July 2014 rating decision that initially established service connection for these disabilities and assigned the initial ratings and its effective dates.  The United States Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled.  See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008).  Thus, to the extent that there is any noncompliance with the statutorily prescribed VCAA notice requirements with respect to the claims for initial increased disability ratings for lumbosacral strain and peripheral neuropathy of the right and left lower extremities, such noncompliance is deemed to be non-prejudicial to these specific claims.
VA also has a duty to assist a claimant in the development of his claims.  See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2016).  Here, reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims.  The pertinent evidence of record includes the Veteran's statements, service treatment records, and post-service VA and private treatment records.
In general, VA's duty to assist includes obtaining records from the Social Security Administration (SSA).  See Murincsak v. Derwinski, 2 Vet. App. 363 (1992).  The record demonstrates that the Veteran is currently in receipt of SSA benefits.  The record further demonstrates that the AMO requested records in connection with the Veteran's SSA disability benefits claim from the SSA in September 2013, and in a subsequent response dated September 2013, the SSA informed the AMO that there are no medical records in connection with the Veteran's SSA disability benefits claim.  The AMO informed the Veteran in an October 2013 letter that an attempt was made to obtain the SSA records.  The Veteran has not submitted or identified any outstanding evidence pertaining to his SSA records which could be obtained to substantiate the claims.  Further, while the Board acknowledges the Veteran's statement in December 2013 that the AMO provided SSA with an incorrect date of his birth, a review of the SSA's negative response reveals that the birth date was corrected by SSA personnel.
Additionally, the Veteran was afforded VA examinations for his lumbar spine and neuropathy in August 2004, January 2015, December 2013 and July 2016 and for his hemorrhoids in December 2014 and July 2016.  The VA examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record.  Furthermore, these examination reports contain sufficient information to rate the Veteran's disabilities on appeal under the appropriate diagnostic criteria.
With regard to range of motion testing of the Veteran's lumbar spine conducted during the above-referenced VA examinations, the Board notes that in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court noted the final sentence of § 4.59 which states "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint."  The Court found this sentence to be ambiguous because the regulation, considered as a whole, is meant to guide adjudicators in determining the proper level of disability of joints, and if the range of motion testing listed in the last sentence is not required, it is unclear how an adjudicator could adequately rate a claimant's joint disability and account for painful motion.  However, compelled by § 4.59's place in the regulatory scheme (it preceded the disability rating schedule), the Court held that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities.  In this case, the Board finds that the current VA examination reports of record are adequate to evaluate the Veteran's lumbar spine disability with respect to weight-bearing and nonweight-bearing, and that range of motion testing is consistent with the record to include the Veteran's lay statements.  Notably, as will be discussed below, the Veteran's statements of difficulty bending and limitation of motion are consistent with the VA examination findings such that further examination is not necessary.  Therefore, the Board finds that the VA examination results are sufficient to evaluate the Veteran's disability.
Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist.  See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument).
The Board finds that under the circumstances of this case, VA has satisfied the notification and assistance provisions of the law, and that no further action need be undertaken on the Veteran's behalf.
Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability.  See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2016).  Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2016).
"Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).
The service-connected residuals of status-post hemorrhoid surgery are rated under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7336 (2016) which pertains to both internal and external hemorrhoids.  A zero percent evaluation is warranted for mild or moderate hemorrhoids.  A 10 percent evaluation is indicated for irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences.  A 20 percent rating is warranted for persistent bleeding and secondary anemia, or with fissures.  Id.
The Veteran was afforded a VA examination in December 2014.  The VA examiner documented external hemorrhoid tags in the 5-6 o'clock position.  There were no findings of external hemorrhoids but rather only skin tags.  The Veteran's treatment plan did not include taking continuous medication and he did not have any scars associated with the hemorrhoids.  The Veteran reported that the hemorrhoids did not impact his ability to work, and the examiner noted that the Veteran's hemorrhoids would not preclude him from securing and maintaining substantially gainful employment as the Veteran would be able to lift objects and ambulate for an eight hour workday.
The Veteran was provided another VA examination in July 2016.  The Veteran reported that he used suppositories for his hemorrhoids as well as topical cream and Metamucil.  The examiner documented mild or moderate hemorrhoids with persistent bleeding and itching.  Upon examination, the examiner recorded no external hemorrhoids, only skin tags; excessive redundant tissue; and enlarged prostate, weight loss, anemia, and urinary and rectal incontinence which was due to the Veteran's history and not his hemorrhoids.  The examiner also noted an October 2013 colonoscopy which did not mention hemorrhoids.  The Veteran noted that the hemorrhoids affected his employment in that the hemorrhoids became worse with heavy lifting or prolonged sitting.  However, the examiner noted that sedentary employment was feasible with adequate seat padding and periodic changes in position.
VA outpatient records also document treatment for the Veteran's hemorrhoids which indicate use of suppositories.
The record reflects that the Veteran is receipt of the maximum schedular evaluation for internal and external hemorrhoids.  Although hemorrhoids have continued to be on his problem list with complaints of persistent bleeding, itching, skin tags, and difficulty with prolonged sitting and heavy lifting, the clinical evidence does not reflect evidence of any untoward symptomatology or specialized treatment not contemplated by the schedular criteria of Diagnostic Code 7336.
Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45.  DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995).  The provisions of 38 C.F.R. § 4.40 state that 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 excursion, strength, speed, coordination and endurance.  Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures.  It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion.  38 C.F.R. § 4.40.  The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement.  38 C.F.R. § 4.45.
Here, the Veteran was awarded service connection for lumbosacral strain in a July 2014 rating decision and assigned an effective date of February 13, 2003 as well as a 20 percent disability rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237.
The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."  See Butts v. Brown, 5 Vet. App. 532, 538 (1993).  One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, the current diagnosis, and demonstrated symptomatology.  Any change in diagnostic code by a VA adjudicator must be specifically explained.  See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Where a Veteran has been diagnosed as having a specific condition and the diagnosed condition is not listed in the Ratings Schedule, the diagnosed condition will be evaluated by analogy to closely-related diseases or injuries in which not only the functions affected, but the anatomical localizations and symptomatology, are closely analogous.  38 C.F.R. § 4.20.
During the course of the Veteran's increased rating claim, VA revised regulations for evaluating disabilities of the spine.  The Court in DeSousa v. Gober, 10 Vet. App. 461, 467 (1997), held that the law "precludes an effective date earlier than the effective date of the liberalizing ... regulation," but the Board shall continue to adjudicate whether a claimant would "receive a more favorable outcome, i.e., something more than a denial of benefits, under the prior law and regulation."  Accordingly, the Veteran's claim will be adjudicated under the old regulation for any period prior to the effective date of the new diagnostic codes, as well as under the new diagnostic code for the period beginning on the effective date of the new provisions.  Wanner v. Principi, 17 Vet. App. 4, 9 (2003).
Diagnostic Code 5289, applicable prior to September 26, 2003, assigns a 40 percent evaluation for favorable ankylosis of the lumbar spine and a 50 percent evaluation for unfavorable ankylosis of the lumbar spine.  38 C.F.R. § 4.71a, Diagnostic Code 5289 (2002).
Under Diagnostic Code 5292 for limitation of motion of the lumbar spine, 10 percent is slight, 20 percent is moderate, and 40 percent is severe.  38 C.F.R.
§ 4.71a, Diagnostic Code 5292 (2002).
The Board also notes that under Diagnostic Code 5295 (lumbosacral strain), a zero percent (noncompensable) rating is warranted for slight subjective symptoms only; a 10 percent rating is warranted for characteristic pain on motion; a 20 percent rating is warranted for muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position; and a maximum 40 percent rating is warranted for severe symptoms, with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion.
The terms "slight," "moderate" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just."  38 C.F.R. § 4.6.
Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation.
Note (1): For purposes of evaluations under 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  Chronic orthopedic and neurologic manifestations' means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so.
Note (2): When evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes.  Evaluate neurologic disabilities separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes.
Note (3): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment.
38 C.F.R. § 4.71a Diagnostic Code 5293 (2003).
The regulations regarding spine disabilities were revised effective September 26, 2003.  Under these regulations, a back disability is evaluated under the General Rating Formula for Diseases and Injuries of the Spine.  See 38 C.F.R. § 4.71a.
38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2016).
The Veteran was provided a VA examination in August 2004.  He complained of constant lower back pain which became worse with bending, lifting, and extensive walking.  He used a scooter but not a cane.  Upon examination, the VA examiner noted that the Veteran was able to walk without support and had a normal gait.  Range of motion testing revealed forward flexion to 60 degrees, extension to 20 degrees, right and left flexion to 30 degrees, and right and left rotation to 50 degrees.  The Veteran had pain in the lumbosacral area at the extreme ranges of motion.  The examiner noted an X-ray taken in 1997 which indicated narrowed L5-S1 disc space, moderate which was consistent with degenerative arthrosis and spur formation.
The Veteran was afforded another VA examination in December 2013.  He reported a sticking pain upon any movement with a constant dull aching pain.  He used a brace occasionally and a cane regularly for assistance.  He was unable to lift over 20 pounds and had limited bending.  Range of motion testing revealed forward flexion to 70 degrees with pain at 40 degrees, extension to 30 degrees or greater with pain at 30 degrees or greater, right and left lateral flexion to 30 degrees or greater, and right and left lateral rotation to 30 degrees or greater.  The Veteran was not able to perform repetitive-use testing with 3 repetitions as he had a sudden sticking pain in the lower back upon attempting the second range of motion flexion.  The examiner documented functional loss manifested by less movement than normal, weakened movement, pain on movement, and interference with sitting, standing, and/or weight bearing.  He did not report ankylosis.  Although the Veteran had intervertebral disc syndrome, he did not have any incapacitating episodes as a result of such over the past 12 months.  The examiner diagnosed the Veteran with lumbosacral strain.
The Veteran was provided a VA examination in January 2015.  He reported flare-ups and functional loss which resulted in difficulty with bending and lifting.  Range of motion testing revealed forward flexion to 60 degrees, extension to 5 degrees, right and left lateral flexion to 20 degrees, and right and left rotation to 20 degrees.  The examiner indicated that range of motion was abnormal and contributed to functional loss in that the Vetera had limited flexion and extension.  However, the pain was at the end range for all ranges tested.  There was no evidence of pain with weight bearing or areas of palpable tenderness.  The Veteran was able to perform 3 repetitions with no additional loss of function or range of motion after 3 repetitions.  The examiner was unable to state without resort to speculation whether pain, weakness, fatigue, or incoordination could significantly limit functional ability with repeated use over a period of time as the examiner only saw the Veteran for 3 repetitions.  The examiner further noted that the examination did not support or contradict the Veteran's statements describing functional loss during flare-ups and he could not state without speculating whether pain, weakness, fatigue, or incoordination could significantly limit functional ability with a flare as the Veteran did not have a flare-up at that time.  There were no findings of ankylosis or bowel or bladder impairment.  An X-ray report dated December 2013 showed mild multilevel degenerative change most pronounced at the lumbosacral junction.  Current X-rays showed 5 nonrib-bearing lumbar type vertebral bodies with unchanged alignment, disc spaces, soft tissues, and lumbar vertebral body heights.  The examiner documented a diagnosis of stable degenerative changes of the lumbar spine, most pronounced at L5-S1 and that the Veteran's level of severity was mild.
The Veteran was provided another VA examination in July 2016.  He continued to report constant back pain.  He did not report flare-ups but had functional loss consisting of bothersome prolonged walking, bending, lifting, and prolonged sitting.  He used a cane regularly for assistance.  Range of motion testing revealed forward flexion to 65 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion to 30 degrees, and right and left lateral rotation to 20 degrees.  The examiner noted guarding and near falls with flexion as well as difficulty bending.  There was no evidence of pain with weight-bearing.  Repetitive use testing revealed additional limitation of motion, in particular forward flexion to 50 degrees.  There were no findings of ankylosis.
The Board also notes a June 2006 private MRI that indicated multilevel degenerative changes, most pronounced at L5-S1 where central and right paracentral osteophytes and low volume disc material appeared to contact the descending right-sided S1 nerve root as well as L4-5 annular tear.  Additionally, a private MRI dated November 2016 revealed impression of L3-4, L4-5 disc degenerative bulging with facet hypertrophy, moderate to severe bilateral foraminal stenosis L4-5 and mild to moderate foraminal stenosis L3-4, and moderate central canal stenosis present at L4-5; L5-S1 advanced degenerative disc space narrowing with moderate endplate marrow reactive edema present, disc bulge and facet arthropathy resulting in moderate to severe bilateral foraminal stenosis; and straightening of the normal lumbar lordosis.  Also, December 2016 private treatment reports from J.N., D.C. and R.K., D.O. indicating that the Veteran is unable to work due to his low back symptoms.
The current evaluation contemplates pain on motion.  It is also consistenet with moderate limitiaton of motion or remaining flexion better than 30 degrees.  In order to warrant a higher evaluation, there must be the functional equivalent of severe limitiaotn of motion or flexion limited to 30 degrees of less.
With regard to his claim for service-connected lumbosacral strain under the current diagnostic code, the Board notes that the Veteran is entitled to no more than the currently assigned 20 percent rating.  In this regard, as discussed above, after the revised code was made effective, to warrant a higher 40 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show that the Veteran's lumbar spine disability results in forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine.
Review of the evidence of record reveals that the Veteran's low back symptomatology does not approach a 40 percent disability rating.  With respect to favorable ankylosis of the entire thoracolumbar spine, the objective medical evidence of record is pertinently absent any indication that ankylosis exists.  Neither the medical or lay evidence of record suggests that the Veteran's lumbar spine is immobile.  On the contrary, the record shows that the Veteran has maintained motion, albeit limited motion, throughout the course of the appeal.  Moreover, the evidence demonstrates that forward flexion is greater than 30 degrees.    Specifically, the August 2004, December 2013, January 2015, and July 2016 VA examinations noted forward flexion of 60, degrees, 40 degrees, 60 degrees, and 50 degrees with consideration of pain and functional loss.  There is no evidence to the contrary.  Further, these findings are consistent with the Veteran's reports of difficulty bending, and he has not indicated greater forward flexion than the results from the VA examinations.  Accordingly, a 40 percent disability rating of the Veteran's lumbosacral strain is not warranted under the General Rating Formula for Diseases and Injuries of the Spine.
The Board notes that Diagnostic Code 5292 would allow for a higher rating of 40 percent if the Veteran's limitation of motion was determined to be severe with regard to the lumbar spine.  Diagnostic Code 5295 would also allow for a rating of 40 percent if the Veteran had severe low back strain.  While the term "severe" is not specifically defined, the Board notes that an equivalent rating under the current rating criteria would require that the Veteran have at least favorable ankylosis of the thoracolumbar spine.  Here, there is no ankyloses.  The Board reiterates that the Veteran's complaints are consistent with the VA examination findings as to range of motion and there are no range of motion findings to the contrary.  Also, the evidence is absent criteria listed under "severe" impairment under Diagnostic Code 5295, in particular listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of these findings with abnormal mobility on forced motion.  Thus, the Board finds that a disability rating in excess of 20 percent is not warranted under Diagnostic Codes 5289, 5292, and 5295.
The Board also notes that although the Veteran has contended that his lumbosacral strain causes pain and interference in daily activities, he has not reported incapacitating episodes due to the disability.  Further, the medical evidence does not indicate that he has been prescribed bed rest by a physician based on incapacitating episodes totally at least four weeks but less than six weeks during any twelve month period.  Therefore, the Veteran's service-connected lumbosacral strain does not warrant an increased disability rating alternatively under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes at any time during the course of this appeal.
In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 (2016).  See DeLuca, supra.  The Board recognizes the Veteran's complaints of pain, flare-ups, and functional loss as a result of his lumbosacral strain, notably his difficulty walking and standing and use of a cane primarily for support.  However, the Board places greater probative value on the objective clinical findings which do not support an increased disability rating.  In this regard, the probative evidence of record does not indicate significant functional loss attributed to the Veteran's low back complaints which warrant an increased disability rating.  While the Board acknowledges the Veteran's reports of pain during range of motion testing during the VA examinations, the August 2004 and January 2015  VA examiners noted the Veteran had pain at the end point of range of forward flexion which was at 60 degrees.  Further, the December 2013 VA examiner noted pain at 40 degrees with forward flexion testing.  Also, the January 2015 VA examiner documented the Veteran's level of low back symptomatology as "mild."  The Board is therefore unable to identify any clinical findings that would warrant an increased evaluation under 38 C.F.R. § 4.40 and 4.45.  The Board further finds that the current 20 percent rating adequately compensates the Veteran for any functional impairment attributable to his lumbosacral strain.  See 38 C.F.R. §§ 4.41, 4.10 (2016).
Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately.  See 38 C.F.R. § 4.25 (2016); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994).  However, the evaluation of the same disability under various diagnoses is to be avoided.  See 38 C.F.R. § 4.14 (2016); see also Fanning v. Brown, 4 Vet. App. 225 (1993).  As will be discussed below, the Board will evaluate the Veteran's peripheral neuropathy of the right and left lower extremities.  The Board further notes that while the Veteran has bowel and bladder impairment, such is not attributable to the lumbosacral strain.  In this regard, the Veteran's bladder impairment is related to his prostate condition.  See, e.g., a VA treatment record dated November 2013.  Further, his bowel impairment has been attributed to diarrhea not caused by the lumbosacral strain.  See, e.g., the July 2016 VA examination report.
The Veteran is assigned 10 percent disability ratings for peripheral neuropathy of the right and left lower extremities associated with his service-connected lumbosacral strain.
Associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a , Diagnostic Code 5239, General Rating Formula for Diseases and Injuries of the Spine, Note 1 (2016).
Neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain which at times can be excruciating and is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis.  The maximum rating which may be assigned for neuritis not characterized by the organic changes referred to above is that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis.  38 C.F.R.
Neuralgia is characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. Â§ 4.124  (2016).
The Veteran is in receipt of separate ratings for peripheral neuropathy of the right and left lower extremities which are rated 10 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8521 (paralysis of the external popliteal nerve).  Mild incomplete paralysis warrants a 10 percent rating.  Moderate incomplete paralysis warrants a 20 percent rating.  Severe incomplete paralysis warrants a 30 percent rating.  Complete popliteal nerve paralysis warrants the assignment of a 40 percent rating and contemplates foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes.  38 C.F.R. § 4.124a , Diagnostic Code 8521 (2016).
The Board has also considered rating the Veteran's radiculopathy under Diagnostic Code 8521.  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.  See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a).
The Veteran was provided a VA examination in August 2004.  He reported a history of pain along the back of his right leg with some numbness, however there was no weakness or numbness in his feet.  Upon examination, the VA examiner reported physiological reflexes at both lower extremities as well as normal sensation and excellent motor strength.  Straight leg raising was 75 degrees bilateral with pain in the lower back and on dorsiflexing his toes, he had increased pain in the lower back and posterior thighs.
The Veteran was afforded another VA examination in December 2013.  He reported radiating pain into his left leg from his lower back with any movement. Reflex testing revealed 3+ for the right knee and 4+ for the left knee as well as 3+ for the right ankle and 4+ for the left ankle.  Sensory testing was normal, although straight leg testing was positive.  While the examiner noted that the Veteran had radiculopathy and he indicated moderate constant pain and severe intermittent pain of the left lower extremity, he reported no constant or intermittent pain of the right lower extremity as well as no paresthesias and/or dysthesias or numbness of either the right or left lower extremity.  He indicated moderate impairment of the right lower extremity and severe impairment of the left lower extremity.  There were no other signs of radiculopathy or neurologic abnormalities.
The Veteran was provided a VA examination in January 2015.  Deep tendon reflex was 1+ at the knees and ankles.  Sensory and straight leg testing were normal.  The examiner documented sharp radicular pain which was on an intermittent basis as well as right lower extremity weakness.  He specifically noted the severity of the neurological symptoms to be mild.
The Veteran was afforded another VA examination in July 2016.  He reported tingling to his left lower extremity on a constant basis as well as intermittent numbness of both feet and shooting pain to the left lower extremity intermittently.  Upon examination, the VA examiner documented normal reflex testing and decreased sensory testing.  Straight leg testing was negative and the Veteran had intact motor strength.  The examiner further noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy or any other neurological abnormalities.
Based on the evidence of record, the Board finds that disability ratings in excess of 10 percent are not warranted for the Veteran's right and left lower extremity peripheral neuropathy at any time during the appeal period.  In this regard, the Board acknowledges the Veteran's complaints of numbness, pain, and tingling in his lower extremities.  Also, the August 2004 VA examiner reported pain on examination, and the December 2013 VA examination revealed impaired reflex testing in the knees and ankles as well as positive straight leg testing and pain on examination.  Further, the January 2015 VA examination revealed deep tendon reflex of 1+ at the knees and ankles and intermittent pain, and the July 2016 VA examiner noted decreased sensory testing.  However, the Board finds that the probative evidence does not demonstrate at least moderate impairment of the right or left lower extremity.  Notably, as discussed above, the August 2004 VA examiner reported physiological reflexes at both lower extremities as well as normal sensation and excellent motor strength.  Additionally, the December 2013 VA examination indicated normal sensory testing and while the Veteran had moderate constant pain and severe intermittent pain of the left lower extremity, the examiner reported no constant or intermittent pain of the right lower extremity as well as no paresthesias and/or dysthesias or numbness of either the right or left lower extremity.  The Board also notes that the January 2015 VA examination documented normal sensory and straight leg testing, and the examiner specifically noted the Veteran's neurological symptoms to be mild.  Finally, the July 2016 VA examination documented normal reflex testing, negative straight leg testing, intact motor strength, and no signs of radicular pain or other neurological abnormalities.  Thus, while the Board acknowledges that the lay and medical evidence indicates neurological impairment in the right and left lower extremities, the evidence as a whole shows that the overall level of functional impairment resulting therefrom is no more than mild in the right and left lower extremities.
Accordingly, the Board finds that disability ratings in excess of 10 percent are not warranted for the Veteran's peripheral neuropathy of the right or left lower extremity under Diagnostic Code 8521 at any time during the appeal period.  The claims of entitlement to disability ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities are therefore denied.
Neither the Veteran nor his representative has raised any issue pertaining to extraschedular consideration, nor have any other issues pertaining to extraschedular consideration been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. Ap. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).
Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more.  See 38 C.F.R. §§ 3.340, 3.341, 4.16(a).  In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment.  38 C.F.R. § 4.16(b).
In this case, the Veteran does not meet the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a TDIU, as service connection is in effect for lumbosacral strain (rated as 20 percent disabling), status post hemorrhoid surgery (rated as 20 percent disabling), peripheral neuropathy of the right lower extremity (rated as 10 percent disabling), peripheral neuropathy of the left lower extremity (rated as 10 percent disabling), and tinnitus (rated as 10 percent disabling); his combined rating is 50 percent.
However, a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases (and pursuant to specifically prescribed procedures), when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities (per 38 C.F.R. §§ 3.321 (b) and 4.16(b)).  Hence, consideration of whether the Veteran is, in fact, unable to obtain and follow substantially gainful occupation, is still necessary in this case.
It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled.  Therefore, in the case of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet these schedular percentage standards, the case should be submitted to the Director, Compensation and Pension Service, for extra-schedular consideration. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed.  See 38 C.F.R. § 4.16(b).
The central inquiry is "whether a veteran's service- connected disabilities alone are of sufficient severity to produce unemployability."  See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).  Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities.  See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993).
The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough.  A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment.  The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment.  Van Hoose, 4 Vet. App. at 363.
Initially, the Board recognizes that the Veteran, who is 77 years old, has not been employed at any time pertinent to this appeal.  However, as indicated above, unemployed does not mean unemployable.
On his August 2014 application for TDIU, the Veteran reported working as a truck driver from 1964 to 1980.  He also reported that he had completed two years of high school.  He contends that he was not able to continue working due to back, hemorrhoid, and tinnitus problems.
With regard to the Veteran's tinnitus, on February 2004 VA audiological evaluation, the Veteran reported that the tinnitus was bilateral and constant, and had been getting progressively louder over the years.  Another VA audiological examination dated December 2014 notes the Veteran's report that his tinnitus frequently bothers him.
As to the Veteran's hemorrhoids, a VA examiner noted in a September 2007 report that the Veteran's hemorrhoids required continuous treatment and medical attention and may, in part, have been responsible for his perceived inability to continue working as an auto transport truck driver due to difficulty with prolonged sitting.  However, the Veteran reported during a December 2014 VA examination that the hemorrhoids did not impact his ability to work, and the examiner noted that the Veteran's hemorrhoids would not preclude him from securing and maintaining substantially gainful employment as the Veteran would be able to lift objects and ambulate for an eight hour workday.  Further, another VA examiner opined in a July 2016 examination that sedentary employment was feasible with adequate seat padding and periodic changes in position.
The Veteran has been afforded multiple VA examinations for his lumbosacral strain and peripheral neuropathy of the right and left lower extremities.  During an August 2004 VA examination, he complained of constant lower back pain which became worse with bending, lifting, and extensive walking.  He used a scooter but not a cane.  Upon examination, the VA examiner noted that the Veteran was able to walk without support and had a normal gait.  Range of motion testing revealed forward flexion to 60 degrees, extension to 20 degrees, right and left flexion to 30 degrees, and right and left rotation to 50 degrees.  The Veteran had pain in the lumbosacral area at the extreme ranges of motion.
On VA examination in December 2013, the Veteran reported a sticking pain upon any movement with a constant dull aching pain.  He used a brace occasionally and a cane regularly for assistance.  He was unable to lift over 20 pounds and had limited bending.  Range of motion testing revealed forward flexion to 70 degrees with pain at 40 degrees, extension to 30 degrees or greater with pain at 30 degrees or greater, right and left lateral flexion to 30 degrees or greater, and right and left lateral rotation to 30 degrees or greater.  The Veteran was not able to perform repetitive-use testing with 3 repetitions as he had a sudden sticking pain in the lower back upon attempting the second range of motion flexion.  The examiner documented functional loss manifested by less movement than normal, weakened movement, pain on movement, and interference with sitting, standing, and/or weight bearing.  He did not report ankylosis.
On VA examination in January 2015, the Veteran reported flare-ups and functional loss which resulted in difficulty with bending and lifting.  Range of motion testing revealed forward flexion to 60 degrees, extension to 5 degrees, right and left lateral flexion to 20 degrees, and right and left rotation to 20 degrees.  The examiner indicated that range of motion was abnormal and contributed to functional loss in that the Veteran had limited flexion and extension.  However, the pain was at the end range for all ranges tested.  There was no evidence of pain with weight bearing or areas of palpable tenderness.  The Veteran was able to perform 3 repetitions with no additional loss of function or range of motion after 3 repetitions.  The examiner was unable to state without resort to speculation whether pain, weakness, fatigue, or incoordination could significantly limit functional ability with repeated use over a period of time as the examiner only saw the Veteran for 3 repetitions.  The examiner further noted that the examination did not support or contradict the Veteran's statements describing functional loss during flare-ups and he could not state without speculating whether pain, weakness, fatigue, or incoordination could significantly limit functional ability with a flare as the Veteran did not have a flare-up at that time.  There were no findings of ankylosis or bowel or bladder impairment.  The examiner reported that the Veteran's level of severity was mild.
The Veteran continued to report constant back pain on VA examination in July 2016.  He did not report flare-ups but had functional loss consisting of bothersome prolonged walking, bending, lifting, and prolonged sitting.  He used a cane regularly for assistance.  Range of motion testing revealed forward flexion to 65 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion to 30 degrees, and right and left lateral rotation to 20 degrees.  The examiner noted guarding and near falls with flexion as well as difficulty bending.  There was no evidence of pain with weight-bearing.  Repetitive use testing revealed additional limitation of motion, in particular forward flexion to 50 degrees.  There were no findings of ankylosis.
Also, December 2016 private treatment reports from J.N., D.C. and R.K., D.O. indicated that the Veteran is unable to work due to his low back symptoms.
With respect to the Veteran's peripheral neuropathy of the right and left lower extremities, he reported on VA examination in August 2004 that he had a history of pain along the back of his right leg with some numbness, however there was no weakness or numbness in his feet.  Upon examination, the VA examiner reported physiological reflexes at both lower extremities as well as normal sensation and excellent motor strength.  Straight leg raising was 75 degrees bilateral with pain in the lower back and on dorsiflexing his toes, he had increased pain in the lower back and posterior thighs.
On VA examination in December 2013, the Veteran reported radiating pain into his left leg from his lower back with any movement.  Reflex testing revealed 3+ for the right knee and 4+ for the left knee as well as 3+ for the right ankle and 4+ for the left ankle.  Sensory testing was normal, although straight leg testing was positive.  While the examiner noted that the Veteran had radiculopathy and he indicated moderate constant pain and severe intermittent pain of the left lower extremity, he reported no constant or intermittent pain of the right lower extremity as well as no paresthesias and/or dysthesias or numbness of either the right or left lower extremity.  He indicated moderate impairment of the right lower extremity and severe impairment of the left lower extremity.  There were no other signs of radiculopathy or neurologic abnormalities.
A VA examination report dated January 2015 documented deep tendon reflex of 1+ at the knees and ankles.  Sensory and straight leg testing were normal.  The examiner documented sharp radicular pain which was on an intermittent basis as well as right lower extremity weakness.  He specifically noted the severity of the neurological symptoms to be mild.
On VA examination in July 2016, the Veteran reported tingling to his left lower extremity on a constant basis as well as intermittent numbness of both feet and shooting pain to the left lower extremity intermittently.  Upon examination, the VA examiner documented normal reflex testing and decreased sensory testing.  Straight leg testing was negative and the Veteran had intact motor strength.  The examiner further noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy or any other neurological abnormalities.
Based on the evidence of record, the Board finds that the Veteran's service-connected lumbosacral strain, peripheral neuropathy of the right and left lower extremities, hemorrhoids, and tinnitus do not render him unable to obtain or sustain substantially gainful employment such that referral for extraschedular evaluation is warranted.  Overall, the evidence indicates that the Veteran's lumbosacral strain and peripheral neuropathy of the right and left lower extremities as well as his hemorrhoids might preclude him working as long haul truck driver.  However, the evidence does not indicate that the Veteran's lumbosacral strain, peripheral neuropathy, and hemorrhoids in conjunction with his service connected tinnitus would preclude him from other forms of substantially gainful employment, which do not involve such prolonged sitting or frequent bending.  Indeed, as discussed above, the VA examination reports indicate that the Veteran's hemorrhoids do not preclude him from obtaining substantial gainful employment as sedentary employment would be feasible with adequate seat padding and periodic changes in position.  Further, while his lumbosacral strain results in functional loss consisting of bothersome prolonged walking, bending, lifting, and prolonged sitting, he has maintained range of motion and unaltered gait.  The Board also reiterates the January 2015 VA examiner's finding following examination of the Veteran that the lumbosacral strain symptomatology is of mild severity.  While Dr. R.K. and J.N., D.C. noted that the Veteran is unable to work due to his back problems, neither provided a rationale as to why the Veteran is unable to work due to these problems to include why he could not perform at least sedentary employment.  Moreover, the VA examination reports discussed above indicate that his peripheral neuropathy results in no more than mild impairment.
The Board is also cognizant that the Veteran's education was apparently limited to two years of high school.  However, even with this limited educational background, the evidence simply does not show that the Veteran would be unable to work in any form of substantial gainful employment as a result of his service connected disabilities.  Indeed, there is no indication in the examination report or other evidence of record that there are any restrictions on the Veteran's ability to accomplish tasks from a sedentary position as a result of the service-connected lumbosacral strain, peripheral neuropathy of the right and left lower extremities, hemorrhoids, and tinnitus that would preclude substantially gainful occupation.
In this case, the objective evidence simply does not demonstrate that the Veteran is unable to obtain or retain substantially gainful employment solely because of his service-connected disabilities.  The Board concludes that the objective evidence outweighs the Veteran's lay assertions regarding unemployability.  As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim is denied.  See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).
Entitlement to a disability rating in excess of 20 percent for residuals of status-post hemorrhoid surgery is denied.
Entitlement to a disability rating in excess of 20 percent for lumbosacral strain is denied.
Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied.
Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied.

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