Citation Nr: 1616851 Decision Date: 04/27/16 Archive Date: 05/04/16 DOCKET NO. 10-08 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected disability. 3. Entitlement to a rating in excess of 20 percent for post-operative residuals of right shoulder injury. 4. Entitlement to a rating in excess of 10 percent for plantar wart, distal fourth metatarsal of the left foot. REPRESENTATION The Veteran is represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Sean G. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from July 1974 to March 1979, from September 1980 to March 1983, and from March 1984 to January 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2008 and July 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. These claims were before the Board in July 2015, at which time they were remanded for additional development. After the Agency of Original Jurisdiction (AOJ), issued two October 2015 supplemental statements of the case, the appeal was remitted to the Board for further appellate review. In July 2015, the Board also remanded the issue of entitlement to service connection for a cervical spine disability. While this claim was in remand status, service connection was granted for cervical strain with degenerative arthritis, as well as right upper extremity radiculopathy. As this constitutes a full grant of the benefits sought on appeal, further appellate consideration is not required. In a February 2016 brief, the Veteran's representative asked that the Board ascertain whether the proper diagnostic code was utilized in assigning the rating to the Veteran's service-connected right upper extremity radiculopathy. It is unclear whether the Veteran, through his representative, is disagreeing with the initial 20 percent rating assigned thereto. The RO/AOJ should contact the Veteran and/or his representative in order to obtain clarification. The issues of entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected disability, and entitlement to a rating in excess of 10 percent for plantar wart, distal fourth metatarsal of the left foot, will be addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's hepatitis C is etiologically related to in-service risk factors. 2. The Veteran's post-operative residuals of a right shoulder injury are pain, including flare-ups of pain; reduced range of motion; tenderness; aching; muscle weakness; stiffness; fatigability; crepitus; and impaired functionality of overhead activities. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C have been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 2. The criteria for a rating in excess of 20 percent for post-operative residuals of a right shoulder injury have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5201 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). With respect to the Veteran's claim of entitlement to service connection hepatitis C, the Board is granting the benefit sought on appeal herein. Consequently, any failure to satisfy the duty to notify and/or assist is moot. Prior to the initial adjudication of the Veteran's claim of entitlement to a rating in excess of 20 percent for post-operative residuals of a right shoulder injury, the RO's November 2007 letter to the Veteran satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Moreover, the November 2007 letter notified the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability and the different types of evidence available to substantiate his claim for a higher rating. Further, this letter also provided the Veteran with notice of the need to submit evidence of how the worsening of his claimed disability affected his employment. The purpose behind the notice requirement has been satisfied because the Veteran has been afforded ample and meaningful opportunities to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. As such, the Board finds that the content requirements of the notice VA is to provide have been met and no further development is required regarding the duty to notify. See Pelegrini, 18 Vet. App. at 120. The duty to assist was also met in this case. VA obtained the Veteran's service treatment and personnel records; assisted the Veteran in obtaining evidence; afforded the Veteran physical examinations; obtained medical opinions as to the severity of his service-connected disability; and afforded the Veteran the opportunity to give testimony. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's electronic claims file, and the Veteran has not contended otherwise. Moreover, the record shows that the Veteran was represented by a Veteran's Service Organization throughout the adjudication of the claim. Overton v. Nicholson, 20 Vet. App. 427 (2006). The Board finds that the AOJ substantially complied with the Board's July 2015 remand instructions. The AOJ obtained and associated with the electronic claims file the Veteran's VA treatment records dated from July 2014 and provided the Veteran a VA examination for the purpose of determining the nature and extent of the service-connected disability. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, a remand for corrective actions is not warranted. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the Veteran's increased rating claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Service Connection for Hepatitis C Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For service connection to be granted for hepatitis C, the evidence must show that the Veteran's hepatitis C infection, risk factor(s), or symptoms were incurred in or aggravated by service. The evidence must further show by competent medical evidence that there is a relationship between the claimed in-service injury and the Veteran's current hepatitis C. Risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. See VBA letter 211B (98-110) November 30, 1998. The evidence of record clearly demonstrates a current diagnosis of hepatitis C. As such, this aspect of service connection has been established. In October 2015, the Veteran underwent a VA examination in order to ascertain whether his hepatitis C was incurred in or due to his active duty. During the examination, the Veteran stated that his risk factors for hepatitis C are intranasal cocaine use in 1986; self-piercing of ear in 1981; 4 sexual partners in the 1970's; and a history of sexually transmitted disease and alcohol abuse in the 1970's and 1980's. The Veteran stated that all of these risk factors occurred during a period of active duty. The Veteran denies any history of intravenous drug abuse and a history of receiving a blood transfusion. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). After reviewing the relevant evidence of record and administering a clinical examination, the examiner rendered the following opinion: This Veteran is claiming service connection for Hepatitis C that is at least as likely as not incurred in or caused by or during service. He was in the military from 1974-1993. He was diagnosed with Hepatitis C in 1999. His risk factors for Hepatitis C included intranasal cocaine use in 1986, self piercing of ear in 1981, 4 sexual partners in the 1970's; [and] history of [sexually transmitted disease] and alcohol abuse in the 1970's and 1980's. All of these risk factors occurred in the service. His hepatitis C is at least as likely as not is the result of one of these in-service risk factors. In this, and in other cases, the Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The only competent and probative etiological opinion of record was that of the October 2015 VA examiner, which, as discussed above, is positive to the Veteran's claim. There is no evidence of record that disassociates the Veteran's hepatitis C from his active duty and, thus, the Board finds that the evidence of record is at least in equipoise. Accordingly, with applicable of the benefit of doubt, service connection for hepatitis C is warranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Right Shoulder Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating 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 military 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.A. § 1155; 38 C.F.R. § 4.1. In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; see Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. See Powell v. West, 13 Vet. App. 31, 34 (1999). Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21. Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Preliminarily, the Board observes that service connection has been granted for the Veteran's cervical strain with degenerative arthritis, as well as right upper extremity radiculopathy. To the extent that these disabilities and the associated symptoms have been distinguished from the disability picture associated with the Veteran's post-operative residuals of a right shoulder injury, they will not be considered herein. To the extent that these disabilities have not been distinguished, the Board will consider the associated symptoms herein. 38 C.F.R. § 4.14 (2015); see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Throughout the pendency of this appeal, the Veteran's service-connected post-operative residuals of right shoulder injury have been assigned a 20 percent rating under Diagnostic Code 5010, which concerns arthritis, and Diagnostic Code 5201, which concerns limitation of arm motion, hyphenated as 5010-5201. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5201. In the selection of diagnostic codes assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2015). Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. 38 C.F.R. § 4.27; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Degenerative arthritis (established by X-ray findings) is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. Limitation of arm motion under Diagnostic Code 5201, distinguishes between the major (dominant) extremity and minor (non-dominant) extremity. The evidence demonstrates that the Veteran's right shoulder is his minor (non-dominant) side. Under Diagnostic Code 5201, a 20 percent disability rating is contemplated for limitation of motion of the minor arm at shoulder level or for limitation of the minor arm to midway between side and shoulder level. A maximum 30 percent disability rating is warranted for limitation of the minor arm to 25 degrees from the side. For VA purposes, normal range of forward elevation (flexion) is zero degrees to 180 degrees; shoulder abduction is zero degrees to 180 degrees, internal rotation is zero degrees to 90 degrees; and external rotation is zero degrees to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2015). In December 2007, the Veteran underwent a VA examination to assess the severity of his service-connected post-operative residuals of a right shoulder injury. Range of motion testing showed right shoulder forward flexion from zero degrees to between 90 and 115 degrees; right shoulder abduction from zero degrees to 120 degrees; right shoulder external rotation from zero degrees to 45 degrees; and right shoulder internal rotation from zero degrees to 75 degrees. According to a January 2009 VA orthopedic record, the Veteran was able to forward flex to approximately 130 degrees and could abduct to approximately 120 degrees. In April 2013, the Veteran underwent a VA examination to assess the severity of his right shoulder disability. Range of motion testing demonstrated that forward flexion was from zero degrees to 110 degrees and abduction was from zero degrees to 90 degrees. A March 2015 VA community-based outpatient clinic physical therapy consultation report shows that the Veteran was able to achieve 165 degrees of right shoulder flexion, as well as 150 degrees right shoulder abduction. In October 2015, the Veteran underwent a VA examination to assess the severity of his service-connected right shoulder disability. Range of motion testing showed right shoulder flexion from zero to 140 degrees; abduction from zero to 105 degrees; external rotation from zero to 55 degrees; and internal rotation zero to 60 degrees. The evidence of record does not demonstrate that the Veteran's service-connected post-operative residuals of a right shoulder injury included limitation of minor arm movement to 25 degrees or less from his side. The most severe limitation shown by the evidence was abduction to 90 degrees. Consequently, the Board finds that a maximum 30 percent rating is not warranted under Diagnostic Code 5201. However, when evaluating disabilities of the musculoskeletal system, an evaluation of the extent of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204 -06 (1995). In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. VA treatment records dated throughout the pendency of this appeal showed that the Veteran complained of ongoing pain. These records also demonstrate that the Veteran participated in physical therapy. During the December 2007 VA examination, the Veteran endorsed right shoulder ache at rest and pain of no less than 6, but up to 10, on a 10-point pain scale. With overhead movement, the Veteran stated that the pain became sharp. The Veteran also reported weakness, stiffness, and fatigability. The Veteran said he was able to perform routine daily activities, but with pain. He complained of sleep disruption if he rolled onto his right arm. Range of motion testing showed that pain began at 90 degrees during right shoulder forward flexion and right shoulder abduction. It appears that the Veteran experienced pain throughout right shoulder external and internal rotation, but that neither movement was limited by pain. After "flexing and extending," and testing for weakness, pain, incoordination, and fatigability, the examiner determined that there was no additional limitation of motion, only pain. The Veteran stated that he experienced pain and tenderness upon palpation, as well as flare-ups consisting of increased pain associated with increased activity and cold or moist weather. Upon physical examination, deltoid strength was determined to be 4/5. An April 2008 VA orthopedic record demonstrated ongoing complaints of pain, as well as crepitus, which was limiting his daily activities. Upon physical examination, the examiner observed that the Veteran's right shoulder was "unchanged" since his most recent examination. The Veteran endorsed pain with forward flexion, abduction, internal rotation, and external rotation, but no measurements, in terms of degrees, were reported. However, the examiner described the Veteran's motion as "fairly limited." The examiner also observed tenderness to palpation and a positive grind test. According to the January 2009 VA orthopedic note showed that the Veteran exhibited muscle strength of 4+/5 with respect to both internal and external rotation, 5/5 with respect to his deltoids, biceps, triceps, wrist flexors, wrist extensors, and grip. The Veteran endorsed tenderness to palpation. During the April 2013 VA examination, the Veteran endorsed chronic pain that was worse with overhead lifting, pushing, and pulling movements, which the examiner deemed to be limitations on the Veteran's ability to work. During range of motion testing, painful motion began at 90 degrees during right shoulder flexion and pain began at 60 degrees during right shoulder abduction. After repeat range of motion testing, these ranges did not change. The examiner determined that the Veteran experienced functional loss, functional impairment, and/or additional limitation of motion after repetitive use due to "less movement than normal" and "pain on movement." The examiner also determined that the Veteran's right shoulder was tender to palpation, but that there was no guarding. Muscle testing resulted in scores of 4/5 for right shoulder abduction and right shoulder flexion. Additional testing revealed the presence of "clicking" or "catching." In March 2015, the Veteran testified at a Board hearing before the undersigned. In relevant part, the Veteran testified that he experienced pain. If he held anything in his hand, the Veteran stated that he could raise his arm to the side about 20 degrees before experiencing pain and could raise it forward to between 30 and 35 degrees before experiencing pain. The Veteran also stated that, although he is left-hand dominant, he had been using his right hand as his dominant hand due to medical issues that limited the use of his left hand. As discussed above, the Veteran reported right shoulder aching, stiffness, and fatigability, and that he was unable to perform daily activities without pain, especially overhead activities. This functional limitation applied to the Veteran's ability to perform overhead occupational tasks. The clinical evidence of record also demonstrated decreased right shoulder muscle strength and ongoing pain. Additionally, the evidence demonstrated that the Veteran's right shoulder range of motion was additionally limited by pain. Mitchell v. Shinseki, 25 Vet. App. 32, 37-44 (2011) (holding that pain itself is not functional loss, but can cause functional loss to the extent that it affects the normal working movements of the body such as excursion, strength, speed, coordination, or endurance). With this said, however, there was no evidence showing that these symptoms, or that flare-ups or repetitive use resulted in additional limitation of mot ion or functional impairment that met the criteria for a higher rating. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.16, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5201 (2015). Specifically, even with consideration of the Veteran's symptoms, additional range of motion limitation, and functional limitations, the Board finds that the disability picture does not more nearly approximate the criteria for a higher rating under the applicable the diagnostic code. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5201. In order for the maximum 30 percent rating to assigned, the evidence must demonstrate that the Veteran's right shoulder disability is manifested by, or more nearly approximate, a limitation of motion to 25 degrees or fewer from his side (i.e. abduction). The evidence demonstrated that the most severe limitation of right shoulder abduction was to 60 degrees. Accordingly, an evaluation in excess 20 percent for the Veteran's service-connected post-operative residuals of a right shoulder injury is not warranted based on functional loss. In making this determination, the Board observes that the Veteran testified during the March 2015 hearing that he was unable to raise his right arm away from his side more than 20 degrees without experiencing pain. Lay testimony is competent to establish the presence of observable symptomatology. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). Further, lay evidence is competent and sufficient in certain instances related to medical matters. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent measurements, in terms of degrees, with respect to anatomical ranges of motion. This is especially true given that there is no evidence that the Veteran utilized a goniometer to ascertain that measurement or that he possess the ability, knowledge or experience to use such a device. As such, the Board finds the Veteran's assertion as to his right shoulder range of motion is outweighed by ranges of right motion reported by medical professionals. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015); see Yancy v. McDonald, No. 14-3390 (February 26, 2016). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by a disability. As such, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (finding that "[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Throughout the pendency of this appeal, the Veteran's post-operative residuals of a right shoulder injury have been evaluated as a musculoskeletal disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5201, which concern arthritis and limitation of arm motion. The Board finds that the Veteran's disability picture regarding his post-operative residuals of a right shoulder injury is not so unusual or exceptional in nature as to render the schedular rating inadequate. The evidence demonstrated that the Veteran's post-operative residuals of a right shoulder injury pain, reduced range of motion, tenderness, aching, muscle weakness, stiffness, fatigability, and crepitus. Moreover, the Veteran experienced flare-ups of pain, as well as impaired functionality of overhead activities. The Veteran did not assert, and the evidence of record was not otherwise supportive of finding that this disability was manifested by unusual or extraordinary symptoms that fall outside the scope of the applicable rating criteria. The Board acknowledges that certain symptoms, for example pain, are associated with the Veteran's post-operative residuals of a right shoulder injury may not be specifically addressed in the applicable rating criteria. However, when comparing the disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's disability picture is adequately contemplated by already assigned schedular rating. Accordingly, the schedular evaluation is adequate and no referral is required. See 38 C.F.R. § 4.71a, Diagnostic Codes, 5010, 5201; see also VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Thus, the threshold determination for a referral for extraschedular consideration is not met and, consequently, the Board finds that referral of the claim for an extraschedular rating is not warranted. Thun, 22 Vet. App. at 115. Additionally, the Board notes that the Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. See Johnson v. Shinseki, 26 Vet. App. 237, 246 (2013) (en banc). However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected or a non-service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim of entitlement to a rating in excess 20 percent, the doctrine is not for application. Gilbert, 1 Vet. App. at 53. ORDER Service connection for hepatitis C is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating in excess of 20 percent for post-operative residuals of a right shoulder injury is denied. REMAND Lumbar Spine In July 2015, the Board remanded the Veteran's claim of entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected disability. Specifically, the Veteran asserted that a current lumbar spine disability was caused or aggravated by his service-connected post-operative residuals of a right shoulder injury. In October 2015, the Veteran underwent a VA examination. The examiner rendered a diagnosis of degenerative arthritis and, ultimately, rendered the following etiological opinion: This Veteran is claiming service connection for a thoracolumbar spine condition that is at least as likely as not incurred in or caused by or during service. He did not have any back injuries or conditions or diagnoses while on active duty. He was not found to have LS spine arthritis until 13 years after service. Therefore, it is less likely than not that this veteran has any thoracolumbar back conditions that are related to his military service. It is also less likely than not that this [V]eteran has any thoracolumbar back conditions that were caused or aggravated by the Veteran's service-connected residuals of right shoulder injury because his service connected right shoulder conditions would not lead to the development of spinal arthritis. However, as discussed in the July 2015 remand, the Veteran testified that he began to experience back pain within two or three years after he injured his right shoulder and that all of his pain was located on his right side. The October 2015 VA examiner did not discuss or consider the Veteran's assertions. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury, but relied on the service treatment records to provide a negative opinion). Additionally, the Board finds that the examiner's opinion regarding service connection on a secondary basis is conclusory. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that the articulated reasoning enables the Board to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion). For these reasons, the Board finds that the October 2015 VA examination is inadequate and, thus, a remand is required in order to obtain a supplemental opinion. Plantar Wart Throughout the pendency of this appeal, the Veteran's service-connected plantar wart, distal fourth metatarsal of the left foot, has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5284, which concerns "foot injuries, other." See Yancy v. McDonald, No. 14-3390 (February 26, 2016) (holding that Diagnostic Code 5284 applies only to actual foot injuries and, for disabilities not specifically listed in the Rating Schedule, can only be applied to non-foot injuries by analogy). Throughout the pendency of this appeal, the Veteran's plantar wart, distal fourth metatarsal of the left foot, has also been evaluated 38 C.F.R. § 4.118, Diagnostic Code 7819, concerning benign skin neoplasm, which directs the rater to evaluate the disability at issue under either a relevant scar diagnostic code (Diagnostic Code 7801, 7802, 7804, and/or 7805), or based on impairment of function. During the March 2015 Board hearing, the Veteran testified that his plantar wart, distal fourth metatarsal of the left foot, was painful and that he required the use of a shoe insert. The Veteran also testified that he altered the way he walked due to the plantar wart. In July 2015, the Board remanded the Veteran's claim in order to ascertain the present severity of his service-connected plantar wart. In October 2015, the Veteran underwent a VA examination. The examiner did not address the issues of whether the Veteran's plantar wart resulted in functional impairment, beyond the question of whether it impaired his ability to work. To that question, the examiner limited the response to "no," without an underlying rationale. Although the examiner referenced the Veteran's use of a shoe insert, the examiner did not consider the Veteran's assertion that he altered the way he walked due to his plantar wart. Indeed, the examination report is completely devoid of any reference to or assessment of the severity of the pain associated with the Veteran's plantar wart. As such, the Board finds that the October 2015 VA examination is inadequate for the purpose of adjudicating the Veteran's claim and, thus, a remand is required in order to provide the Veteran with another examination. See Littke v. Derwinski, 1 Vet. App. 90, 93 (1990) (noting that remand may be required if record before the Board contains insufficient medical information for evaluation purposes). Accordingly, the case is REMANDED for the following action: 1. The AOJ must forward the Veteran's electronic claims file to the October 2015 VA examiner or an appropriate substitute, in order to obtain a supplemental opinion. After reviewing all of the relevant evidence of record, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any found lumbar spine disability was: (a) incurred in or due to his active duty, to include consideration of the right shoulder injury and the Veteran's assertions as to the onset and course of his lay-observable lumbar spine symptoms; AND/OR (b) caused or aggravated by any service-connected disability, with an emphasis on, but not limited to, the Veteran's post-operative residuals of a right shoulder injury. A complete rationale for all opinions must be provided. 2. The AOJ must schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected plantar wart, distal fourth metatarsal of the left foot. The electronic claims file and a copy of this remand must be made available to and contemporaneously reviewed by the examiner. Any medically indicated tests must be accomplished and all pertinent symptomatology and findings must be reported in detail. The examiner must address the severity of the Veteran's symptoms, including pain, and ascertain whether the Veteran's plantar wart is manifested by any limitation of function, including the Veteran's assertion that he has altered the way he walks. A complete rationale must be provided for any opinion or conclusion expressed. 3. The AOJ must notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the associated claim. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. Once the above actions have been completed, the AOJ must re-adjudicate the Veteran's claim on appeal, taking into consideration all of the relevant evidence. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs