Citation Nr: 0813061 Decision Date: 04/21/08 Archive Date: 05/01/08 DOCKET NO. 05-15 942 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for residuals of an injury to the right little finger. 2. Entitlement to service connection for a chronic right knee disability. 3. Entitlement to service connection for a chronic skin disorder, claimed as due to exposure to herbicides. 4. Entitlement to service connection for hypertension, claimed as due to exposure to herbicides. 5. Entitlement to service connection for left ear hearing loss and tinnitus. 6. Entitlement to an initial disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD). 7. Entitlement to an initial disability rating in excess of 20 percent for bursitis of the left shoulder, with degenerative changes. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had active service from March 1967 to March 1969. His medals and badges include the Air Medal and the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the VARO in Waco, Texas. A review of the evidence of record reveals that in addition to PTSD and bursitis of the left shoulder, service connection is in effect for diabetes mellitus, rated as 10 percent disabling, and for hearing loss of the right ear, rated as noncompensably disabling. A combined disability rating of 50 percent has been in effect since April 24, 2006. FINDINGS OF FACT 1. The veteran's current residuals of a right little finger injury are attributable to his combat service. 2. Any current right knee disability is not shown to be related to the veteran's active service. 3. The competent medical evidence of record indicates that the veteran's currently diagnosed hypertension is not related to his military service, to include his exposure to herbicides in Vietnam. 4. The competent medical evidence of record indicates that the veteran's currently diagnosed skin disorder is not related to his active service, to include his exposure to herbicides in Vietnam. 5. The competent medical evidence of record reflects that the veteran's current left ear hearing loss with tinnitus is not related to his active service. 6. Manifestations of the veteran's PTSD include depression, flashbacks, emotional distress, avoidance, diminished social interest, and persistent arousal symptoms. The veteran takes psychotropic medication and is being followed on a regular basis for therapy purposes. 7. Spatial disorientation, neglect of personal appearance and hygiene, suicidal ideation, and other symptoms commonly associated with severe impairment have not been shown. 8. The veteran is right-handed. 9. The veteran failed to report for a VA examination of his left shoulder disability. 10. Available medical records pertaining to the left shoulder do not show limitation of motion to 25 degrees from the side, any indication of ankylosis, or fibrous union of the humerus. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a right little finger injury are reasonably met. 38 U.S.C.A. §§ 1110, 5103, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 2. The veteran does not have a chronic right knee disability that was incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2007). 3. The veteran does not have a chronic skin disorder that was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2007). 4. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 5. The criteria for service connection for left ear hearing loss and tinnitus are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 6. The criteria for a disability rating of 50 percent, but not more, for PTSD are reasonably met throughout the entire appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2007). 7. The criteria for a disability rating in excess of 20 percent for bursitis of the left shoulder are not met throughout the entire appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.71a, Codes 5109-5003, 5200, 5201, 5202, (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the provisions of the VCAA. The VCAA includes an enhanced duty on the part of VA to notify a claimant of the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA was to inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim in accordance with the provisions of 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision in the claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that VCAA letters sent to the veteran in April 2004, March 2006, and June 2006 essentially complied with the statutory notice requirements as outlined above. Those letters informed him that it was his responsibility to make sure VA received all requested records that were not in the possession of a Federal department or agency. He was given information with regard to examinations of veterans who had been exposed to herbicides while in Vietnam. He was also told what the evidence had to show to establish service connection. The Board acknowledges that notice of the disability rating and effective date elements was not provided until March 2006, after the initial adverse decision. However, the Board finds this error to be essentially not prejudicial. With regard to the allowance of the claim for service connection for residuals of a right little finger injury, the RO will assign an effective date and a disability rating for the disorder. With regard to the other issues for service connection being sought, with the claims being denied, the questions involved in the assignment of a disability rating and effective date are rendered moot. With regard to an increased rating for PTSD, in view of the favorable outcome of the appeal with regard to that issue, compliance with the VCAA need not be discussed. With regard to the claim for an increased rating for the left shoulder disability, § 5103(a) requires, at a minimum, that the Secretary of VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on nature of the symptoms of the condition for which disability compensation is being sought, the severity and duration, and their impact upon employment and daily life. However, the Board notes that in Sanders v. Nicholson, 487 Fed. 3d 881(Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once a defect is identified as to any of the notice elements, the burden shifts to VA to demonstrate that the RO was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent for the purposes of the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant (see Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his claim); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 Fed. 3d at 889. In this case the Board finds that the notice error did not affect the essential fairness of the adjudication with regard to the left shoulder disability because the veteran has had representation throughout the course of the appeal and it is expected that his representative, the Texas Veterans Commission, would keep him advised as to the criteria necessary for entitlement to higher disability ratings and of the various steps in the appeals process. The veteran was accorded a comprehensive joints examination by VA in July 2005. Accordingly, assuming, that any error was committed with respect to the duty to notify, such error was harmless and will not be further discussed. A remand would serve no useful purpose at this time. See Soyini v. Derwinski, 1 Vet. App. 540 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit going to the claimant). VA has also satisfied its duty to assist the appellant under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. Service medical records and VA and non-VA treatment records have been associated with the claims folder. Additionally, the veteran has been accorded specialty VA examinations with regard to the various disabilities at issue. Accordingly, no further assistance to the veteran is required to fulfill VA's duty to assist him in the development of his claims. Smith v. Gober, 14 Vet. App. 227 (2007), affirmed 281 F. 3d 1384 (Fed. Cir. 2002). The Board finds that the duty to assist has been fulfilled and any error in the duty to notify would in no way change the outcome of the decision below. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303. Service connection may also be granted for disability shown after service, when all the evidence, including that pertinent to service, demonstrates it was incurred in service. See 38 C.F.R. § 3.303(d). The United States Court of Appeals for Veterans Claims (Court) has held that for service connection to be awarded, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of an inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Colburn v. Nicholson, 19 Vet. App. 427 (2006); accord Disabled American Veterans v. Secretary of Veterans Affairs, 419 F. 3d 1317 (Fed. Cir. 2005); Shedden v. Principi, 381 F. 3d 1163, 1166 (Fed. Cir. 2004). If the veteran fails to demonstrate any one element, denial of service connection will result. In the case of any veteran who was engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). "Satisfactory evidence" is credible evidence. Collette v. Brown, 82 F. 3d 389, 392 (1996). Such credible, consistent evidence may be rebutted only by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Board assures the veteran that it has made a thorough review of the record in conjunction with the claims. Although the Board has an obligation to provide reasons and bases supporting its decisions, there is no need to discuss in detail the evidence submitted by the veteran or in his behalf. See Gonzales v. West, 218 F. 3d 1378, 1380 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, what fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive, and provide reasons for rejecting any material evidence favorable to the claimant). Residuals of a Right Little Finger Injury A review of the service medical records is without reference to complaints or findings indicative of the presence of a disability involving the right little finger. The post service medical evidence includes the report of a VA X-ray study of the right hand in December 2003. No comparison studies were available. Notation was made of a flexion deformity of the metacarpophalangeal joint of the fifth digit. It was noted as being "probably old trauma" with soft tissue prominence. In a July 2004 statement, the veteran indicated that he injured the right little finger when he was jumping from a helicopter and the finger got caught on the door of the helicopter. He claimed he had not been able to extend the finger normally ever since. There is no indication in the record of any other possible cause for the function deformity of the fifth digit on the right. The Board finds that the veteran has presented satisfactory evidence that the finger injury was incurred in combat. There is no clear and convincing evidence to the contrary. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Accordingly, the Board finds the evidence supports the claim and service connection is granted. Right Knee Disability A review of the service medical records is without reference to complaints or findings indicative of the presence of a right knee disability. There is a complete lack of continuity of symptomatology indicating the presence of a right knee disability for years following service discharge. It was not until examination of the right knee was done in December 2003 by VA that there was medical documentation of the presence of a knee disorder. At that time, the X-ray study showed the presence of degenerative joint disease of the patellofemoral joint with narrowing and articular lipping. They were described as mild in degree. There is no medical opinion of record relating any current right knee disability to the veteran's active service. See Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered in service connection claims and weighs against the claim). As the preponderance of the evidence is against the claim with regard to a right knee disability, the benefit of the doubt doctrine is not applicable and the claim for service connection for a chronic right knee disability must be denied. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F. 3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that the benefit of the doubt rule is not for application when the preponderance of the evidence is found to be against the claim); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Service Connection for Left Ear Hearing Loss and Tinnitus A review of the service medical records reveals no complaints with regard to hearing loss or tinnitus during service. At the time of service separation examination high frequency loss was noted in the right ear on audiogram study. However, audiogram study at the time of discharge examination in February 1969 showed normal hearing in the left ear. Service connection is currently in effect for hearing loss of the right ear. A noncompensable disability rating is in effect. The post service records are without reference to the presence of hearing loss or tinnitus for years following service discharge. The medical evidence includes the report of an ears disease examination of the veteran in July 2006. The veteran gave a long history of bilateral progressive hearing loss and a 15 to 20 year history of bilateral progressive tinnitus, which is now constant. An audiogram study showed bilateral mild to severe sensorineural hearing loss. The examiner opined that it "would appear" that all of the veteran's current hearing loss in the left ear had occurred subsequent to separation from service. The examiner opined that it was "less likely than not" that any current left-sided hearing loss was related to military noise exposure. It was the examiner's opinion that the most likely etiology of the current left hearing loss was related to presbycusis, or age-related hearing loss. With regard to the veteran's claim of service connection for tinnitus, the examiner noted his review of the service medical records was negative for tinnitus and there were no pertinent complaints at service separation. He further noted that the veteran's history indicated that his complaints occurred subsequent to service. The examiner opined that the most likely etiology of the veteran's hearing loss was presbycusis and was no likely related to military acoustic trauma. He further indicated that it was his opinion that it was less likely than not that the veteran's current tinnitus would be related to military noise exposure/acoustic trauma. There is no medical opinion of evidence to the contrary. Also, as noted above, the absence of medical records documenting the presence of a disorder over a prolonged period of time is a fact for the Board to consider in reaching a determination of the claim and weighs against a claim. Maxson v. Gober, 230 F. 3d 1330 (Fed. Cir. 2007). The veteran himself is not competent to provide a nexus between any current left ear hearing loss or tinnitus and his service, as the evidence does not show that he has the requisite knowledge of medical principles that would allow him to render opinions regarding matters involving medical diagnosis or medical etiology. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In view of the foregoing, the Board finds that the evidence is against the claim for service connection for hearing loss in the left ear and tinnitus. Service Connection for Hypertension and a Chronic Skin Disorder to Include as Due to Exposure to Herbicides The law and applicable regulatory provisions pertaining to Agent Orange exposure, expanded to include all herbicides used in Vietnam, provide that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R § 3.307(a)(6)(ii). The law and regulations for this stipulate that diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The enumerated disease processes do not include hypertension or a skin disorder except for chloracne or other acneform disease consistent with chloracne. In Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994), the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to the regulatory presumption of service connection for a given disability, a claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See also Brock v. Brown, 10 Vet. App. 155 (1997) (holding the rationale employed in Combee also applies to claims based on exposure to Agent Orange). As such, the Board must not only determine whether the veteran had a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, See 38 C.F.R. § 3.309(e), but was also determined whether such disability was the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). As noted above, in order to establish service connection, there must be (1) evidence of a current disability; (2) evidence of the incurrence or aggravation of a disease or injury in service; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the current disability. See Colburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Initially, with regard to the claim for a skin disorder, the service medical records are without reference to complaints or findings indicative of the presence of a skin disorder. Further, the post service medical evidence is without confirmation of the presence of a chronic skin disorder. In Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992), the Court stated that Congress specifically amended entitlement for a service-connected disease or injury to cases where such incidents resulted in a disability. The Court further held that in the absence of proof of a current disability, there can be no valid claim. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). The Board recognizes the veteran's own assertions that he has a skin disorder attributable to his active service. However, there is no medical evidence of record showing a current diagnosis of such a disorder. The veteran himself is not competent to provide a causal nexus between any current claimed skin disorder and service, as the evidence does not show that he has the requisite knowledge of medical principles that would permit him to render opinions regarding matters involving medical diagnoses or medical etiology. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). See also Routen v. Brown, 10 Vet. App. 183 (1997) (a lay person is generally not capable of opining on matters requiring medical knowledge). Service Connection for Hypertension With regard to the claim for service connection for hypertension, there is medical evidence of the presence of hypertension. A private osteopath stated in November 2004 that the veteran reported that he had been under his care "during the early 1970's." The osteopath stated that he had no medical record pertaining to the veteran "due to the length of time that has passed." The pertinent medical evidence also includes a report of a diabetes mellitus examination accorded the veteran by VA in September 2006. The claims file was reviewed by the examiner. It was reported the veteran had a longstanding history of hypertension. Following the examination, a diagnosis was made of hypertension, currently controlled on medication. The examiner opined that the hypertension was not due to the veteran's diabetes mellitus. In reviewing the claim, the Board refers to the statutory presumption which attaches it to Agent Orange exposure. However, because hypertension is not among the disabilities listed in 38 C.F.R. § 3.309(e), presumptive service connection due to Agent Orange exposure is not warranted. Accordingly, the Board will proceed to discuss whether service connection may be awarded on a direct basis. See Combee and Brock. The physician who made the statement regarding his longtime treatment of the veteran for hypertension in 2004 did not refer to when the first visit took place. He made no reference to the veteran's service. The service medical records that are available do not give indication of the presence of hypertension and the medical evidence of record does not document its presence for at least more than one year following service discharge. The veteran has provided no medical documentation indicating a causal nexus between any hypertension on the one hand and his active service many years ago, to include his time in Vietnam and his presumed exposure to herbicide agents while serving there. Further, the Board notes that at the time of examination by VA in September 2006, a VA physician opined that the veteran's hypertension was not due to diabetes mellitus, a condition for which service connection is now in effect. The veteran has provided no medical evidence supporting his assertion of hypertension being attributable to his active service. As noted elsewhere in this decision, competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); See also 38 C.F.R. § 3.159(a)(1). Accordingly, the veteran's contentions with regard to a causal connection between hypertension in service are not competent medical evidence. Accordingly, the Board concludes that there is a preponderance of the evidence is against the claim for entitlement to service connection for hypertension, to include as due to herbicide exposure in Vietnam. The benefit sought on appeal is accordingly denied. Increased Ratings Disability ratings are based upon schedular requirements of the average impairment for earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2007). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Also, when there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the time of the examination. When evaluating the level of disability for a mental disorder, the rating agency will consider the extent of such impairment, but shall not assign an evaluation solely on the basis of such impairment. 38 C.F.R. § 4.126. Under the general formula for rating mental disorders, a 30 percent rating is provided when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of ability to perform occupational tasks (although generally functioning satisfactorily, with retained behavior, self-care, and conversation normal), due to such symptoms as: Depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The next higher rating of 50 percent is provided when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: Flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment in short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The next higher rating of 70 percent is provided for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The maximum schedular rating of 100 percent is assigned when there is total occupational and social impairment, due to such symptoms as: Gross impairment of thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss of names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. Pertinent case law reveals that in determining whether the veteran meets the criteria for a 70 percent evaluation, the Board must consider whether the veteran has deficiencies in most of the following areas: Work, school, family relations, judgment, thinking, and mood. See Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Global assessment of functioning scores are rated on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health status." See Carpenter v. Brown, 8 Vet. App. 240-242 (1995); See also Richard v. Brown, 9 Vet. App. 1266 (1996), citing The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), page 32. A score of 51 to 60 is provided when there are moderate symptoms (e.g., flat affect and circumstantial speech, or occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Following review of the evidence and the pertinent provisions of the Rating Schedule set forth above, the Board finds the manifestations of the veteran's PTSD most nearly approximate the criteria for a disability rating of 50 percent, but not more, during the entire appeal period. The pertinent medical evidence includes the report of a July 2004 psychiatric examination of the veteran by VA. The claims file was reviewed by the examiner. The veteran had worked for the past 30 years as a truck driver and was still working a 40 hour week. He stated that he had not missed any work because of physical or emotional illness. He had been married one time and had two grown children with whom he had regular contact. He indicated the relationship was good. Currently, he was described as neatly dressed. He maintained normal eye contact. Psychomotor activity was normal. Posture was erect. He talked at a normal rate and volume. Answers to questions were logical, relevant, and coherent. There were no loose thought associations, attentionality, or circumstantiality. Mood during the examination was euthymic. Affect was broad and flexible. There was no blunting of affect. Thought processes were not over or underabundant. He had recurrent thoughts about Vietnam and obsessive thoughts about Vietnam and the experiences he had there. Intrusive memories are also reported. He was properly oriented and gave concrete interpretations to proverbs. The examiner opined that the veteran did not appear to be socially or occupationally impaired at the present time from his PTSD. The veteran was given an Axis I diagnosis of "very mild" PTSD. He was given a current GAF score of 80. The veteran was given another psychiatric examination by VA in February 2007. Psychological testing was accomplished. It was reported that review of the record revealed that reviews were done by a physician in July 2004 and June 2005. The last GAF score for PTSD and depressive disorder was 50. The veteran was currently taking Celexa and Trazodone. The veteran stated he was receiving treatment at the Dallas VA Medical Center for his psychiatric problems. On current examination he presented as depressed and somber. Thought processes were logical, coherent, and relevant. He was described as attractive, articulate, verbal, well dressed, and well groomed. He exhibited good social skills. He seemed intelligent and speech was well understood. He was properly oriented, but affect was flat and blunted. Verbal comprehension was good and concentration was also good. He stated that his short term memory was poor. Sensorium was clear. Reference was made to symptoms including anxiety, panic attacks, depression, insomnia, sleep disturbance, crying spells, anhedonia, and nightmares. His problem behaviors mainly had to do with his personal dissatisfaction and his despondency. He stated that he would get angry at his wife and preferred to work alone. It was the examiner's opinion that the veteran was "as likely as not" worse than his current rating reflected. He persistently re experienced Vietnam trauma through thoughts, flashbacks, emotional distress, and reaction to similar symbols. Persistent avoidance symptoms included diminished social interest, social and emotional detachment, and a foreshortened future. He had persistent arousal symptoms, including sleep difficulties, anger, paranoia, and hallucinations, as well as suicidal ideation. While the examiner opined that the psychological testing might have been exaggerated, the veteran showed "a good deal of distress in the interview..." despite the fact that he had been in a stable marriage and had a stable work history. It was noted that his job seemed to fit a pattern of desiring to be alone and isolated. The veteran was given an Axis I diagnosis of PTSD and of major depressive disorder with psychosis secondary to the PTSD. He was given a GAF score of 55. Based on a longitudinal review of the evidence of record, the Board finds that the disability picture attributable to the veteran's PTSD symptomatology reasonably warrants an increase in the initial disability rating to 50 percent during the entire appeal period. The Board notes that the principal basis for a 100 percent rating is total occupational and social impairment and that is not shown in this case. Sellers v. Principi, 372 F. 3d 1318 (Fed. Cir 2004). With regard to the criteria for a 70 percent disability rating, the veteran has not been shown to be exhibiting symptoms commonly associated with the disability picture warranting that rating. The symptoms include obsessional rituals, poor impulse control, spatial disorientation, neglect of personal appearance and hygiene, and speech that is intermittently illogical, obscure, or irrelevant. The medical evidence of record during the appeal period in question does not show the presence of a disability picture manifested by these symptoms. However, the Board finds that the evidence shows the veteran has difficulty in establishing and maintaining effective work and social relationships to a degree that the assignment of a 50 percent rating is reasonably in order. Throughout the appeal, he has reported occasional panic attacks, depression, some social isolation, and complaints of nightmares and flashbacks. Further, the Board notes that the veteran takes medication for his psychiatric symptomatology and is seen on a regular basis for therapy purposes. While he was given a fairly high GAF score at the time of the 2004 examination, his symptoms were essentially the same as those reported at the time of the February 2007 examination. The Board notes, as was pointed out by the examiner at the time of the later examination, that while the veteran might have a stable work history, his job as a truck driver seemed to fit his pattern of wanting to be alone and isolated. Accordingly, although the Board finds that the veteran is not severely or totally incapacitated from a social or industrial standpoint because of his PTSD symptomatology, the Board finds that the symptom picture is reasonably indicative of impairment that a 50 percent rating is warranted throughout the appeal period, particularly with resolution of all reasonable doubt in his favor. Left Shoulder Disability Initially, the Board notes that 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202 (1995); require the Board consider the veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using limitation of motion diagnostic codes. Within this content, a finding of functional loss due to pain must be supported by adequate pathology, and evidence about the physical behavior of the claimant. Johnson v. Brown, 10 Vet. App. 80, 85 (1997). However, under Spurgeon v. Brown, 10 Vet. App. 194 (1997), the Board is not required to assign a separate rating for pain. The veteran's bursitis is rated under Diagnostic Code 5019. That code provides that that particular disease process will be rated on limitation of motion of the affected part as degenerative arthritis. Accordingly, Code 5003 provides a maximum rating of 20 percent when there is X-ray evidence of two major joints or two or more minor joint groups, with occasional incapacitating exacerbations. As noted above, the veteran is right-handed. Accordingly, the rating provided for his left shoulder bursitis is that for his minor extremity. The available evidence during the entire appeal period shows no ankylosis of the shoulder. Accordingly, the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5200 (2007) are not for application. Further, impairment of the humerus, including malunion or recurrent dislocation, has not been shown by the evidence of record. Therefore, 38 C.F.R. § 4.71a, Code 5202 (2007) is not for application. With regard to limitation of motion of the arm, a 20 percent disability rating is assigned for motion limited to shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2007). In order for there to be assigned the next higher rating of 30 percent, Code 5201 provides that limitation of motion of the arm be to 25 degrees from the side. 38 C.F.R. § 4.71a, Code 5201. The medical evidence of record includes a report of a July 2005 joints examination. The claims file was reviewed by the examiner. It was reported that in Vietnam in 1967, the veteran jumped out of a helicopter and injured his left shoulder. The veteran complained that he had had pain in the shoulder ever since service. He was taking 500 milligrams of Naproxen twice daily for the pain. He had recently received a course of physical therapy for several days and was placed on home exercises. He claimed these gave him little relief. He did not use any assistive devices. He did not have any increased limitations with flareups or repetitive motion. It was noted that he drove a truck locally and did not do any lifting. He had not missed time from work because of his shoulder. He stated that he "just worked through the pain." He was also able to drive his vehicle and take care of his activities of daily living. There had been no surgery or injections involving the shoulder. On examination from a visual standpoint, the right and left shoulders appeared to be the same. The left acromiclavicular joint was tender. He was able to flex the left shoulder to 110 degrees with pain. He was able to flex the right shoulder to 140 degrees without pain. He had 80 degrees of abduction with pain and 150 degrees on the right without pain. He exhibited 20 degrees of adduction bilaterally without pain. He had 70 degrees of internal rotation with pain on the left. He had 90 degrees of external rotation without pain. The right shoulder had 90 degrees of internal and external rotation. There was no crepitation. There was tender musculature in the shoulder girdle. Left hand grip was weaker than the right. He had a weaker left arm as compared to the right against resistance motion. There was no muscular atrophy. Reference was made to magnetic resonance imagining of the upper extremity by VA in May 2004. This showed a suprahumeral cuff tendinosis with partial tearing of the supraspinatus, subacromial, sub-deltoid bursa fluid, and degeneration of the acromioclavicular joint. The examination impressions were: Rotator cuff tear; subacromial sub-deltoid bursitis; and degenerative arthritis of the acromioclavicular joint. Of record is an indication that another joints examination was scheduled for the veteran in October 2006, but for some reason did not take place. Additional medical evidence includes a notation on a VA outpatient visit in July 2007 that the veteran was seen for refill of medications. Among other things, the veteran stated that shoulder pain kept him awake at night. In view of the foregoing evidence, the Board finds that a 30 percent rating for a shoulder disorder, is not warranted because the veteran has not demonstrated motion of the arm limited to 25 degrees from the side, and this is required to assign a 30 percent rating to a nondominant arm. The Board has considered the objective and subjective evidence. However, nothing in the evidence suggests impairment of function at 25 degrees from the side. The Board acknowledges the veteran has complaints of pain involving the shoulder, but notes that there has been no indication of significant work impairment or even much impairment in the veteran's ability to function in his normal activities. Accordingly, the Board finds no indication of a symptom picture that would warrant the assignment of a disability rating in excess of the 20 percent already in effect for his left shoulder disability. ORDER Service connection for residuals of a right little finger injury is granted. A disability rating of 50 percent, but not more, for the veteran's PTSD is granted. To the above extent, the appeal is allowed. Service connection for a chronic right knee disability is denied. Service connection for a chronic skin disorder, to include as due to Agent Orange exposure, is denied. Service connection for hypertension, to include as due to exposure to herbicides is denied. Service connection for left ear hearing loss and tinnitus is denied. A disability rating in excess of 20 percent for a left shoulder disability is denied. To the above extent, the appeal is denied. ____________________________________________ V. L. JORDAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs