Citation Nr: 1000010 Decision Date: 01/04/10 Archive Date: 01/14/10 DOCKET NO. 06-01 602 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to service connection for a psychiatric disorder to include depression. 2. Entitlement to a rating in excess of 30 percent for degenerative changes with a history of strain, cervical spine. 3. Entitlement to a rating in excess of 20 percent for early degenerative changes, L5-S1. 4. Entitlement to a rating in excess of 10 percent for tendinitis/bursitis of the right shoulder. 5. Entitlement to a rating in excess of 10 percent for status post (S/P) cholecystectomy with irritable bowel syndrome (IBS). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from December 1985 to February 1990. His DD 214 lists an additional 9 years of prior active service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision entered in August 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana, which denied the claims for entitlement to ratings in excess of 20 percent for cervical strain with osteoarthritis, and low back pain with sciatica; and, ratings in excess of 10 percent for tendinitis/bursitis of the right shoulder, and S/P cholecystectomy with IBS. In addition, entitlement to service connection for depression was also denied. Subsequently, in a November 2005 decision, a decision review officer increased the 20 percent rating for cervical strain with osteoarthritis to 30 percent disabling. In addition, the descriptions of the claimed disorders were recharacterized as shown above. The instant claims were raised in May 2004. FINDING OF FACT 1. Depression was not shown during service or for years thereafter, and there is no competent evidence linking the disorder either to service or a service-connected disability. 2. Degenerative changes of the cervical spine are not manifested by unfavorable ankylosis of the entire cervical spine. 3. Degenerative changes of the lumbar spine, L5-S1, are not manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. 4. The appellant's right shoulder disorder has not been manifested by a limitation of arm motion to shoulder level. 5. The appellant's S/P cholecystectomy with IBS has been manifested by no more than mild to moderate bowel disturbances and abdominal distress. CONCLUSIONS OF LAW 1. Depression was not incurred in or aggravated in-service, and is not proximately due to or the result of a service- connected disorder. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2009). 2. The criteria for an evaluation in excess of 30 percent for degenerative changes of the cervical spine with a history of strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5242 (2009). 3. The criteria for an evaluation in excess of 20 percent for degenerative changes of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5242. 4. The criteria for an evaluation in excess of 10 percent for a right shoulder disorder have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5201 (2009). 5. The criteria for entitlement to an evaluation in excess of 10 percent for S/P cholecystectomy with irritable bowel syndrome have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A; 38 C.F.R. §§ 3.159, 4.1-4.10, 4.114, Diagnostic Code 7319 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in June 2004, and March and April 2006 correspondence of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant and notice of what part VA will attempt to obtain. The March 2006 communication explained how VA assigns disability ratings and effective dates. In any event, as the instant claims are denied, no disability rating or effective date is assigned and any deficiency as to such notice is moot. VA fulfilled its duty to assist the claimant in obtaining identified and available evidence needed to substantiate a claim. The claims were readjudicated in a March 2006 supplemental statement of the case. The claimant was afforded a meaningful opportunity to participate in the adjudication of the claims. The claimant was provided the opportunity to present pertinent evidence in light of the notice provided. Because appellant has actual notice of the rating criteria, and because the claims have been readjudicated no prejudice exists. There is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. Indeed, the appellant has not suggested that such an error, prejudicial or otherwise, exists. Hence, the claims are ready for adjudication. The Board has reviewed the evidence in the Veteran's claims files that includes her written contentions, service personnel and treatment records, private and VA medical records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. Service connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as a psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310. The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the appellant's appeal was already pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). Generally, to prove service connection, the record must contain: (1) Medical evidence of a current disability, (2) medical evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of injury or disease, and (3) medical evidence of a nexus or relationship between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). It is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence. See Owens v. Brown, 7 Vet. App. 429 (1995). Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. In a May 2004 claim the Veteran alleged that she suffered from depression as a result of her multiple disorders. She has submitted no medical evidence, any diagnosis of depression, or any medical nexus opinions. The service treatment records are entirely silent as to any complaints or treatment referable to a psychiatric disability. Moreover, there is no competent evidence that a psychosis as defined under 38 C.F.R. § 3.384 was manifested to a compensable degree within one year following the Veteran's discharge from active duty. The post-service record since that time does not reflect any psychiatric treatment. In an August 2004 response to a June 2004 VCAA letter, the Veteran noted that she had no further evidence to submit. She reiterated in a March 2006 response to a January 2006 letter accompanying the SSOC that she had no further evidence to submit. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against entitlement to service connection for depression. Indeed, in the absence of evidence of a current disability, the claim must fail. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching the above conclusion, the Board has considered the Veteran's lay statements and acknowledges that she is competent to report what comes to her through her senses, she does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). Moreover, in Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Here, however, none of the criteria set forth in Jandreau are for application. Accordingly, the lay statements do not here serve to establish any diagnosis and, as stated above, the claim must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). II. Increased ratings The Veteran filed the current claim in May 2004. She initially failed to report for her VA examination scheduled in July 2004. In a May 2005 VA examination, the Veteran reported injuring her lower back doing some heavy lifting during service. The onset of her pain was in 1991, and it had gradually worsened. She now had continuous pain accompanied by pain radiating down the right hip to the right foot. Some days she could walk a mile without any problems; other days it would cause discomfort. She was able to do all activities of daily living. She could ambulate without a cane, crutches, walker, or brace. She injured her neck in a motor vehicle accident in 1983, and developed arthritis. The pain has gradually worsened and increases with repetitive movement such as raking, typing, and prolonged sitting. It was a dull aching pain and she rated it as 6/10 in intensity. She injured her right shoulder in 1978 while loading a ladder onto a truck. She received cortisone injections. Intermittent physical therapy gave some relief. She was unable to sleep on her right side or hold anything over her head. Objectively, lumbar examination revealed no scoliosis. Lordosis was not decreased. Lumbar range of motion was forward flexion to 70 degrees; extension to 10 degrees; lateral bending left and right to 45 degrees; rotation left and right to 45 degrees. The assessment was lumbar spine pain with radiculopathy. X-rays revealed early degenerative changes at L5-S1 manifested by joint space narrowing. No additional bony abnormalities were evident. The diagnosis was mild degenerative changes L5-S1. Examination of the cervical spine revealed forward flexion to 30 degrees; extension to 15 degrees; and, right and left lateral rotation to 30 degrees. The assessment was arthritis of the cervical spine. X-rays demonstrated joint space narrowing at C5-6 and to a slighter degree at C6-7. The rest of the evaluation was unremarkable. The impression was degenerative changes at C5-6, C6-7. A right shoulder examination revealed no deformity, swelling, erythema, warmth, or crepitus. Range of motion was elevation to 90 degrees; adduction was intact; abduction was to 90 degrees, then pain; external rotation was to 45 degrees; and internal rotation to 80 degrees. The assessment was a rotator cuff strain. In a September 2005 VA examination, the range of motions for the right shoulder, lumbar and cervical spines were repeated as the May 2005 results were inadequate. The examiner noted that the Veteran's gait was even and her posture erect. She ambulated with a steady balance and no use of assistive devices. She was right hand dominant. A thoracolumbar spine examination noted that the range of motion measurements failed to match the known pathology. Forward flexion was to 70 degrees; extension to 10 degrees; lateral flexion and lateral rotation was to 25 degrees. There was limitation of the range of motion due to complaints of pain, but there was no objective evidence of spasms. Repetitive motion was not done due to discomfort. and complaints of localized tenderness on palpitation of the lumbar spine. There was no additional loss of motion due to pain, or repeated use, fatigue, weakness, lack of endurance, or incoordination. The thoracolumbar examination revealed early degenerative changes at L5-S1 manifested by joint space narrowing. No additional bony abnormalities were evident. The diagnosis was mild degenerative changes L5-S1. A cervical spine examination revealed the position of the head to be neutral; and, curvature of the spine was normal. Range of motion was forward flexion to 10 degrees; extension to 15 degrees; lateral flexion to 10 degrees; lateral rotation to 45 degrees. There was pain with all movements. Range of motion was limited by pain. Forward flexion, extension, and lateral tests were all reduced. Repetitive motion was not done due to complaints of pain with initial range. Range of motion measurements failed to match the known pathology. There was no objective evidence of spasm. The Veteran complained of tenderness on palpation of the cervical spine. There was no additional loss of motion due to pain, repeated use, fatigue, weakness, lack of endurance, or incoordination. The cervical examination demonstrated joint space narrowing at C5-6 and to a slighter degree at C6- 7. The remains of the evaluation were unremarkable. The impression was degenerative changes at C5-6, C6-7. A right shoulder examination revealed no objective evidence of edema, effusion, instability, redness, heat, abnormal movement, or guarding. Range of motion was forward flexion to 140 degrees; abduction to 90 degrees; external rotation to 90 degrees; and internal rotation to 80 degrees; extension to 10 degrees, and, adduction to 25 degrees. The examiner noted that strength testing was not consistent with the reported activities, such as pushing a lawnmower, raking, and other repetitive movements such as glazing windows. There was no additional loss of motion due to pain, or repeated use, fatigue, weakness, lack of endurance, or incoordination. Regarding the lumbar, cervical, and right shoulder disorders, the examiner added, that he would have to resort to mere speculation in order to express additional limitation due to flare-ups "as I have no objective evidence to support flare claim." An October 2005 EMG (electromyogram) and NCV (Nerve conduction study) revealed no evidence of neuropathy, brachial or lumbosacral plexopathy, cervical or lumbar radiculopathy or myopathy. Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating a loss of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 (2009) an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Under 38 C.F.R. § 4.71a, Diagnostic Code 5010, arthritis, due to trauma, substantiated by X-ray findings, will be rated as degenerative arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under 38 C.F.R. § 4.40, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Additionally, 38 C.F.R. § 4.45 provides as regards to the joints that the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (range of motion flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight- bearing are related considerations. A. Degenerative changes of the lumbar and cervical spine. Degenerative changes of the lumbar and cervical spine are rated under the general rating for diseases and injuries of the spine. Under that formula, the ratings are assigned with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under this formula, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 2, General Rating Formula for Disease and Injuries of the Spine. 38 C.F.R. § 4.71a, Plate V (2009). The pertinent evidence of record includes the May and September 2005 VA examinations. Significantly, no medical evidence of record reveals evidence of unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Indeed, the May and September 2005 VA examinations revealed motion in each plane of cervical movement. Hence, entitlement to a higher 40 percent rating for the cervical spine disorder is not warranted. Likewise, the thoracolumbar spine examination revealed forward flexion to 70 degrees. This fails to meet the criteria for the next-higher 40 percent evaluation under the general rating formula, even when considering DeLuca factors. Again, the examiner expressly indicated that there was no additional limitation of motion due to pain, fatigue, weakness, lack of endurance, or incoordination in the September 2005 examination. It is noted that repetitive motion was not performed due to the Veteran's reported discomfort. However, as this finding appears at odds with, or at least disproportionate to the objective findings reported, this alone does not serve to warrant an increase here. In sum, the manifestations of the Veteran's cervical and lumbar disabilities do not meet or more nearly approximate the criteria for increased rating under any of the applicable diagnostic codes. Accordingly, the Veteran is appropriately rated at a 30 percent evaluation for her cervical spine degenerative disease and at a 20 percent evaluation for her lumbar spine degenerative disease. In light of the foregoing, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for his cervical spine disorder. VA examiners found no identifiable abnormal musculoskeletal pathology of the cervical spine, and no evidence of neuropathy, cervical radiculopathy or myopathy. Subjective pain was noted to appear to be the greatest functional impact. The Veteran's range of motion clearly remained within the criteria for no more than the current 30 percent evaluation during the entire appeal period. Therefore, she is appropriately rated at a 30 percent evaluation for her cervical spine disorder. Regarding the lumbar spine disorder, the Board finds that the Veteran is not entitled to a rating in excess of 20 percent. As noted, she has not been shown to have had any evidence of neuropathy, brachial or lumbosacral plexopathy, or lumbar radiculopathy or myopathy. She has not exhibited favorable ankylosis of the entire thoracolumbar spine and forward flexion of the thoracolumbar spine has always exceeded 30 degrees. Therefore, she is appropriately rated at a 20 percent for her lumbar spine disorder for the entire rating period. While the Veteran does demonstrate some limitation of cervical and lumbar motion, the Board finds that she is not entitled to a rating in excess of 30 percent for her cervical spine or 20 percent for her lumbar spine disability. Further, the Veteran does not qualify for a higher rating under the formula for rating an intervertebral disc syndrome based on incapacitating episodes. As noted above, the Veteran has not exhibited any signs or symptoms due to intervertebral disc syndrome. Therefore, the Veteran does not qualify for higher ratings for degenerative disease of the cervical spine or lumbar spine under Diagnostic Code 5243. B. Increased rating for a right shoulder disorder The Veteran contends that her right shoulder disorder is manifested by adverse symptomatology that warrants a rating in excess of the currently assigned 10 percent evaluation. The Board observes that the VA examination in May 2005 revealed no deformity, swelling, erythema, warmth, or crepitus of the right shoulder. The range of motion was elevation to 90 degrees; adduction was intact; abduction was to 90 degrees, then pain; external rotation was to 45 degrees; and internal rotation to 80 degrees. The examination was returned as inadequate as it failed to address Deluca criteria. In a September 2005 VA examination, the ranger of motions for the right shoulder was repeated. The examiner noted that the Veteran was right hand dominant. Range of motion was forward flexion to 140 degrees; abduction to 90 degrees; external rotation to 90 degrees; and internal rotation to 80 degrees. The right shoulder disability has been rated under Diagnostic Code 5024, for tenosynovitis, which in turn is evaluated as degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. In this case it is Diagnostic Code 5201 which provides that a minimum rating of 20 percent is warranted when limitation of motion of the major arm is at shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Because the Veteran is right- hand dominant (as noted in the September 2005 examination report) and since she continues to demonstrate a range of shoulder motion above the shoulder level a higher schedular evaluation is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5024, 5201. When the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of- motion loss due to pain on use or during flare-ups." DeLuca v. Brown at 206. The May and September 2005 examiners noted some pain, weakness and lack of endurance limiting shoulder motion. There was no objective evidence of right shoulder swelling, deformity, or atrophy. Overall, the limitation demonstrated in the record is accounted for by the already- assigned 10 percent rating and the functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 do not equate to the level of disability contemplated by a 20 percent rating for limitation of motion under Diagnostic Code 5201. As previously noted in the absence of compensable limitation of motion, a 10 percent evaluation is warranted in light of the evidence of pain on motion under 38 C.F.R. § 4.71a, Diagnostic Code 5003, but no greater. Accordingly, the Veteran has not met the criteria for a rating in excess of the current 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5024, 5201. C. Increased rating S/P cholecystectomy with IBS The RO has evaluated the Veteran's S/P cholecystectomy with IBS as 10 percent under hyphenated Diagnostic Code 7318-7319 which indicates a digestive disorder including gall bladder removal and irritable colon syndrome. See 38 C.F.R. § 4.27 (2009) (noting that the diagnostic code for diseases may contain the diagnostic code for the disease followed by a hyphen and the diagnostic code for the residual condition on which the rating is based); 38 C.F.R. § 4.114, Diagnostic Codes 7318 (gall bladder removal), 7319 (irritable colon syndrome). Under Diagnostic Code 7318, a noncompensable rating is warranted where the condition is nonsymptomatic; a 10 percent rating is warranted where there are mild symptoms; and, a 30 percent rating is warranted for severe symptoms. Under Diagnostic Code 7319, a noncompensable rating is assignable for mild irritable colon syndrome; disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is assignable for moderate irritable colon syndrome; frequent episodes of bowel disturbance with abdominal distress. A 30 percent evaluation is assignable for severe irritable colon syndrome; diarrhea, or alternating diarrhea and constipation with more or less constant abdominal distress. Based on these criteria, the evidence fails to establish that the Veteran's digestive system disability picture more nearly approximate the criteria for a higher evaluation. A review of the claims file reveals that the objective evidence of record fails to support the Veteran's assertions, noted above, regarding the severity of her S/P cholecystectomy with IBS, as will be discussed further below. In the May 2005 VA examination, the Veteran reported recurring heartburn, but no abdominal pain. She reported chronic diarrhea with 3 watery stools a day since her cholecystectomy. She denied nausea or vomiting, and had no black tarry stools. She reported some relief with coral calcium. Examination revealed bowel sounds; palpation indicated the abdomen was soft and tender; a mass was not palpated, and the liver was not enlarged. An upper GI study revealed that the swallowing act was performed without difficulty. The esophagus was normal; there was no hiatal hernia or reflux; and no strictures were seen. The stomach pylorus channel, duodenal bulb, and proximal small bowel all appeared normal. The impression was a normal upper GI. The Board notes that there is simply no objective evidence of record confirming that the Veteran's S/P cholecystectomy with IBS is severe. Rather, based on the objective evidence, particularly the recent May 2005 VA examination, the Board finds that, during the course of this appeal, the Veteran's S/P cholecystectomy with irritable bowel syndrome caused bowel disturbances and abdominal distress, but was no more than mild to moderately disabling. An evaluation in excess of 10 percent is thus not assignable under Diagnostic Codes 7318 or 7319. In reaching the above conclusions, the Board acknowledges the Veteran's own statements as to her symptoms, and that she is competent to report such symptoms. However, when weighing her subjective complaints against the clinical findings taken during a thorough examination, the latter are found to have greater probative weight here. Accordingly, the request for an increase is denied. III. Extraschedular Considerations Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2009); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record) An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service- connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are not inadequate. Evaluations in excess of those assigned are provided for certain manifestations of the service-connected disabilities at issue, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describes the severity and symptomatology of the Veteran's disorders. Moreover, the evidence does not demonstrate other related factors. The Veteran has not required frequent hospitalization due to service-connected disorders. Moreover, while the Veteran indicates that she has missed some time at work, evidence of marked interference with employment has not been shown. In the absence of any additional factors, the RO's failure to consider or to refer this case for consideration of an extraschedular rating was not prejudicial. IV. Conclusion In reaching the above conclusions, the Board has not overlooked the Veteran's statements to the RO and to VA examiners. While lay witnesses are competent to describe experiences and symptoms that result there from, because lay persons are not trained in the field of medicine, they are not competent to provide medical opinion evidence as to the current severity of a service connected disability. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Therefore, the Veteran's statements are not competent evidence as to the issues on appeal. The Board also considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran's claims. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claims are denied. ORDER Service connection for a psychiatric disorder to include depression is denied. Entitlement to a rating in excess of 30 percent for degenerative changes of the cervical spine with a history of strain is denied. Entitlement to a rating in excess of 20 percent for early degenerative changes, L5-S1 is denied. Entitlement to a rating in excess of 10 percent for tendinitis/bursitis of the right shoulder is denied. Entitlement to a rating in excess of 10 percent for status post (S/P) cholecystectomy with irritable bowel syndrome (IBS) is denied. ____________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs