Citation Nr: 1036282 Decision Date: 09/27/10 Archive Date: 09/30/10 DOCKET NO. 06-00 366A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 20 percent for a service-connected lumbar spine disability. 2. Entitlement to a rating in excess of 10 percent for a service-connected psychiatric disability. 3. Entitlement to service connection for a left shoulder disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. L. Northcutt, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1992 to April 1992 and from December 2001 to March 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Jurisdiction has since been transferred to the RO in St. Petersburg, Florida. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for a total disability rating based on unemployability (TDIU) is part of an increased rating claim when such a claim is raised by the record. In the instant case, the Veteran reports unemployment since his involvement in a fall during active duty, which resulted in his service-connected lumbar spine and psychiatric disabilities, addressed in the instant appeal, as well as his service-connected seizure disorder, not addressed in the instant appeal. However, no determination as to how the Veteran's service-connected disabilities affect his employability has been made. Thus, the issue of entitlement to a TDIU has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for a left shoulder disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's lumbar spine disability is not shown to be productive of severe limitation of motion. 2. The Veteran's lumbar spine disability is not shown to be productive of incapacitating episodes lasting at least 4 weeks but less than 6 weeks. 3. The Veteran's lumbar spine disability has not resulted in forward flexion of the thoracolumbar spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 4. The Veteran has been service-connected for the only neurological manifestation of his lumbar spine disability, radiculopathy of the lower left extremity, and the evidence of record does not reflect that it is more than mildly disabling (as reflected by the currently assigned evaluation). 5. The evidence of record reflects that the Veteran's service- connected acquired psychiatric disability causes occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks; however, his psychiatric disability is not productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A & 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5243 (2009); 38 C.F.R. § 4.71a Diagnostic Codes 5292, 5293 (2003). 2. The criteria for a disability rating of 30 percent for a psychiatric disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9424 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The VA has a duty to provide notification to the Veteran with to respect establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). Here, however, the Board notes that the Veteran's claims for higher ratings arise from his disagreement with the initial evaluations assigned following the grant of service connection. Courts have held that in these circumstances, once notice has been satisfied in conjunction with the grant of service connection, additional notice is not required under 38 U.S.C.A. § 5103. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As notice with regard to the Veteran's initial service connection claims was satisfied by a letter issued in September 2003, the instant appeal may be adjudicated without remand for further notification. Regarding VA's duty to assist, the Board finds that all relevant facts have been properly developed and that all available evidence necessary for equitable resolution of the issues on appeal has been obtained. The Veteran's service treatment records have been obtained (which are relevant to the instant increased rating claims because they reflect the history of the Veteran's psychiatric and lower back disabilities), as well as the Veteran's private and VA treatment records, and the Veteran has not identified any pertinent, available records that have not been obtained. The Veteran was also provided with several appropriate VA examinations during the instant rating period, and he was offered the opportunity to testify at a hearing before the Board, but he declined. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Increased Rating Claims Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. See 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of a veteran working or seeking work. See 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. See 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the Veteran's disability is the primary concern, although staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Lower Back Disability The Veteran's service-connected lower back disability is currently rated 20 percent disabling. After filing his initial service connection claim in July 2003, the Veteran was awarded service connection and assigned a disability evaluation pursuant to Diagnostic Code 5243 for intervertebral disc syndrome, based on the regulations in effect at the time the rating decision was issued. However, the Board finds that because the Veteran filed his claim before the effective date of the revisions to the rating criteria regarding spinal disabilities, the Board should consider both the rating criteria in effect when the Veteran filed his claim and the revised regulations. In that regard, the Diagnostic Code 5293 outlined the rating criteria for intervertebral disc syndrome in effect at the time the Veteran's claim was filed. Diagnostic Code 5293 provides that preoperative or postoperative intervertebral disc syndrome is evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). Thus, intervertebral disc syndrome warranted a 10 percent disability rating when there were incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent rating when there were incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent rating when there were incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating when there were incapacitating episodes having a total duration of at least six weeks during the past 12 months. The schedule does not provide for an evaluation higher than 60 percent. For purposes of evaluations under the spinal disability rating criteria, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurologic manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. See 38 C.F.R. § 4.71a, Diagnostic Code 5293, Note (1) (2003). When evaluating on the basis of chronic manifestations, orthopedic disabilities are evaluated using the rating criteria of the most appropriate orthopedic diagnostic code or codes; neurologic disabilities are evaluated separately using the rating criteria for the most appropriate neurologic diagnostic code or codes. See 38 C.F.R. § 4.71a, Diagnostic Code 5293, Note (2) (2003). Impairment of the sciatic nerve is addressed under Diagnostic Code 8520. Under this code, in effect throughout the appeal period, complete paralysis, where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is assigned an 80 percent rating. Incomplete paralysis that is mild is assigned a 10 percent rating. Moderate incomplete paralysis is assigned a 20 percent rating, moderately severe incomplete paralysis is assigned a 40 percent rating, and severe, incomplete paralysis of the sciatic nerve, with marked muscle atrophy is assigned a 60 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2009). Orthopedic considerations of the Veteran's disability are contemplated under Diagnostic Code 5292 for limitation of motion of the lumbar spine which was in effect prior to September 26, 2003. This provided for a 10 percent evaluation for slight limitation of motion of the lumbar spine, a 20 percent evaluation for moderate limitation of motion of the lumbar spine, and a 40 percent evaluation when limitation of motion was severe. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2003). Effective September 26, 2003, VA revised the criteria for evaluating general diseases and injuries of the spine. 68 Fed. Reg. 51,454 (Aug. 27, 2003). This amendment to 38 C.F.R. § 4.71a changed the Diagnostic Codes for spine disorders to 5235 through 5243. 38 C.F.R. § 4.71a (2006). Spine disorders are now rated under the General Rating Formula for Diseases and Injuries of the Spine. (As indicated above, at that time, VA reiterated the September 2002 changes to Diagnostic Code 5293 for intervertebral disc syndrome, although re-numbered as Diagnostic Code 5243.) The amended rating criteria now define normal range of motion for the various spinal segments for VA compensation purposes. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexions are zero to 30 degrees, and left and right lateral rotations 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 thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2) (2008). 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, the revised rating criteria provide a 100 percent rating for unfavorable ankylosis of the entire spine; and a 50 percent rating for unfavorable ankylosis of the entire thoracolumbar spine. The criteria for a 40 percent rating are forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2008). The fact that the revised criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurological sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003); see also 38 C.F.R. § 4.124a Diagnostic Code 8520, outlined above. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5) (2009). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. In evaluating the Veteran's disability, the Board must also consider whether a higher disability evaluation is warranted on the basis of functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 (2009); see DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40 (2009). A part that becomes painful on use must be regarded as seriously disabled. Id.; see also DeLuca. As regards the joints, factors to be evaluated include more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45(f) (2009). The relevant evidence of record reflects the Veteran's frequent reports of lower back pain and that he has received epidural steroid injections and lysis of scar tissue resulting from his prior back surgery to make his injections more effective. However, the evidence does not reflect that the Veteran has ever been prescribed bed rest to treat his lower back condition. The Veteran's lumbar ranges of motion have been assessed during the two VA spinal examinations afforded to the Veteran during the pendency of his appeal and during one private treatment assessment of record. A September 2003 private treatment record reflects that the Veteran demonstrated decreased lumbar flexion, with pain increasing on flexion with tenderness on palpation to his lumbar spine. During his examination conducted in February 2004, the Veteran demonstrated lumbar range of motion from 0 degrees of extension to 45 degrees of flexion, with the Veteran reporting tenderness in the lumbar paraspinal muscles. During his November 2008 VA examination, the Veteran demonstrated forward flexion to 60 degrees (recorded as erect forward flexion, with seated forward flexion to 90 degrees), extension from 0 to 10 degrees, right and left lateral flexion from 0 to 20 degrees, and right and left lateral rotation from 0 to 40 degrees, with no pain noted on range of motion testing. The only evidence reflecting any neurological impairment related to the Veteran's service-connected lumbar spine disability is an impairment to his left lower extremity, variously referred to as sciatica or radiculopathy of the left lower extremity. This impairment has been reported by the Veteran and diagnosed in his private treatment records. During the pendency of this appeal, the Veteran was service-connected for this disability (effective throughout the rating period), and his radiculopathy has been rated as 10 percent disabling based on evidence of mild impairment. The Board notes, however, that the Veteran was not diagnosed with any neurological disorders related to his lumbar spine disability at either his February 2004 or November 2008 VA examinations. The 2004 examiner noted very active reflexes of the Veteran's ankles and knees and the 2008 examiner noted no objective evidence of any radiculopathy, stating that all sensory testing revealed normal results. Turning first to the an analysis of whether the Veteran is entitled to an increased rating based on the regulations in effect at the time the Veteran filed his claim, the Board determines that an increased rating cannot be awarded based on evidence of incapacitating episodes of the Veteran's lower back disability, as the evidence of record fails to reflect that the Veteran has been prescribed bed rest to treat his lumbar spine disability. Moreover, the Veteran denied any such history during his 2008 VA examination. Pursuant to the rating criteria in effect at the time the Veteran filed his claim, he may also be entitled to an increased rating based on the severity of the orthopedic and neurological manifestations of this lumbar spine disability. However, the Board does not find that the Veteran's ranges of motion recorded during the instant rating period are reflective of severe limitation of motion, as the Veteran has demonstrated at least 45 degrees of forward flexion (a range of motion finding recorded in 2004, at which time the examiner characterized the Veteran's limitation of motion as moderately severe). Furthermore, the evidence does not reflect that the Veteran should be awarded an increased rating based on the neurological manifestations of his lumbar spine disability. The evidence of record does not reflect that the only neurological abnormality related to the Veteran's lumbar spine disability, radiculopathy of the lower left extremity, can be characterized as more than mild in severity. Pursuant to Diagnostic Code 8520, the next higher rating of 20 percent rating is assigned based on evidence of moderate incomplete paralysis of the sciatic nerve. As the Veteran was not diagnosed with any radiculopathy at either of his VA examinations, both of which note normal results of the Veteran's sensory testing, the Board concludes that the evidence of record fails to reflect that the Veteran's radiculopathy is productive of moderate incomplete paralysis of his sciatic nerve. Thus, an increased rating based on the neurological manifestations of the Veteran's lower back disability is not warranted. Turning next to the revised rating criteria applicable to the Veteran's lumbar spine disability, the Board again notes that the evidence of record fails to reflect that the Veteran has been prescribed bed rest to treat his back disability; accordingly, an increased rating based on evidence of incapacitating episodes of the Veteran's lower back disability is not warranted. Regarding the orthopedic manifestations of the Veteran's lumbar spine, the evidence of record fails to reflect that the Veteran has demonstrated forward flexion of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Thus, a rating in excess of 20 percent based on the orthopedic manifestations of the Veteran's lumbar spine disability is not warranted. Furthermore, as discussed above, the evidence of record does not reflect that the Veteran should be awarded an increased rating based on the neurological manifestations of his lumbar spine disability, as the only neurological manifestation of record is the radiculopathy of the lower left extremity, and the evidence does not reflect that the Veteran's radiculopathy can be categorized as more than mild paralysis of the sciatic nerve. With regard to the Deluca provisions allowing increased ratings based on evidence of functional loss, the Board notes that during his 2008 VA examination, the Veteran reported that he experiences daily flare-ups of his back pain after extended periods of walking or riding in a car, although he reported that he is independent in his activities of daily living. On repetitive motion testing, the Veteran did not evidence any additional pain on motion, spasms, weakness, tenderness, warmth, redness, or edema. The examiner further noted that any additional limitation of function due to flare-ups could not be calculated without resorting to mere speculation. The Board acknowledges the Veteran's reports of increased pain during flare-ups of his lumbar spine disability; however, given the Veteran's entire disability picture, including his forward flexion recorded as at least 60 degrees during his most recent VA examination and his reports that he is able to independently conduct his activities of daily living, the Board does not find that the Veteran should be awarded an increased rating based on functional loss. The Board specifically acknowledges its consideration of the evidence of the lay evidence of record when adjudicating this claim, including the Veteran's reports of the severity of his back pain, his daily flare-ups, and the effect of his back pain on his daily activities. The Board further acknowledges that the Veteran is competent to report these symptoms, and the Board finds the Veteran's reports to be credible. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). However, given the objective evidence of record, including range of motion findings, prescribed treatment for his lumbar spine disability, and the results of neurological testing, a basis for awarding a rating in excess of 20 percent has not been presented. Psychiatric Disability The Veteran contends that the current severity of his service- connected psychiatric disability entitles him to a disability evaluation in excess of 10 percent. Regarding the rating criteria for psychiatric disabilities, a 10 percent rating is assigned when a psychiatric disability causes occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or when symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9424. A 30 percent rating is assigned when a psychiatric disability causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned when a psychiatric disability causes 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 of short-term 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; or difficulty in establishing and maintaining effective work and social relationships. Id. Private treatment records spanning the year prior to the date the Veteran submitted the instant claim include September 2002 assessments reflecting that the Veteran was alert and fully oriented with his mood assessed as depressed in one instance and improved in a second instance. The Veteran also denied any current suicidal or homicidal ideation and evidenced no auditory or visual hallucinations or delusions. The Veteran was assessed as demonstrating good insight and intact judgment, and he was assigned a Global Assessment of Functioning (GAF) score of 55. In November 2002, the Veteran's mood was assessed as improved and stable, with no suicidal or homicidal ideation reported or any psychotic symptoms demonstrated. In December 2002, the Veteran was assessed as appearing anxious and depressed due to his financial hardships; however, he demonstrated no psychotic features. In January and February 2003, the Veteran was noted to be alert and fully oriented with intact judgment and demonstrating no suicidal ideation or psychotic symptoms. In March 2003, the Veteran was noted to be upset after recently experiencing a seizure (the Veteran is service-connected for a seizure disorder); however, on mental status examination, the Veteran was alert, with no current suicidal or homicidal ideation or psychotic symptoms, Furthermore, the Veteran demonstrated goal- directed thought processes and adequate judgment. In April 2003, the Veteran was noted to be troubled and preoccupied with his unemployment. On mental status examination, the Veteran was fully-oriented and alert with a strained and tense affect, but no suicidal or homicidal ideations, hallucinations, or delusions. The Veteran also demonstrated goal-directed thought processes and adequate judgment. In July 2003, the Veteran was again noted to have no suicidal or homicidal ideations, hallucinations, or delusions. The Veteran was afforded a VA mental disorders examination in March 2004, during which the Veteran reported experiencing irritability and depression. The Veteran also denied experiencing any current suicidal ideation or hallucinations, and the examiner noted that the Veteran was calm and cooperative, with logical, goal-oriented speech of normal rate and rhythm. The examiner assigned a GAF score of 60. A February 2005 VA treatment record reflects the Veteran's report that his depression was controlled by his prescription anti- depressant medication and that he was separated from his wife at the time of the treatment. The treating medical provider noted that the Veteran had no suicidal or homicidal ideation or any auditory or visual hallucinations. In October 2005, the Veteran submitted a statement in which he reported experiencing depression and insomnia. An April 2008 VA treatment record reflects that the Veteran was assessed as alert and oriented to time and place, with a fairly calm, mildly dysthymic, and reactive mood. The Veteran's thought processes were noted to be goal-directed, and the Veteran evidenced no abnormalities of his thought content, including auditory or visual hallucinations or suicidal or homicidal ideations, with his judgment and insight both assessed as fair. The treating medical professional assigned a GAF score of 60. The Veteran was afforded a second VA examination in November 2008, during which he reported experiencing depression due to his physical and personal problems, including his back pain and related unemployment, his financial problems, and his failed prior marriage and strained current marriage. The examiner noted that the Veteran demonstrated no impairment in his thought processes or communication and that the Veteran appeared well- groomed, friendly, and cooperative. The examiner also noted that the Veteran appeared depressed and irritable with full and congruent affect and that the Veteran denied any suicidal or homicidal ideations, hallucinations, delusions. The Veteran's attention, memory, and judgment were also noted to be within normal limits. The examiner noted a GAF score in relation to the Veteran's service-connected chronic adjustment disorder with depressed mood of 75 (noting a different GAF score with regard to the Veteran's nonservice-connected psychiatric disorders). After reviewing all of the evidence of record, the Board concludes that the Veteran's psychiatric disability picture is more accurately reflected by a 30 percent disability evaluation. The Veteran's mood has been assessed as depressed, irritable, and mildly dysthymic, and he has reported chronic sleep impairment related to his psychiatric disability. The Veteran has also reported impaired social relationships, including a failed marriage and a strained current marriage. Moreover, the GAF scores of record, which include scores of 55 and 60, are indicative of a psychiatric disability that is more than 10 percent disabling. However, the Board does not find that a rating in excess of 30 percent is warranted based on the evidence of record. The Veteran's mental status examinations have been largely normal, with no noted impairment of his memory, speech, thought content, thought processes, judgment, or insight. The Veteran has also consistently denied having any suicidal or homicidal ideations, and he has not reported experiencing any panic attacks. Moreover, at his most recent examination, the examiner assigned a GAF score of 75 in conjunction with the Veteran's service- connected psychiatric disability, indicating that any more severe psychiatric symptoms that would warrant a lower GAF score were attributable to two nonservice-connected psychiatric disabilities. The Board specifically acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran's reported psychiatric symptomatology. Indeed, the Veteran's reported symptomatology, including his chronic sleep impairment, were considered by the Board when awarding his increased rating. However, the objective evidence of record, including the results of the numerous mental status examinations of record, fails to reflect a basis for awarding a rating in excess of 30 percent. Extraschedular Consideration The Board has also considered whether a referral for an extraschedular evaluation is warranted with regard to the Veteran's lower back and psychiatric disability increased rating claims. The threshold factor for extraschedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service connected disabilities at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. See VAOGCPREC 6- 1996 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology and provides for additional or more severe symptoms with regard to both disabilities than is currently shown by the evidence; thus, the Veteran's psychiatric and lower back disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. Consequently, referral for extraschedular consideration is not warranted. ORDER A disability rating in excess of 20 percent for a service- connected lower back disability is denied. A disability rating of 30 percent for a service-connected psychiatric disability is granted. REMAND The Board finds that further evidentiary development is warranted before the Veteran's service connection claim for a left shoulder disorder may be adjudicated on its merits. The Veteran has had two periods of active service, the first from January 1992 to April 1992, and the second from December 2001 to March 2002. The Veteran reports having several left shoulder surgeries, one before his first period of service and two between his two periods of service. However, the Veteran also contends that he reinjured his left shoulder during his second period of duty. The evidence of record reflects that the Veteran did not seek treatment for any left shoulder problems during his first period of service, nor were any left shoulder abnormalities noted on his separation from that period of active duty. The evidence also does not reflect, nor does the Veteran contend, that he reinjured or aggravated his left shoulder condition during a period of active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). Regarding the Veteran's contention that he reinjured, and therefore permanently aggravated, his left shoulder during his second period of active duty, the record does not reflect that a physical examination was conducted prior to the Veteran's entrance into his second period of active duty. However, the evidence does reflect assessments of his left shoulder condition conducted in May and June 2001, relatively soon before his entrance into active service in December 2001. These May and June 2001 records reflect that the Veteran's left shoulder condition was assessed as impingement syndrome with mild shoulder instability. The record further reflects that the Veteran sought treatment for his left shoulder in March 2002, during the end of his second period of active service, at which time he was diagnosed left shoulder cuff tendonitis and recurrent anterior GH instability. That same month, the Veteran was also issued a physical profile restricting him from lifting more than 10 pounds with his left arm, overhead lifting with his left arm, prolonged overhead use of his left arm, and performing pushups or pull-ups. Although the record includes an administrative decision that the Veteran's shoulder disability was not aggravated by his 2001/2002 service, a medical opinion on that question is more appropriate for purposes of determining entitlement to VA benefits. Additionally, any outstanding VA treatment records should be obtained and associated with the Veteran's claims file. 38 C.F.R. § 3.159(c)(2) (2009). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from November 2008 to the present. 2. Schedule the Veteran for an appropriate VA examination to determine whether any currently-diagnosed left shoulder disorder underwent a permanent increase in severity during the period of service from December 2001 to March 2002, and if so, whether or not that increase in severity represented a natural progression of the condition. The examiner should be provided with a copy of the Veteran's claims file. A complete rationale for any opinion expressed also should be provided. If the examiner determines that a medically-sound opinion cannot be reached, it is requested that an explanation as to why that is so be included. 3. Thereafter, the evidence should be reviewed, and the claim re-adjudicated. If the claim remains denied, the Veteran should be provided a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board for further 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 Supp. 2009). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs