Citation Nr: 1122769 Decision Date: 06/14/11 Archive Date: 06/28/11 DOCKET NO. 10-01 808 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an initial increased rating for service-connected right shoulder strain, currently evaluated as 10 percent disabling. ATTORNEY FOR THE BOARD Shabnam Keyvan, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1999 to October 2008. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from the February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which, in pertinent part, granted service connection for the right shoulder strain, and evaluated it as 10 percent disabling. Before the matter was certified to the Board, in a December 2009 rating decision, the RO granted service connection for depression, combined it with the Veteran's service-connected anxiety disorder, and re-characterized the Veteran's psychiatric disorder as major depression and anxiety disorder with panic attacks, evaluating it as 50 percent disabling, effective October 24, 2008. This grant of service connection constitutes a full award of the benefit sought on appeal with respect to this claim. See Grantham v. Brown, 114 F. 3d 156, 1158 (Fed. Cir. 1997). The record on appeal contains no indication that the Veteran has appealed the downstream elements of effective date or initial rating for this disorder. Thus, this matter is not in appellate status. The February 2009 rating decision also granted service connection for costochondritis of the right shoulder blade and medial to the right shoulder blade/rib area, and evaluated it as 10 percent disabling, effective October 24, 2008. The Veteran filed a Notice of Disagreement (NOD) with this rating decision in March 2009, and in the December 2009 Statement of the Case (SOC) the Decision Review Officer (DRO) denied the Veteran's claim for an initial evaluation in excess of 10 percent for costochondritis of the right shoulder blade and medial to the right shoulder blade/rib area. In her January 2010 substantive appeal, the Veteran checked the box indicating that she had reviewed the SOC, and she only wished to appeal the RO's denial of an initial increased rating for her service-connected right shoulder strain, rated as 10 percent disabling. As such, the Board finds that the issue of entitlement to an initial evaluation greater than 10 percent for service-connected costochondritis of the right shoulder blade and medial to the right shoulder blade/rib area is not in appellate status. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) (pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA). FINDINGS OF FACT 1. The Veteran is right-hand dominant. 2. The Veteran's right shoulder disability is not manifested by nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula; nor is it productive of limitation of motion of the arm at shoulder level. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 10 percent for the right shoulder strain have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Codes 5200-5203 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. In Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. When VA receives a substantially complete application for benefits, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Where service connection has been granted and an initial disability rating and effective date have been assigned, the claim for service connection has been substantiated, and any defect in the notice regarding that claim was therefore not prejudicial to the claim. Dingess, 19 Vet. App. at 491. Where the appellant then files a notice of disagreement with the initial rating and/or the effective date assigned, the appellant has initiated the appellate process and different, and in many respects, more detailed notice obligations arise, the requirements of which are set forth in sections 7105(d) and 5103A of the statute. Id; Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); 38 U.S.C.A. § 5103(A) & 7105(d). Here, prior to the initial adjudication of the Veteran's claim seeking service connection for a right shoulder condition in February 2009, the RO sent the Veteran a letter in September 2008 which satisfied the duty to notify provisions with respect to this service connection claim, and informed her how a disability rating and effective date would be assigned should service connection be granted. In any event, because the claim for service connection has been granted, any defect in the notice or timing of the notice about how a disability rating and effective date would be determined was harmless error as to this claim. Dingess, 19 Vet. App. at 491; Goodwin, 22 Vet. App. at 137. Rather, in the current appeal, the Veteran challenges the initial evaluation assigned following the grant of service connection for her right shoulder sprain. The Veteran submitted her NOD regarding the February 2009 rating decision, in March 2009, thereby triggering the notice obligations set forth in sections 7105(d) and 5103A of the statute. The RO then fulfilled these notice obligations by issuing an SOC in December 2009 which informed the Veteran of the regulations pertinent to her appeal (including the applicable rating criteria), advised her of the evidence that had been reviewed in connection with her appeal, and provided her with reasons for its decisions. 38 U.S.C.A. § 7105(d). Thus, the notice obligations set forth in sections 7105(d) and 5103A of the statute have been fulfilled. The Board also concludes that VA's duty to assist the Veteran has been satisfied in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's increased rating claim. Moreover, in addition to obtaining all relevant records, the Veteran was also afforded a VA examination for her shoulder condition in August 2009. There is no objective evidence indicating that there has been a material change in the severity of her service-connected disorder since the Veteran was last examined. See 38 C.F.R. § 3.327(a) (2010). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examination obtained in this case is more than adequate, as it was predicated on an interview with the Veteran, a review of her medical records, and a discussion of her medical history and because the examination fully addresses the rating criteria that is relevant to rating the disability in this case. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the initial increased rating issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). With no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more 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. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a Veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous...." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, 'staged' ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the 'present level' of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the scheduler criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluation a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2010). However, it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In reaching the following decision, the Board has considered the Veteran's assertions regarding the severity of her right shoulder symptoms. Indeed, in the current appeal, the Veteran contends that she is entitled to a higher evaluation for her service-connected right shoulder strain because the current disability evaluation does not adequately reflect the current severity of her disability. See March 2009 NOD and January 2010 substantive appeal. The Board finds that the Veteran is certainly competent to discuss the severity of her symptomatology. As a lay person, however, the Board gives more weight to the specific objective findings obtained through specialized testing and physical examinations. Such matters require medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran's chronic right shoulder strain is currently assigned a 10 percent disability evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5203. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The Veteran is right handed and as such, major, as opposed to minor, extremity disability ratings are applicable. 38 C.F.R. § 4.69. Under Diagnostic Code 5201, for a dominant arm, a 20 percent evaluation is provided for limitation of motion of the arm at shoulder level; a 30 percent evaluation may be assigned for limitation of motion midway between the side and shoulder level; and a 40 percent evaluation may be assigned for limitation of major arm motion to 25 degrees from the side. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. The standard ranges of motion of the shoulder are 180 degrees for forward elevation (flexion) and 180 degrees for abduction. The standard range of motion for internal and external rotation is 90 degrees. 38 C.F.R. § 4.71, Plate I. Under Diagnostic Code 5203, a 20 percent disability evaluation is contemplated for impairment of the clavicle or scapula, manifested by nonunion with loose movement. A 20 percent disability evaluation may also be assigned for dislocation of the clavicle or scapula. The Veteran was afforded a VA examination in November 2008, during which she reported to experience recurring pain in her shoulder two times a month, which continues to linger until she changes her position. She also described a popping sensation in her right shoulder, but no grinding or swelling. During their discussion, the Veteran informed the examiner of the difficulty she experiences when she works at a computer, and stated that she can only do so for 15 minute intervals until she needs to take a break. She also indicated that she does not have any functional limitations when it comes to lifting and overhead work. According to the Veteran, she is currently unemployed and taking a break before she returns to work. However, this decision is voluntary and not due to any medical reasons. Physical examination of the right shoulder revealed 5/5 strength and pain to palpation of the right shoulder blade. The Veteran was shown to have forward elevation to 180 degrees with no pain; abduction to 180 degrees, with pain from 100 degrees to 180 degrees; internal rotation to 90 degrees, with pain from 0 to 90 degrees; and external rotation to 90 degrees, with no pain. Besides the pain noted herein, the examiner did not observe signs or flare-ups of pain following repetitive motion. The examiner further observed that the Veteran's joint function was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive motion. In addition, the Veteran also underwent an X-ray of the Veteran's right shoulder, the findings of which revealed an intact humerus, a well-maintained joint space, and an acromioclavicular joint that was within normal limits. Based on the examiner's impression, results from the X-ray were unremarkable with respect to the right shoulder condition. Based on his review of the Veteran's claims file and medical records as well as the physical examination of the Veteran, the examiner diagnosed the Veteran with a chronic right shoulder strain. Private medical records dated from November 2008 to February 2009 reflect that the Veteran received numerous physical therapy treatment sessions for her right shoulder condition. During these treatment sessions, the Veteran described persistent pain, soreness and discomfort in her right scapular and interscapular region, and reported to experience difficulty when brushing her teeth. Her treatment consisted of electric stimulation therapy, deep tissue and trigger point massage treatment sessions, and several myofascial release techniques. In the February 2009 progress report, the physical therapist took note of the Veteran's progression with respect to strengthening her shoulder, but noted that the Veteran continued to experience severe pain in the interscapular area, involuntary muscle contractions in the right shoulder blade, and certain limitations as a result of this shoulder pain. However, the Board notes there were no range of motion findings reflecting limitation of motion of the arm at the shoulder area, at the area midway between her side and shoulder level, or to 25 degrees from the side. In addition, there was nothing in the treatment records to show that the Veteran had any impairment in her clavicle or scapula demonstrated by nonunion of or dislocation of the clavicle or scapula. An April 2009 magnetic resonance imaging (MRI) of the Veteran's thoracic spine reveals findings of a small syrinx within the thoracic cord which begins at the T4-5 disk space and extends inferiorly from T7 through the T10 disk level. The impression derived from this MRI was that of mild syringomyelia. The Veteran was afforded another VA examination in August 2009, during which she provided her medical history, and explained that she first began experiencing pain in her right shoulder blade in 2001 while sitting in class. According to her, the pain would arise whenever she took a deep breath. The Veteran describes the pain as tender and constant, and states that she takes over the counter medication which helps alleviate the pain to some level, thereby making it more bearable. She also experiences a popping sensation in her right shoulder, but no grinding or swelling. The Veteran explained that the pain in her right shoulder flares up three times a month, lasts two to three days, and "will usually clump together," causing her to limit the use of her right arm. The Veteran further states that the pain in her right shoulder worsens after sitting for a period longer than 10 to 15 minutes. According to her, the pain radiates from her right neck, down to her right shoulder blade to her mid-back, and is unbearable during these flare-ups. On a scale of one to ten (one being the least pain and ten being the most), she rates her pain at a seven. She claims that her shoulder pain limits her activities of daily living, and that such pain is aggravated during activities which involve repetitive motion of the right arm and shoulder, to include brushing her teeth or washing her hair. She also claims to experience pain with repetitive overhead movements of the right shoulder, but experiences no limitation when it comes to lifting objects. The Veteran worked as an Intel personnel while serving in the Navy, and wishes to find a desk job, but fears sitting for long periods of time could exacerbate her shoulder pain. Physical examination of the right shoulder reflects that she is tender to palpation of the right lower medial scapular edge. She was shown to have forward elevation to 180 degrees, with no pain; abduction to 180 degrees, with pain from 100 to 180 degrees; and internal and external rotation to 90 degrees with pain. Based on the examiner's observations, other than the pain noted above, the Veteran did not experience additional pain or flare-ups of pain during range of motion exercises. The examiner also observed that the Veteran's joint function was not additionally limited by pain, weakness, fatigue or lack of endurance after repetitive use. Upon review of the April 2009 MRI, the examiner noted that the results showed mild syringomyelia extending from the T4-5 disk space inferiorly to the T10 disk level. Based on his discussion with the Veteran, review of the medical records, and physical examination of the Veteran, the examiner diagnosed the Veteran with mild syringomyelia that extends from the fourth to fifth thoracic disk space to the tenth thoracic vertebra, and causes radicular pain in the fourth to fifth thoracic vertebra region on the right side. The examiner concluded that there were no clinical or objective findings for a right shoulder joint condition. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial increased rating for her chronic right shoulder strain. The competent medical evidence of record fails to show nonunion of or dislocation of the clavicle or scapula at any time during the appeal period. Both the November 2008 X-ray report and the August 2009 MRI results were negative for findings of any joint condition in the right shoulder. Indeed, the November 2008 X-ray report indicated that the acromioclavicular joint was within normal limits. In addition, the medical evidence of record does not reflect limitation of motion of the arm at shoulder level, midway between the side and shoulder level, or major arm motion to 25 degrees from the side. Specifically, the November 2008 and August 2009 VA examination reports reflect forward elevation to 180 degrees and abduction to 180 degrees. While the Veteran expressed some complaints of pain on movement during abduction, these measurements still far exceed the criteria for an evaluation greater than 10 percent under Diagnostic Code 5201. The Board also observes that the rating schedule contains additional diagnostic codes pertaining to the shoulder and arm. See 38 C.F.R. § 4.71a, Diagnostic codes 5200 and 5202. While the Board has considered whether an increased evaluation would be in order under other relevant diagnostic codes, the Board finds that the criteria for a rating in excess of 10 percent for the Veteran's right shoulder disability are simply not met. In this regard, the medical evidence of record does not show the Veteran to have ankylosis of the scapulohumeral articulation or other impairment of the humerus. As demonstrated by the range of motion findings of record, the Veteran's arm and shoulder do not appear to be fixed or immobile. The Board notes that ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint", citing Stedman's Medical Dictionary 87 (25th ed. 1990). Moreover, the November 2008 and August 2009 examiners indicated that the Veteran's right shoulder had a normal configuration, and the report of the November 2008 X-ray revealed the proximal humerus to be intact. There is no other indication that she has a malunion of the humerus or recurrent dislocation of the scapulohumeral joint at any time during the appeal periods. Therefore, the Board finds that the Veteran is not entitled to a higher or separate evaluation under Diagnostic Codes 5200 and 5202. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's right shoulder strain is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions and the medical evidence of record reveals objective findings of pain during range of motion exercises. The August 2009 VA examiner specifically observed the Veteran's complaints of pain while performing certain day to day activities, such as brushing her teeth and washing her hair. However, the Board notes that the effect of the recurrent pain in the Veteran's right shoulder is contemplated in the currently assigned 10 percent disability evaluation under Diagnostic Code 5203. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant a higher initial evaluation. In fact, both the November 2008 and August 2009 VA examiners noted that there was no additional limitation of joint function due to pain, weakness, fatigue or lack of endurance after repetitive use. Therefore, the Board finds that the preponderance of the evidence is against an initial increased evaluation for the Veteran's right shoulder strain. III. Extraschedular Consideration In denying the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon 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 that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2010). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected right shoulder disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's right shoulder with the established criteria found in the rating schedule for disabilities of the shoulder shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology; as discussed above, the rating criteria considers range of motion, and pain on motion. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for her service-connected right shoulder disability. Indeed, based on the post-service treatment records, it does not appear that the Veteran has required any additional surgery or hospitalization for her right shoulder condition. Additionally, there is not shown to be evidence of marked interference with employment due to the disability. While the Veteran asserts in her January 2010 substantive appeal that she is currently unemployed and unable to obtain employment, the evidence of record reflects that the Veteran's unemployment is her own voluntary decision, and not due to a medical reason. During the November 2008 VA examination, the Veteran indicated that she wished to take some time off before returning to work. During the August 2009 VA examination, she stated that she had been unable to find a job, but wished to work at a desk job. While she expressed concern regarding her ability to work at a desk job due to her shoulder condition, there is no evidence to show that she has actually worked at a desk job and/or experienced any difficulty obtaining or maintaining employment due to her service-connected shoulder condition. Indeed, there is nothing in the record which suggests that the right shoulder disability has markedly impacted her ability to pursue any form of employment. Indeed, even if the Veteran did experience difficulty working at a desk job, there is nothing in the record to show that she is unable to obtain a different form of employment. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the Veteran's service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER An initial evaluation in excess of 10 percent for the service-connected right shoulder strain is denied. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs