Citation Nr: 1126490 Decision Date: 07/14/11 Archive Date: 07/21/11 DOCKET NO. 10-08 199 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for thoracic back strain. 2. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 3. Entitlement to an initial rating in excess of 20 percent for status post left shoulder dislocation. 4. Entitlement to an initial rating in excess of 10 percent for myospasm of the cervical spine. 5. Entitlement to an initial compensable rating for hyperhidrosis. ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from September 2004 to November 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July and October 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The July 2008 rating decision granted service connection for status post left shoulder dislocation, assigned an initial 20 percent rating; myospasms of the cervical spine, assigned an initial 10 percent rating; and, acne and pseudofolliculitis barbae, hyperhidrosis, and hypertension, each assigned initial noncompensable ratings. At that time, the RO denied service connection for gastroenteritis, myopia, thoracic back strain, erythema multiforme, residuals of circumcision, and PTSD. The October 2008 rating decision granted service connection and an initial 50 percent rating for PTSD. The Veteran perfected an appeal only as to the matters set forth on the decision title page. FINDINGS OF FACT 1. A clear preponderance of the evidence is against a finding that chronic thoracic back strain had its onset during or was otherwise caused by active service. 2. PTSD has not been productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 3. Status-post left shoulder dislocation is not exhibited by ankylosis or humerus symptomatology, nor has it more nearly approximated limitation of motion to 25 degrees from the side at any time during the appeal period. 4. Cervical spine myospasm is not manifested by forward flexion of the cervical spine of less than 30 degrees, or muscle spasm severe enough to result in abnormal spinal contour. 5. Hyperhidrosis has not rendered the Veteran unable to handle paper or tools because of moisture or been unresponsive to therapy. CONCLUSIONS OF LAW 1. Chronic thoracic back strain was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 2. The schedular criteria for an initial rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code (DC) 9411 (2010). 3. The schedular criteria for an initial rating in excess of 20 percent for status post left shoulder dislocation are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a, DC 5201 (2010). 4. The schedular criteria for an initial rating in excess of 10 percent for myospasm of the cervical spine are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a, DC 5237 (2010). 5. The schedular criteria for an initial compensable rating for hyperhidrosis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.118, DC 7832 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist In a March 2008 letter, the agency of original jurisdiction (AOJ) satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010) and 38 C.F.R. § 3.159(b) (2010). The AOJ notified the Veteran of the information and evidence necessary to substantiate his claims. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In the March 2008 letter, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dings/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran's increased rating claims arise from his disagreement with the initial evaluations following the grants of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). His service treatment and personnel records were obtained. The Veteran's VA records have been associated with the claims file, to the extent available, and he has not identified any relevant non-VA treatment records. All reasonably identified and available medical records have been secured. In May and October 2008, the Veteran underwent VA examinations in conjunction with his claims and the reports are of record. The Board finds that the duty to assist the Veteran has been satisfied in this case. II. Factual Background and Legal Analysis The Board has reviewed the record in conjunction with this case that includes the Veteran's service treatment records, VA medical records and examination reports, dated from 2008 to 2009, and his written statements in support of his claim. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). A. Service Connection The Veteran contends that he sustained a thoracic back strain due to heavy lifting (see May 2008 VA orthopedic examination report) and, in his February 2008 initial claim for benefits, said he had thoracic back pain since June 2007. He also indicated that he developed thoracic back pain after an incendiary explosive device blast in which he injured his left shoulder (see June 25, 2008 VA outpatient record) and had back pain in his thoracic region since that time. Thus, he believes that service connection for thoracic back strain is warranted. Under 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. "[I]n order to establish service connection or service- connected aggravation for a present disability the veteran must show: (1) the existence of a present disability; (2) in- service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F. 3d 1163, 1166-67 (Fed. Cir 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (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. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, or even leg numbness, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran asserts that he a thoracic back strain that was incurred as a result of a heavy lifting or, alternatively, a truck accident in which he injured his left shoulder. Thus, he maintains that service connection is warranted for a thoracic back strain. Service treatment records indicate that, when examined for enlistment into service in July 2004, the Veteran's spine was normal and he was found qualified for active service. An April 2005 clinical record reflects the Veteran's complaints of back pain that was assessed as a back strain. In July 2006, the Veteran reported a 5-month history of upper back and neck pain, for which he requested physical therapy. During July and August 2006, clinical records indicate that he underwent physical therapy for upper thoracic and lower cervical pain that was slowly resolving. A December 2006 clinical record indicates that the Veteran was evaluated for a shoulder tissue injury and a backache. He reported upper back pain between his shoulder blades and the assessment was strain in the left upper trapezium and periscapular soft tissues. Subsequent records include his report of a backache. When examined for separation in July 2007, neither a spine nor musculoskeletal abnormality was noted. According to a May 2008 VA orthopedic examination report, the examiner reviewed the Veteran's medical records. The Veteran reported that his low back pain started in 2005 while lifting heaving objects. He was seen in sick call, treated with medications and given limited duty, and his pain resolved. The Veteran experienced recurrent back pain with heavy lifting and completed a course of physical therapy, but still had intermittent episodes of low back pain with heavy lifting or bending the wrong way. He had not recently been evaluated for his back pain. Objectively, there was normal range of thoracolumbar spine motion with no evidence of pain on active range of motion. Results of x-rays taken at the time revealed no fracture or dislocation or significant degenerative changes seen. The VA examiner reported no objective findings and did not diagnose a back/thoracic disorder. A June 2008 VA outpatient physical therapy record indicates that the Veteran developed neck and back pain after his left shoulder injury. He had back pain in his right lower thoracic region and upper lumbar area. Objectively, there was full range of lumbar motion with pain. The assessment included neck pain due to compensation by upper trapezium and levator to elevate arm and right mid-low back to stabilize a weak left scapular. It was noted that the Veteran was relieved to know that his neck and back pain were related to shoulder pain and not a new problem. The Veteran has contended that service connection should be granted for thoracic back strain. No thoracic back strain was found on separation from service. Moreover, on VA examination after the Veteran's separation from service, there was no showing that the Veteran had thoracic back strain. Furthermore, the Veteran has submitted no evidence to show that he currently has a thoracic back strain. In short, no medical opinion or other medical evidence showing that the Veteran currently has a thoracic back strain has been presented. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); see also Degmetich and Brammer, supra. The Veteran is competent to state that he has pain in the area of his thoracic spine. However pain is not analogous to disability. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (the claimant was seeking service connection for a neck disability and an increased rating for a low back disability. On the issue of service connection, the Court held that pain alone without a diagnosed or identifiable underlying malady or condition did not constitute a disability for which service connection may be granted. Subsequently, the Federal Circuit dismissed the issue of service connection stating it was precluded from reviewing the factual determinations of the Board or the Court.). The Veteran is not competent to diagnose any thoracic spine disability and even if he could, any claim to this effect is contradicted by the clinical evidence. On VA orthopedic examination in May 2008, there was no thoracic back strain detected and the Veteran's back was essentially normal. In fact, there is no clinical corroboration that the Veteran has a chronic thoracic back strain and his claim is not established. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Caluza v. Brown, 7 Vet. App. 498, 505 (1995) (recognizing that "[a] service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability"). The June 2008 VA physical therapist related the Veteran's complaints of neck and upper back pain to his service-connected left shoulder disability. The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for a thoracic back strain, and his claim must be denied. B. Increased Ratings The present appeal involves the Veteran's claim that the severity of his service-connected left shoulder, cervical spine, PTSD, and hyperhidrosis disabilities warrant higher initial disability ratings. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Additionally, although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1, 4.2, when assigning a disability rating, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation during the relevant rating period. Fenderson v. West, 12 Vet. App. 119 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 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) (2010). 1. Initial Rating in Excess of 50 Percent for PTSD The General Rating Formula for Mental Disorders, including Diagnostic Code 9411, that evaluates PTSD, at 38 C.F.R. § 4.130, provides the ratings for psychiatric disabilities. A 50 percent rating is warranted if the disability is productive of 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- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32). A GAF score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 denotes mild symptoms or some difficulty in social and occupational functioning. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). The Veteran contends that he is entitled to a higher rating for his service-connected PTSD. Upon review of the evidence of record, the Board concludes that a rating in excess of 50 percent for PTSD is not warranted for any time since the Veteran filed his initial claim. Service treatment records, dated in March 2007, refer to the Veteran's history of psychological issues. On a report of medical history completed in July 2007, when examined for separation, the Veteran reported having sleep difficulty including nightmares and depression. Post service, VA medical records, dated from 2008 to 2009, reflect that the Veteran's PTSD was treated with outpatient psychotherapy and prescribed anti-depressant and anti-anxiety medications. In June 2008, the Veteran was initially evaluated by a VA psychiatrist in the outpatient clinic. The Veteran complained of sleep difficulty, nightmares, fatigue, hypersensitivity, people watching him, fear of going out, fear of being in a car, anxiety, and depression. He was in combat in Iraq during 2006 and 2007 and was in a truck that was hit by mortar fire. The Veteran had an ongoing fear of being killed. He had some college education, wanted to be a computer engineer, was married, and currently worked in a warehouse. Objectively, the Veteran was casually dressed with fair hygiene and well groomed. H was alert, oriented, and cooperative during the interview. His eye contact was good, his mood/affect was "depressed", and his speech was fluent with normal rate and volume. The Veteran's thought processes were organized and there was no evidence of delusions, obsessive thoughts, or phobias. He was fearful of being watched and his judgment and insight were fair. The Veteran denied any suicidal and homicidal thoughts, intents and/or plans. The Axis I diagnoses were PTSD and depression, not otherwise specified. A GAF score of 50 was assigned. When seen by his VA clinic psychiatrist in August 2008, the Veteran's symtoms included numbness regarding his feelings, emotionally painful flashbacks, and feeling self-conscious about people looking at him. Since last seen, his wife left to stay with her family. They were getting pastoral counseling through the church and he was depressed at her leaving. Objectively, the Veteran was calm, well groomed and appropriately dressed. He was alert and oriented, his speech was coherent, his thought processes were organized and his insight and judgment were good. He denied auditory and visual hallucinations and suicidal and homicidal ideations or plans. A GAF score of 55 was assigned. A September 2008 VA outpatient psychiatry note includes the Veteran's complaints of depressed mood, startle response, discomfort with war trauma events, feeling detached, and trying to cope with the uncertainty of his wife having left him to return to her family. Objectively, he was calm, cooperative, and well groomed and appropriately dressed. He was alert and oriented with good eye contact. His speech was clear, his mood was "blunted but better" and his judgment and insight were good. The Veteran's thought processes were organized and there were no delusions or auditory or visual hallucinations. He denied suicidal and homicidal ideations. A GAF score of 55 was assigned. As to efficacy of the therapy, his VA psychiatrist noted that the Veteran was beginning to make progress in increased motivation to face and deal with fears. The Veteran agreed to go out with a friend to a nightclub where he used to enjoy the music. The Veteran underwent VA examination in October 2008. According to the examination report prepared by a nurse practitioner, the Veteran's medical records were reviewed. He reported having a depressed and irritable mood since 2006. The Veteran indicated that he had a fairly good childhood and reported being socially active and was involved in multiple extracurricular activities. He had some college education. The Veteran said he worked in a fast food restaurant and was an after care assistant for children (evidently from 1999 to 2003). He denied any problems associated with alcohol use or abuse and gave a history of being wounded during an ambush while in a truck in Iraq when he sustained a shoulder fracture. Further, the Veteran reported having significant marital problems as a result of his changed personality since returning from Iraq and was separated from his spouse. He was significantly more reclusive and denied seeing many people. He preferred to stay in his home and did not enjoy public venues or events. He denied having any activities or leisure pursuits. The Veteran denied suicidal attempts and a history of assaultiveness. He said he was depressed and "numb" particularly since his wife moved out one month earlier. Since his November 2007 service discharge, he was not himself, and preferred to be alone in his home. Before service, he was very social with his wife and regularly saw friends and family. He reported sleep difficulty and next day fatigue. Objectively, the Veteran was neatly groomed and appropriately and casually dressed. He was cooperative, with a constricted affect and a depressed and irritable mood. The Veteran said he was sometimes distracted during work when he started to recall some events in Iraq. He was oriented with unremarkable thought processes. His thought content had ruminations and paranoid ideation but no delusions. The Veteran understood the outcome of behavior and that he had a problem. He had persistent auditory hallucinations. The Veteran had inappropriate behavior in that he reported being verbally aggressive and losing his temper inappropriately at work and with his wife. He denied having obsessive/ritualistic behavior but had moderate to severe panic attacks approximately once a week since 2007. The Veteran had passive homicidal and suicidal thoughts without intent or plan. He had poor impulse control and reported incidents of verbal aggression that resulted in his avoiding people and public venues. His memory was normal. He said he had moderate to severe PTSD symtoms since his combat incident in Iraq. Moreover, the Veteran was currently employed full time in warehouse distribution. He had problems with decreased concentration, difficulty following instructions, inappropriate behavior, and poor social interaction. The Axis I diagnoses were PTSD and major depressive disorder. It was noted that the Veteran endorsed symtoms of irritability, depressed mood, insomnia, anhedonia, decreased energy, etc., that met the criteria for major depressive disorder. The examiner was unable to separate the symtoms as they over overlapped. A GAF score of 55 was assigned. The VA examiner commented that the Veteran said that, since his accident in Iraq, he was chronically depressed, irritable, and isolative with poor impulse control and socially avoidant behavior. He had decreased concentration, hyperaroual, hypervigilance, paranoid ideation, flashbacks, nightmares, and depressed/irritable mood. The Veteran said he was sometimes distracted and at times had difficulty following instructions at work. When seen by his VA clinic psychiatrist in early October 2008, the Veteran's mood was depressed and he reported heavily drinking beer since earlier in the week. It was noted that his wife called and said their relationship was definitely over. She wanted her furniture and belongings. He was saddened and missed several days of work. He planned to return to work. The Veteran felt he was back in control and was motivated to get his life together with plans to obtain a day job and go to school at night. He felt that, while he hurt over this news, he was able to accept what happened and work on his own life path. The Veteran did not take his prescribed medication while drinking but would resume it. He was overall optimistic about the future. Objectively, the Veteran was well-groomed and appropriately dressed. He was calm, cooperative, and oriented, with good eye contact and normal speech. His thought processes were organized and his insight and judgment were good. He denied auditory and visual hallucinations and suicidal and homicidal ideations. A GAF score of 60 was assigned. A late October 2008 VA psychiatry note indicates that the Veteran was seen for treatment of his symtoms of flashbacks, sleep discontinuity, and depressed mood. He reported that he stopped drinking, and continued to work a night shift at his job, but hoped to get positive news from the VA Vocational Rehabilitation division regarding getting him a better job and educational funding. His affect appeared a bit brighter. The Veteran said his sleep was improved; he recently had a flashback for the first time in two weeks, and saw his former wife a few days ago, but was better able to cope with it. His sleep was improved; and he talked with another girl at church over the past weekend and was positive about it. Objectively, the Veteran was calm, cooperative, well groomed and appropriately dressed. He was alert and oriented. His mood was depressed at times and his speech was clear, his thought processes were organized and there were no delusions expressed. The Veteran denied auditory and visual hallucinations and suicidal and homicidal ideations. A GAF score of 55 was assigned. According to a November 2008 VA psychiatry note, the Veteran's target symtoms included difficulty with sleep continuity and falling asleep, nightmares, depressed mood, coping with his marriage breakup, and working the night shift at a labor intensive job. Since last seen, he was observed to be doing significantly better. His sleep was much improved, although he still had periodic combat-related nightmares and flashbacks. He appeared more animated, got together with a friend as they were teaching each other more about computing as he wanted to get into programming and return to school once he can find a day job. He tolerated prescribed medications well and benefitted from individual psychotherapy. The Veteran was accepting his divorce and no longer preoccupied with the hurt of the breakup. Objectively, the Veteran appeared calm, cooperative, well-groomed and appropriately dressed. He was alert and oriented with good eye contact. The Veteran's was "depressed at times but much less". His speech was clear and coherent and his thought processes were organized and goal-directed. The Veteran denied preoccupations and did not express any delusions. He denied having any hallucinations. His insight and judgment were good and he denied suicidal and homicidal thoughts. A GAF score of 60 was assigned. A May 2009 VA outpatient social work note indicates that the Veteran reported that he was recently laid off from his job and since then had been drinking. He said he enjoyed his job that distracted him from his intrusive thoughts. He currently was "just sitting on the couch and drinking", that was not what he wanted to do. He reported no longer taking his antidepressant medication after it ran out and did not want a follow up appointment at that time. The Veteran agreed to attend Alcoholics Anonymous. Objectively, the Veteran was casually dressed and well groomed. He was oriented and alert. His mood was depressed and his affect was congruent with mood. His speech was normal and eye contact was good. The Veteran's memory was intact, his thought process was logical and coherent, and his attention and concentration appeared within normal limits. He exhibited sufficient awareness of his current condition and limitations. There were no signs of perseveration, impulsivity or problems with initiation, no agitation, and no evidence of abnormal thought content such as hallucinations or delusions. He denied suicidal or homicidal ideation. After reviewing the record and the relevant rating criteria, it is concluded that no more than the currently assigned 50 percent rating is warranted for the Veteran's service-connected PTSD. The VA examination and outpatient treatment records suggest that no more than a 50 percent rating is in order. In June 2008, a VA clinic psychiatrist reported the Veteran's complaints of sleep difficulty, anxiety, depression, and fear of going out and assigned a GAF score of 50. However, in July 2008, that VA psychiatrist said that the Veteran had good restful sleep without nightmares and felt brighter and more energetic and assigned a GAF score of 55. In August 2008, the VA clinic psychiatrist noted the Veteran's depression over his marital separation, but a GAF score of 55 was again assigned. Further, in September 2008, the VA clinic psychiatrist noted that the Veteran was sleeping better with his prescribed medication, engaged in individual psychotherapy, but still had fears of the stimulus of being outside the house too much, and assigned a GAF score of 55. But, in October 2008, a VA examiner noted the Veteran's paranoid ideation and auditory hallucinations and panic attacks, although a GAF score of 55 was again assigned. In November 2008, the VA clinic psychiatrist noted the Veteran's sleep difficulty, depressed mood, coping with marital breakup and working on a night shift at a labor intensive job, but said the Veteran was doing "significantly better" then when last seen and assigned a GAF score of 60. Thus, it seems that the GAF scores assigned during the appeal period are not inconsistent with the symtoms reported of moderate psychiatric disability. The available outpatient records reflect the Veteran's complaints of depression, social isolation, easy irritability and anger, combat-related sleep difficulty, and hyperarousal. The October 2008 VA examination report reflects symptoms consistent with a 50 percent evaluation. The other objective medical evidence, including the VA treatment records, dated from 2008 to 2009, further demonstrates that the Veteran reported anger and irritability, sleep difficulty and nightmares, intrusive thoughts, hyperarousal, social isolation, depression, and impaired concentration. However, the record does not show persistent symptoms that equal or more nearly approximate the criteria for a rating in excess of 50 percent at any time during the pendency of the Veteran's appeal. Symptoms such as a decline in personal hygiene, spatial disorientation, near-continuous panic, or other symptoms set out for the 70 percent rating are not shown. VA examiners have repeatedly described the Veteran as oriented with no evidence of psychotic thought. Although, in October 2008, the VA examiner noted the Veteran's report of paranoid ideation and auditory hallucinations, the Veteran denied such symtoms in all subsequent clinical records prepared by his VA clinic psychiatrist. Also, in June 2008, that VA psychiatrist said that the Veteran as well-groomed with fair hygiene, and subsequent records repeatedly describe the Veteran as well groomed and appropriately dressed. The October 2008 VA examiner described the Veteran as neatly groomed and appropriately and casually dressed. The Board acknowledges that the Veteran has reported difficulty with his marital relationship that he attributed to his changed personality since returning from Iraq, although in November 2008, he told his VA clinic psychiatrist that he was accepting of the divorce and no longer preoccupied with the hurt of the breakup. As such, an initial rating in excess of 50 percent is not warranted at any time since the Veteran filed his initial claim. In sum, the Veteran's symptoms do not more closely approximate the criteria required for a higher rating. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). 2. Left Shoulder and Cervical Spine Disabilities In evaluating musculoskeletal disabilities additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2010). Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45 (2010). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability and to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2010). In DeLuca v. Brown, 8 Vet. App. 202 (1995), the United States Court of Appeals for Veterans Claims (Court) held that, where evaluation is based on limitation of motion, the question of whether pain and functional loss are additionally disabling must be considered. 38 C.F.R. §§ 4.40, 4.45. The provisions contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and/or impaired ability to execute skilled movement smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. Id. Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). a) Initial Rating in Excess of 20 Percent for Status Post Left Shoulder Dislocation The Veteran maintains that his left shoulder disability is more severe than is represented by the currently assigned initial 20 percent rating assigned under DC 5201. Upon review of the evidence of record, the Board concludes that a rating in excess of 20 percent for the left shoulder disability is not warranted for any time since the Veteran filed his initial claim. The service treatment records and the May 2008 VA examination report, described below, indicate that the Veteran is right-handed. Thus, his service-connected left shoulder is considered his minor extremity. Under DC 5201, a 20 percent evaluation is assigned for limitation of minor arm motion at shoulder level. 38 C.F.R. § 4.71a, DC 5201. When there is limitation of motion midway between the side and shoulder level, a 20 percent rating is again warranted for limitation of motion of the minor arm, and a 30 percent rating is warranted for limitation of motion of the minor arm to 25 degrees from the side. Id. Under DC 5202, for impairment of the humerus in the minor arm, a 20 percent rating is assignable when there is malunion, with moderate deformity or when there is marked deformity of the arm. 38 C.F.R. § 4.71a, DC 5202 (2010). Also under DC 5202, for recurrent dislocation of the minor arm at the scapulohumeral joint, a 20 percent rating is assignable with infrequent episodes, and guarding of movement only at shoulder level and also, where there are frequent episodes and guarding of all arm movements. Id. Fibrous union of the humerus of the minor arm warrants a 40 percent rating; nonunion (false flail joint) warrants a 50 percent rating; and loss of the head of the humerus (flail shoulder) warrants a 70 percent rating. Id. Under 38 C.F.R. § 4.71a, DC 5203 (2010), for impairment of the clavicle or scapula in the major or minor arm manifested by dislocation, a 20 percent rating is warranted. For nonunion with loose movement, a 10 percent rating is assignable when involving the minor arm. Id. For nonunion without loose movement, and for malunion, a 10 percent rating is assignable. Id. Under DC 5200, ankylosis of the scapulohumeral articulation of the minor upper extremity is rated 20 percent disabling when favorable (abduction to 60 degrees, can reach mouth and head); 30 percent disabling when intermediate (between favorable and unfavorable); and 40 percent disabling when unfavorable (abduction limited to 25 degrees from side). 38 C.F.R. § 4.71a, DC 5200 (2010). Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved. When there is arthritis and at least some limitation of motion, but the limitation of motion would be rated noncompensable under a limitation of motion code, a 10 percent rating may be assigned for each affected major joint. 38 C.F.R. § 4.71a, DC 5003 and 5010 (2010). Normal range of shoulder motion is forward extension (flexion) from 0 to 180 degrees; shoulder abduction from 0 to 180 degrees; internal rotation from 0 to 90 degrees; and external rotation from 0 to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2010). Service treatment records, dated in March 2007, indicate that the Veteran was evaluated by an orthopedist after he developed left shoulder pain from blunt trauma while riding in a tactical vehicle in November 2006 and was evacuated for a left labrum tear. Objectively, there was left shoulder misalignment, tenderness, and pain. The shoulder was subluxed but no shoulder weakness was noted. The radiologic opinion was labral tear. A July 2007 clinical record reflects the Veteran's history of left shoulder injury in Iraq in March/April 2007. He was evacuated to Germany due to a possible shoulder dislocation. Several studies, including magnetic resonance images (MRIs) were performed and he was returned to the United States. Results of an orthopedic evaluation and a MRI showed a mild labial tear and the Veteran was advised that he was not a surgical candidate. He was advised that he had an abnormal MRI while in Germany. The Veteran reported that his pain limited his ability to perform his military duties and there were times when he was unable to hold things. Results of a MRI of the left shoulder were noted to show no evidence of a labral tear. Post service, the May 2008 VA orthopedic examination report indicates that the Veteran injured his left shoulder in a truck accident in Iraq. He was evaluated with an arthrogram and then had a MRI. A Hill Sachs lesion and anterior labral injury with no surgery was noted. The Veteran had left shoulder pain that he rated as a 5 on a scale of 1 to 10, with popping of his joint with overhead movements or lifting and no dislocations since 2007. He had flare ups that he rated to a 9 out of 10 on the pain scale for which he took Tylenol and used hot/cold packs. His last evaluation was prior to separation in November 2007 and it was noted that he did a course of physical therapy. Further, the Veteran had giving way, pain, stiffness, decreased speed of joint motion, tenderness, and locking episodes several times a week, episodes of dislocation or subluxation (since 2007), and effusions, but no deformity. He had weekly severe flare-ups that lasted one to two days, precipitated by heavy lifting and overhead movements. The Veteran believed the flare ups significantly affected his limitation of motion and functional ability. There were no constitutional signs of arthritis. Objectively, examination of the Veteran's left shoulder revealed that a weight-bearing joint was not affected and there was no loss of a bone. There were recurrent shoulder dislocations with guarding movements at the shoulder level. There was no inflammatory arthritis. There was crepitus, abnormal motion and guarding of movement. There was pain with active motion on the left side. Range of motion of the Veteran's left shoulder was flexion, abduction, and internal rotation all to 90 degrees, and external rotation to 70 degrees. There was objective evidence of pain after repetitive motion but no additional limitations after three repetitions of range of motion. There was no joint ankylosis. Results of x-rays taken at the time revealed no fracture or dislocation and the impression was no bony abnormality. The diagnosis was status post left shoulder dislocation with residuals. It was noted that the left shoulder disability had significant effects on the Veteran's usual occupation with problems lifting and carrying, reaching, lack of stamina, decreased strength in the upper extremity and pain. The Veteran's left shoulder disability had severe effects on his ability to exercise and participate in sports and recreation, and no effect on his other activities of daily life. The June 2008 VA outpatient physical therapy record indicates atrophy of the left scapular musculature was observed. There was tenderness along the medial border of the Veteran's scapular with sensation intact to light touch. Range of motion of the Veteran's left shoulder was flexion to 90 degrees and stopped by pain, abduction to 90 degrees, and full extension, adduction and internal and external rotation. The physical therapist noted shoulder pain, weakness with visible atrophy, decreased range of motion and total scapular unit that was unstable and weak. In light of the objective findings reported above, the Board concludes that a rating in excess of the initial 20 percent evaluation is not warranted at any time since November 2007 when service connection for the left shoulder disability was effectuated. Given the reported range of motion discussed above, the Board finds that the Veteran's left shoulder has not manifested range of motion on abduction of 25 degrees from the side or less. The Board observes that the level of limitation of motion shown above demonstrates that the Veteran is able to raise the left (minor) arm to at least the shoulder level. Additionally, there is no ankylosis as required for a higher rating under DC 5200. Other DCs of 38 C.F.R. § 4.71a have been considered, but do not permit a rating greater than 20 percent for the left shoulder disability. DC 5202 provides a 20 percent rating for infrequent and frequent recurrent dislocation of the scapulohumeral joint of the minor shoulder and a 40 percent rating for fibrous union of the minor shoulder that the Veteran does not have. The maximum rating under DC 5203 for impairment of the clavicle or scapula is 20 percent that would not provide an increased rating. Furthermore, as noted, the evidence does not show ankylosis of the left shoulder. The Veteran's subjective complaints notwithstanding, the examination report and clinical records note that repetitive use did not result in any additional loss of range of motion due to pain, weakness, or fatigue. See 38 C.F.R. §§ 4.40, 4.45. While the June 2008 physical therapy record notes atrophy of the left scapular musculature, there was no other clinical finding of muscle loss, or any sensory loss, due to the left shoulder disability nor was such noted by the May 2008 VA orthopedic examiner. With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. The effects of pain reasonably shown to be due to the Veteran's service-connected left shoulder disability are contemplated in the currently assigned 20 percent rating. Even with consideration of the finding of objective evidence of pain after repetitive motion, but no additional limitations after three repetitions of range of motion, reported by the May 2008 VA orthopedic examiner, and difficulty lifting carrying and reaching overhead with decreased upper extremity strength and stamina, there is no indication that pain, due to disability of the left shoulder, caused functional loss greater than that contemplated by the currently assigned 20 percent evaluation. 38 C.F.R. §§ 4.40, 4.45; DeLuca. A separate evaluation for pain is not for assignment. Spurgeon. The preponderance of the objective medical and other evidence of record is against the Veteran's claim for an initial rating in excess of 20 percent for his service-connected left shoulder disability. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). b) Initial Rating in Excess of 10 Percent for Myospasm of the Cervical Spine The Veteran contends that an initial rating in excess of 10 percent is warranted for his cervical spine disability, currently rated under DC 5237. Upon review of the evidence of record, the Board concludes that a rating in excess of 10 percent for the cervical spine myospasm is not warranted for any time since the Veteran filed his initial claim. Under the current General Rating Formula, the following apply: 20 percent evaluation is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 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. A 30 percent evaluation is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted if the medical evidence shows unfavorable ankylosis of the entire cervical spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. These ratings are warranted if the above-mentioned manifestations are present, 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. 38 C.F.R. § 4.71a, the Spine, General Rating Formula for Diseases and Injuries of the Spine, Diagnostic Codes 5235 to 5243. Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment are evaluated separately under an appropriate diagnostic code. Id., Note (1). Normal forward flexion of the cervical segment of the 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 60 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. See Note 2, General Rating Formula for Disease and Injuries of the Spine. 38 C.F.R. § 4.71a, Plate V (2010) Further, under regulations effective September 23, 2002, intervertebral disc syndrome (IVDS) (preoperatively or postoperatively) was evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under Sec. 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, DC 5293, effective September 23, 2002. A 10 percent evaluation was warranted with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. Id. A 20 percent evaluation was assigned with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Id. With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 evaluation was warranted. Id. A 60 percent evaluation was assigned with incapacitating episodes having a total duration of at least six weeks during the past 12 months. Id. Note (1): For purposes of evaluations under 5293, 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. Note (2): When evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurologic disabilities separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes. Note (3): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Under the current regulations for evaluating IVDS, effective September 26, 2003, under DC 5243 (that now evaluates IVDS), Note 6 directs that IVDS is to be evaluated under the General Rating Formula for Disease and Injuries of the Spine or under the formula for rating based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Service medical records reflect complaints of, and treatment for, neck pain, in July 2006. Post service, the May 2008 VA outpatient record indicates that the Veteran was seen for complaints of chronic neck, shoulder, and low back pain with spasm noted on cervical spine x-rays. The May 2008 VA general medical examination report reflects the Veteran's history of neck pain since 2007 when he fractured his left shoulder. According to the May 2008 VA orthopedic examination report, the Veteran gave a history of cervicalgia that started in 2006 after injuring his left shoulder. He had aching, tightness, cracking and daily pain, with no radiation, visual disturbances and no headaches. While completing physical therapy for his left shoulder he had some treatment for his neck that was helpful. Further, it was noted that the Veteran had a history of stiffness, weakness, spasms, pain, and severe flare ups every one to two months that lasted one to two days and were precipitated by bending and heavy lifting. He denied any incapacitating episodes associated with the left shoulder disability. Objectively, the Veteran's posture and head position were normal and there was symmetry in appearance. His gait was normal and there was no cervical spine ankylosis. Examination of his cervical spine revealed left and right spasm and tenderness with no atrophy, guarding, and pain with motion. The VA examiner said that the muscle spasm, localized tenderness or guarding was not severe enough to be responsible for abnormal gait or spinal contour. Muscle tone was normal and there was no muscle atrophy. Upper extremity strength was essentially normal (5/5) and there were no sensory deficits. Range of motion of the cervical spine was flexion, extension, and left and right lateral flexion all from 0 to 45 degrees; and left and right lateral rotation from 0 to 80 degrees. There was no objective evidence of pain on active range of motion or following repetitive motion and no additional limitations after three repetitions of range of motion. Results of x-rays taken at the time revealed marked straightening of the normal cervical lordosis indicating muscle spasm and the impression was myospasm. The clinical diagnosis was myospasm of the cervical spine with no significant effects on the veteran's daily activities or occupation. The June 2008 VA physical therapy record indicates full range of motion of the Veteran's cervical spine, with tenderness and tightness along the left scalene, upper trapezium and levatore. Upon review of the findings reported above, the Board concludes that an initial rating in excess of the currently assigned 10 percent is not warranted for the Veteran's cervical spine disability. This is so, because, in May 2008, the VA examiner reported essentially minimal loss of range of cervical spine motion, although there was evidence of muscle spasms. However, the VA examiner specifically stated that the muscle spasm, localized tenderness or guarding was not severe enough to be responsible for abnormal gait or spinal contour. Such findings do not meet or even approximate a higher rating under any of the applicable diagnostic codes. 38 C.F.R. § 4.71a, DC 5235-5243. Further, the Veteran denied any incapacitating episodes associated with the cervical spine disability, and neither IVDS nor a neurologic disorder associated with the cervical spine disability has been diagnosed such as to warrant a higher or separate rating as discussed above. Even with consideration of DeLuca, supra, the objective evidence of record reflects the Veteran's complaints of pain and stiffness but is not reflective of deficits of motor strength, muscle atrophy, or the like to warrant an increased evaluation. In May 2008, the VA examiner noted the Veteran's complaints of severe flare ups every one or two months that lasted one to two days and reported that there were no additional limitations after three repetitions of range of motion during clinical evaluation. The exhibited function loss was mild. The Board recognizes the Veteran's subjective complaints of constant cervical spine pain and stiffness, but is of the opinion that such complaints of pain are contemplated in the currently assigned initial 10 percent evaluation. As such, the Board concludes that the preponderance of the evidence of record is against an initial rating in excess of 10 percent for the Veteran's service- connected cervical spine disability. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). 3. Initial Compensable Rating for Hyperhidrosis The Veteran asserts that an initial compensable evaluation is warranted for his service-connected hyperhidrosis that is evaluated under DC 7832. Upon review of the evidence of record, the Board concludes that a compensable rating for hyperhidrosis is not warranted for any time since the Veteran filed his initial claim. Diagnostic Code 7832, for hyperhidrosis, provides a noncompensable rating for hyperhidrosis with the ability to handle paper or tools after therapy. 38 C.F.R. § 4.118, Diagnostic Code 7832. Hyperhidrosis with the inability to handle paper or tools because of moisture and unresponsiveness to therapy warrants the assignment of a 30 percent disability rating, the maximum evaluation allowed for this disability. The post-service VA outpatient records, dated during 2008 and 2009, are not referable to complaints of, or treatment for, the Veteran's hyperhidrosis. According to a May 2008 VA skin diseases examination report, the Veteran said he started to develop excessive sweating in particular, after he fractured his left shoulder. He noticed excessive sweating, especially on the armpits, hands, behind the knees and his lower abdomen. Robinul was recommended and he used it for two weeks with some benefit. After discharge from active service, he still had problems with hyperhidrosis and he was not currently using any treatment at all. Objectively, it was noted that the Veteran was able to handle paper or tools after therapy. There was evidence of excessive sweating on his lower abdomen during the examination, and mild sweating on his palms. Diagnoses included generalized hyperhidrosis that was moderate to severe. It was noted that the Veteran worked at a medical supplies company and was particularly concerned about his hyperhidrosis because he had to change shirts frequently and it was socially disturbing. There was no functional disability reported. In sum, the evidence does not show that the Veteran's hyperhidrosis has hindered his ability to manipulate paper or tools due to moisture, nor does it demonstrate that the Veteran's disorder was unresponsive to therapy. In fact, the May 2008 VA examiner noted that the Veteran used Robinul to some benefit. Although that examiner noted the Veteran's concerns about his hyperhidrosis because he had to change shirts frequently and it was socially disturbing, there was no functional disability associated with the hyperhidrosis As such, the Board concludes that the preponderance of the evidence of record is against an initial compensable rating for the Veteran's service- connected hyperhidrosis disability. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 5107(b). The Board has also considered whether the Veteran's PTSD, left shoulder, cervical spine, and hyperhidrosis disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provide for a greater evaluation for additional or more severe symptoms; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board observes, however, that in this case, although the Veteran reported losing his job in May 2009, he and the record have not indicated that he is unemployable due to his PTSD and left shoulder, cervical spine, and hyperhidrosis disabilities. Finally, in view of the holding in Fenderson, the Board has considered whether the Veteran is entitled to a "staged" rating for his service-connected PTSD, left shoulder, cervical spine, and hyperhidrosis disabilities, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time since the Veteran filed his original claim for service connection have the disabilities on appeal been more disabling than as currently rated under the present decision of the Board. (CONTINUED ON NEXT PAGE) ORDER Service connection for thoracic back strain is denied. An initial rating in excess of 50 percent for PTSD is denied. An initial rating in excess of 20 percent for status post left shoulder dislocation is denied. An initial rating in excess of 10 percent for myospasm of the cervical spine is denied. An initial compensable rating for hyperhidrosis is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs