Citation Nr: 1127979 Decision Date: 07/27/11 Archive Date: 08/02/11 DOCKET NO. 08-28 484 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a right hand disability (claimed as loss of strength, loss of feeling, and loss of motion) secondary to service-connected right shoulder disability. 2. Entitlement to service connection for a left hand disability secondary to service-connected right shoulder disability. 3. Entitlement to service connection for a left shoulder disability secondary to service-connected right shoulder disability. 4. Entitlement to an increased evaluation for chronic bicep tendonitis, right shoulder, post operative (dominant) (also claimed as torn rotator cuff), currently evaluation as 30 percent disabling. 5. Entitlement to an increased evaluation for tender scar, right shoulder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Poulson, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1968 to January 1970, and from November 1978 to May 1982. This matter is before the Board of Veterans' Appeals (Board) from an August 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In August 2010, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge. During the hearing, the Veteran submitted additional evidence along with a waiver of initial RO consideration. A transcript of the hearing is associated with the claims folder, which reflects that the Board would keep the record open for a period of 60 days for the submission of additional evidence. See Hearing Transcript at 2. Additional evidence has been received. In rating decisions dated August 1994 and July 1998, the RO deferred the issue of entitlement to compensation under 38 U.S.C.A. § 1151 for dental treatment. The RO obtained the Veteran's dental records, but it does not appear that a decision was ever issued. Therefore, this issue is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a left shoulder disability and entitlement to an increased evaluation for a right shoulder disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In an August 1994 rating decision, the RO denied a claim for loss of strength, right hand; the Veteran did not appeal the decision, and it is now final. 2. The additional evidence received since the August 1994 rating decision is new but does not, by itself or in conjunction with evidence previously assembled, relate to an unestablished fact necessary to substantiate the right hand claim and does not raise a reasonable possibility of substantiating the claim. 3. A left hand disability is not causally related to the Veteran's service-connected right shoulder disability. 4. The Veteran's right shoulder scar is well healed, but tender; there is no limitation of function, and it is not at least 12 square inches in area. CONCLUSIONS OF LAW 1. The August 1994 rating decision that denied service connection for loss of strength, right hand, is final. 38 U.S.C.A. § 7105 (West 2002). 2. Evidence received since the August 1994 rating decision is not material, and the criteria to reopen the claim for service connection for a right hand disability are not met. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2010); 38 C.F.R. § 3.156 (2010). 3. The criteria for service connection for a left hand disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2010). 4. The criteria for the assignment of an increased evaluation for right shoulder scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1 - 4.7, 4.118, Diagnostic Codes (DC) 7801, 7804 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims to reopen based on new and material evidence, VA must notify a claimant of the evidence and information that is necessary to reopen the claim and VA must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit sought by the claimant. The question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied. Kent v. Nicholson, 20 Vet. App. 1 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the Veteran pre-adjudication notice by letter dated April 2007. The notification letter substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate the underlying claim of service connection for a left hand disability, and for the claim to reopen based on the submission of new and material evidence. The notification also identified the relative duties of VA and the claimant to obtain evidence. In addition, the Veteran was provided notification of why the underlying service connection claim was denied, as well as what type of evidence constituted new and material evidence in this case. Thus, the Veteran was aware of the basis for the denial of the underlying service connection claim and was also aware that he needed to provide new and material evidence to reopen the previously denied claim. See Kent v. Nicholson, 20 Vet. App. 1 (2006). The notice also included the general criteria for substantiating an increased rating claim, but did not contain the applicable diagnostic codes for the increased rating. Notice described in 38 U.S.C. § 5103(a), however, need not be veteran-specific and generic notice is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1281 (Fed.Cir. 2009). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). VA has obtained all available service treatment records (STR's) and VA treatment records, assisted the Veteran in obtaining evidence, and obtained a medical opinion as to the severity of his right shoulder scar. The Board has considered the Veteran's contention, as put forth in his December 2007 notice of disagreement, that the examination of record is inadequate as it was "simply a conversation not an exam." The Board finds that the examination of record is adequate and provides sufficient evidence for the Board to adjudicate the claim. The March 2007 VA examiner provided an opinion as to the severity of the scar based on examination of the Veteran, his reported history, and the entire claims file, and is otherwise adequate for rating purposes. See 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A VA examination was not provided with respect to either hand claim. In a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). A medical examination is necessary when the record (1) contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of the disability; (2) contains evidence, which indicates that the disability or symptoms may be associated with the claimant's active duty; and (3) does not contain sufficient medical evidence for VA to make a decision. 38 U.S.C.A. § 5103A(d); McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Although a VA examination of the right hand has not been provided, there is no duty to provide an examination in this case absent the receipt of new and material evidence. See 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c)(4)(c)(iii); see also DeLaRosa v. Peake, 515 F.3d 1319 (Fed. Cir. 2008). And while the Veteran has a current diagnosis of left carpal tunnel syndrome, as discussed below, there is no evidence that the condition is related to the service-connected right shoulder disability. Thus, no VA examination is necessary in order to decide these claims. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claims at this time. II. New and Material Evidence Prior unappealed rating decisions may not be reopened absent the submission of new and material evidence warranting revision of the previous decision. 38 U.S.C.A § 5108 (West 2002); 38 C.F.R. § 3.156 (2010). "New" evidence means evidence "not previously submitted to agency decisionmakers." 38 C.F.R. § 3.156(a) (2010). "Material" evidence means "evidence that, by itself or when considered with previous evidence of record, related to an unestablished fact necessary to substantiate the claim." Id. In order to be "new and material" evidence, the evidence must not be cumulative or redundant, and "must raise a reasonable possibility of substantiating the claim." Id.; Shade v. Shinseki, 24 Vet. App 110 (2010). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1991); but see Duran v. Brown, 7 Vet. App. 216, 220 (1994) ("Justus does not require the Secretary to consider the patently incredible to be credible"). With respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the claim as in this case dealing with a claim for service connection. Evans v. Brown, 9 Vet. App. 273 (1996). However, it is the specified bases for the final disallowance that must be considered in determining whether the newly submitted evidence is probative. Id. Such evidence must tend to prove the merits of the claim as to each essential element that was a specified basis for that last final disallowance of the claim. Id. If new and material evidence is submitted, the claim will be reopened and adjudicated on the merits. 38 U.S.C.A. § 5108 (West 2002). "The Board does not have jurisdiction to consider [the previously adjudicated claim] unless new and material evidence is presented, and before the Board may reopen such a claim, it must so find." Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). The Board is neither required nor permitted to analyze the merits of a previously disallowed claim if new and material evidence has not been submitted. Butler v. Brown, 9 Vet. App. 167, 171 (1996). No other standard than that articulated in the regulation applies to the determination whether evidence is new and material. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Service connection for loss of strength, right hand, was denied by the RO in August 1994 because there was no evidence showing that this condition was related to the Veteran's right shoulder. The RO also found that there was no in-service treatment for or diagnosis of a right hand disability. However, the Veteran has never alleged that his right hand problems are directly related to service. In January 2007, the Veteran submitted his current claim for secondary service connection. The RO denied the claim in August 2007, again finding that there was no evidence this condition was related to service or the Veteran's right shoulder. Evidence of record at the time of the August 1994 rating decision included STR's, VA treatment records from March 1992 to November 1993, and a November 1993 VA examination. STR's show that the Veteran injured his right shoulder while playing basketball in 1978. A January 1993 VA treatment record establishes that the Veteran was treated for right arm and elbow pain. There was increased pain to wrist extension against resistance. In March 1993, the Veteran complained of numbness and tingling in his right small fingers. The clinician noted that the Veteran did "computer type work." The diagnosis was supraspinatus tendonitis. In June 1993, there was a positive Tinel's sign over the right elbow, with radiation to the ring and small fingers. The November 1993 VA examiner did not note any complaints concerning the Veteran's right hand, nor is there any diagnosis of a right hand disability. Evidence submitted since the August 1994 rating decision consists of VA treatment records from August 2004 to September 2009, a March 2007 VA examination report, private treatment records from University of Colorado Hospital from June to August 2010, as well as the Veteran's statement and testimony that he has been informed by specialists that his right hand disability is secondary to his service-connected right shoulder disability. The evidence received since the 1994 RO decision is new, as it was not previously considered. However, this evidence is not material because it does not tend to establish that the Veteran's right hand disability is related to his service-connected right shoulder disability. A June 2006 VA treatment record shows that gross sensation to light touch was "intact bilateral axillary, radial/medial/ulnar hand distribution." In July 2006, a motor examination revealed normal muscle tone in the Veteran's arms. Strength was 5/5 in all muscle groups in both limbs except the right shoulder. There was a mild tremor at rest with hands outstretched. Rapid alternating movement was performed normally with the arms and fingers. Finger flexors were 2+. Upper extremity sensation was within normal limits. Although the March 2007 VA examination was conducted with respect to the Veteran's right shoulder increased rating claim, the examiner noted that there was normal grip strength. In January 2008, the Veteran reported a history of bilateral carpal tunnel syndrome (CTS) and radiculopathy/neuropathy pain in his hands and arms. There was decreased sharp/soft sensation differentiation in the bilateral 4th/5th digits. There was also somewhat decreased grip strength in both hands. The diagnoses included radiculopathy and neuropathy pain. A June 2010 letter from C.O., M.D., to the Veteran's primary care provider noted that the Veteran had known degenerative disease of the cervical spine. The Veteran reported "carpal tunnel symptoms in the past with frequent use of his hands writing and typing and gradual onset of weakness in his right hand." Initially, the Veteran had trouble moving his right index finger, but recently he had noticed some vibration or trembling sensation in the right index finger with some involuntary movement. He occasionally experienced some sharp, shooting pains at the level of his right elbow along the ulnar nerve. The Veteran also reported some numbness in his fourth and fifth finger. Strength testing was 4+ with finger flexors, 4 with finger extensors, 4 with interosseus strength, 4- abductor pollicis strength, and 4- opponens pollicis strength. The Veteran was unable to differentiate cold and pinprick sensation on the palmar aspect of his hand, but noted tingling of the right index, fourth, and fifth fingers. The impression was (1) right upper extremity weakness primarily involving intrinsic muscles of the hand but some concern for multiple cervical radiculopathies; (2) prior history of CTS; (3) ulnar neuritis; and (4) involuntary right index finger movements secondary to sensory neuropathy and decreased position sense. Dr. C.O. stated that the Veteran's "comorbid illnesses including type 2 diabetes increase his risk of sensory predominant axonal polyneuropathy but the more focal sign in the right upper extremity argue toward a cervical degenerative lesion rather that peripheral sensory axonal neuropathy as the predominant explanation." An August 2010 EMG showed moderately severe median neuropathy at the right wrist (CTS) with acute and chronic features, with no evidence of cervical polyradiculopathy. During the August 2010 hearing, the Veteran stated that he first noticed numbness in his fingers in 2004 or 2005. At that time, his job required him to "write everything out." The Veteran noticed that the more writing he did, the more pain he had. He also started to have pain when using the computer mouse. Hearing Transcript at 12. The Veteran testified that his private doctors "think that there could be a connection" between his right shoulder and the problems with his right hand. He stated "I'll know more when I go in next week to talk to the doctor who referred me and she'll be able to put it all together." Hearing Transcript at 14. Subsequently, the Veteran submitted private treatment records from University of Colorado Hospital (UCH). An August 2010 treatment record shows that the doctor noted the Veteran's history of right shoulder problems, as well as his degenerative cervical disc disease and recent EMG. The doctor opined that the Veteran's right hand symptoms "are most likely referable primarily to his CTS", but noted that "there is also likely a component of ulnar neuropathy as well contributing to these symptoms." The newly submitted VA and private treatment records do not indicate that the Veteran's current right CTS disability is related to, or aggravated by, his service-connected right shoulder disability, which was the relevant basis of the RO's August 1994 rating decision. Rather, the recent treatment records from UCH indicate that any current right hand disability, to include CTS and weakness, is the result of the Veteran's cervical degenerative disc disease, ulnar neuropathy and/or his diabetes mellitus. Accordingly, the Board finds that the evidence received since August 1994 fails to establish an unsubstantiated fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the Veteran's claim. See 38 C.F.R. § 3.156(a). The Veteran is competent to give evidence about what he experienced or observed. See Charles v. Principi, 16 Vet. App. 370 (2002). As a layperson, however, he is not competent to render a diagnosis or an opinion as to whether his right hand disability is related to his service-connected right shoulder disability because he does not have the requisite medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). New and material evidence has not been received to reopen the previously denied claim; the benefit of the doubt doctrine does not apply; and reopening the claim is not warranted. III. Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). To establish service connection, there must be a medical diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in- service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The first notation of any left hand symptomatology was in June 2006. A VA treatment record shows that gross sensation to light touch was "intact bilateral axillary, radial/medial/ulnar hand distribution." In July 2006, a motor examination revealed normal muscle tone in the Veteran's arms. Strength was 5/5 in all muscle groups in both limbs except the right shoulder. There was a mild tremor at rest with hands outstretched. Rapid alternating movement was performed normally with the arms and fingers. Finger flexors were 2+. Upper extremity sensation was within normal limits. A March 2007 VA examination was conducted with respect to the Veteran's right shoulder. The examiner noted that there was normal grip strength. In January 2008, the Veteran reported a history of bilateral CTS and radiculopathy/neuropathy pain in his hands and arms. There was decreased sharp/soft sensation differentiation in the bilateral 4th/5th digits. There was also somewhat decreased grip strength in both hands. The diagnoses included radiculopathy and neuropathy pain. A June 2010 letter from C.O., M.D., to the Veteran's primary care provider noted that the Veteran had known degenerative disease of the cervical spine. The Veteran reported "carpal tunnel symptoms in the past with frequent use of his hands writing and typing." Strength testing was 4+ with finger flexors, 4 with finger extensors, 4 with interosseus strength, 4- abductor pollicis strength, and 4- opponens pollicis strength. The impression included prior history of CTS. An August 2010 EMG showed that the Veteran refused testing of the upper left extremity. Considering the evidence as delineated above, the Board finds that the record does not contain any competent evidence linking a left hand disability to the service-connected right shoulder disability. The Board acknowledges that the Veteran asserts that his left CTS is secondary to his service-connected shoulder disability. The Veteran has not provided any evidence supporting this opinion, however, and as a layperson, he is not competent to assert a relationship between his left hand disability and the service-connected right shoulder disability. Thus, based on the absence of evidence linking the left hand disability to a service-connected disability, service connection is not warranted, and the claim is denied. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and service connection is not warranted. IV. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and 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 required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the veteran, as well as the entire history of the veteran's disorder in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increased disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Different percentage ratings for different periods of time can be applied based on the medical evidence of record. Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. The Veteran's scar is rated under 38 C.F.R. § 4.97, Diagnostic Code 7804. A scar not involving the head, face, or neck can be rated under Diagnostic Codes 7801, 7802, 7804, and/or 7805. 38 C.F.R. § 4.118. Under DC 7801, scars other than of the head, face or neck that are deep or that cause limited motion warrant a 20 percent evaluation when they cover an area or areas exceeding 12 square inches. 38 C.F.R. § 4.118. Ten percent is the maximum possible evaluation under DC 7802. Under DC 7804, a 20 percent evaluation is warranted for three of four scars that are unstable or painful. A June 2006 VA treatment record establishes that the Veteran had a well healed scar on his right shoulder. The March 2007 VA examination report shows that the Veteran complained of numbness with some tenderness to palpation. The examiner noted that the scar was well healed. It measured 8 cm in length and 1 cm in width. There was no edema or inflammation of keloid. The scar was soft, nonadherent, and had normal texture. The overlying skin was normal. There was no tissue loss. There was no disfigurement or lost function. Considering the evidence above, the Board finds that a rating in excess of 10 percent is not warranted. Unde DC 7804 to warrant a 10 percent rating the evidence must show three of four scars are unstable or tender. While the appellant has reported tenderness on palpation, the evidence shows a single scar. Moreover, the scar has been noted to be stable. Furthermore, the scar is not deep, it does not cause limitation of motion, and it does not exceed 12 square inches. Therefore, a higher rating under DC 7801 is not warranted. Finally, 10 percent is the highest rating allowed under DC 7802 and as such a higher evaluation under that diagnostic code is not possible. DC 7805 indicates that scars can be rated on limitation of function of the affected part. 38 C.F.R. § 4.118, DC 7805. However, the evidence shows that there is no limitation of motion caused by the right shoulder scar. See 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2010). The scar regulations were amended effective October 23, 2008 to provide for evaluation of burn scars under DCs 7800-7802. 38 C.F.R. § 4.118, effective October 23, 2008. DC 7803 was eliminated. Id. The provisions of DCs 7804 and 7805 remained essentially unchanged. The regulatory changes only apply to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). As neither situation applies in this case, the Board will not consider the 2008 changes. In any event, the Veteran does not have a burn scar, and has never been evaluated under DC 7803. Therefore, the change in the regulations is not applicable. Consideration has also been given regarding whether the schedular evaluation is inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Id. at 116. The schedular evaluation in this case is adequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected disorder but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's scar. The Veteran has not required hospitalization due to this service-connected disability, and there is no evidence of a marked interference with his employment solely due to the right shoulder scar. The Veteran is employed as a psychologist/social worker by the VA. He told the March 2007 VA examiner that he had missed 10 days in the last year because of his service-connected right shoulder disability. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. Last, an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been considered. The record establishes that the Veteran currently works full-time for the VA. Therefore, any inferred TDIU claim is inapplicable in this case. ORDER Service connection for a right hand disability secondary to service-connected right shoulder disability is denied. Service connection for a left hand disability secondary to service-connected right shoulder disability is denied. An increased evaluation for tender scar, right shoulder, currently rated at 10 percent, is denied. REMAND Right Shoulder The Veteran has reported that his service-connected right shoulder has worsened since his last VA examination for that condition. VA treatment records reflect continued complaints of problems and increasing frequency, supporting his allegation. An examination is required to obtain current findings for evaluation purposes. Left Shoulder The Veteran contends he developed a left shoulder disability as a result of his service-connected right shoulder disability. The Veteran first complained of left shoulder pain in June 2006. A January 2008 MRI of the Veteran's left shoulder revealed a rotator cuff impingement, partial tears of the distal supraspinatus and subscapularis tendons, and tears of the anterior and posterior glenoid labra. A January 2008 VA treatment record contains a diagnosis of chronic left shoulder pain. The Veteran testified that he has been forced to overuse his left shoulder and arm as a direct result of his service-connected right shoulder disability. Accordingly, an opinion is warranted addressing whether the Veteran's left shoulder disability was caused or aggravated by his service-connected right shoulder disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995); 71 Fed. Reg. 52744 (2006). Finally, additional treatment records need to be obtained. A January 2008 VA treatment record indicates that the Veteran receives treatment for both shoulders from his primary care provider. An attempt should be made to obtain any relevant medical evidence. 38 C.F.R. § 3.159(c)(1). Accordingly, the case is REMANDED for the following action: 1. Once a signed release is received from the Veteran, obtain outstanding private treatment records from Dr. Philip Quintana from January 2006 to the present. A copy of any negative response(s) should be included in the claims file. 2. Schedule the Veteran for a VA examination. The claims folder must be reviewed in conjunction with the examination. The examiner should describe the full extent of the Veteran's service-connected right shoulder disability. The examiner should also opine whether it is at least as likely as not that any currently diagnosed left shoulder disability was caused or aggravated by the service-connected right shoulder disability. Aggravation means worsened beyond the natural progression of the disease. A full and complete rationale for all opinions expressed is required. If upon completion of the above action the claim remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ E.I. VELEZ Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs