Citation Nr: 1136835 Decision Date: 09/29/11 Archive Date: 10/11/11 DOCKET NO. 06-13 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased rating for post-operative residuals of a left shoulder dislocation, currently rated as 30 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Veteran represented by: Gregory D. Keenum, Attorney at Law WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service in the United States Navy from June 1968 to January 1970, to include active duty in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 2005 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Jackson, Mississippi. The Veteran appeared at a Travel Board hearing in March 2010. A transcript is associated with the claims folder. In October 2010, the Board remanded this case for additional development. The purposes of this remand have been met and the case is ready for appellate consideration. The Board observes that a claim for a total disability rating based upon individual unemployability (TDIU), as due to the service-connected left shoulder disability, has been raised by the Veteran, to include during the Travel Board hearing in March 2010. As further discussed below, in light of the recent case, Rice v. Shinseki, 22 Vet. App. 447 (2009), entitlement to TDIU is properly considered as part of the determination of the appropriate disability rating rather than as a separate claim. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's service-connected post-operative residuals of a left shoulder dislocation are manifested by no more than a moderately severe injury to Muscle Group I. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for post-operative residuals of a left shoulder dislocation have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.73, Diagnostic Code 5301 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The enactment of the VCAA, codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011), significantly changed the law prior to the pendency of this claim. VA has issued final regulations to implement these statutory changes. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). The VCAA provisions include an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits, and they redefine the obligations of VA with respect to the duty to assist the veteran with the claim. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the April 2005 and March 2006 letters sent to the Veteran by the RO adequately apprised him of the information and evidence needed to substantiate the claim. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, during the pendency of this appeal, on March 3, 2006, the Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (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. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id., at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in April 2005 and March 2006 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the March 2006 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." VA did provide such notice to the Veteran prior to the June 2005 RO decision that is the subject of this appeal in its April 2005 letter. Accordingly, the RO provided proper VCAA notice at the required time. With respect to the Dingess requirements, the Veteran was provided with notice of the laws and regulations governing ratings and effective dates in a March 2006 letter, but such notice was post-decisional. See Pelegrini,18 Vet. App. at 119-20. Despite any timing deficiency, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). In this regard, the Board notes that the case was readjudicated in August 2009 and March 2011 supplemental statements of the case, and as such, the Veteran has not been prejudiced thereby. See Bernard, 4 Vet. App. at 384, 394. The Board notes that the Court had previously held that, with respect to claims for an increased rating, a detailed notice, tailored to the specific aspects of each claim, must be provided under 38 U.S.C.A. § 5103(a). Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The United States Court of Appeals for the Federal Circuit (Federal Circuit), however, reversed that decision, holding that what is required is generic notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009); Dingess, 19 Vet. App. at 473. The Board finds that the April 2005 and March 2006 letters substantially satisfy the current notification requirements for the claim for an increased rating for the Veteran's left shoulder disability. Because the Veteran has not indicated any prejudice caused by a content error and no such error is apparent, the Board finds no basis for finding prejudice against the Veteran's appeal of the issue adjudicated in this decision. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) regarding the rule of prejudicial error. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claim by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received VA examinations in May 2005, May 2006, February 2008, and March 2010, which were thorough in nature and adequate for the purposes of deciding this claim. The aforementioned VA examinations revealed findings that are adequate for rating the Veteran's left shoulder disability. In addition, as explained further below, because the Veteran made a contention against the credibility of the examiner from his February 2008 examination, the Board remanded this case in October 2010 and the Veteran underwent a new VA examination in March 2011, with a different examiner from the previous examination in February 2008. Thus, the Board finds that the medical evidence of record is sufficient to resolve this appeal; VA has no further duty to provide an examination or medical opinion. 38 C.F.R. §§ 3.326, 3.327. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, 4 Vet. App. at 384. II. Factual Background The Veteran's service treatment records show that in April 1969, he was diagnosed with a recurrent dislocation of the left shoulder. He subsequently underwent an open reduction of the left shoulder. In a June 1970 rating action, the RO granted service connection for the post-operative residuals of a left shoulder dislocation. The RO assigned a 10 percent disability rating under diagnostic Code 5301 for the Veteran's service-connected left shoulder disability, effective from January 23, 1970. See 38 C.F.R. § 3.400(b)(2) (the effective date of an award of service connection will be the day following the date of separation from service-if the veteran filed a claim within one year after service). In an April 1976 rating action, the RO increased the disability rating for the Veteran's service-connected left shoulder disability from 10 percent to 30 percent disabling, effective from February 24, 1976. A private medical report shows that in December 1999, the Veteran had an x-ray taken of his left shoulder. The x-ray was reported as showing a screw in the area of the coracoid. The acromioclavicular (AC) joint showed some arthritic changes. There was no evidence of dislocation or fracture. In March 2005, the Veteran requested that his service-connected left shoulder disability be reevaluated for a higher rating. In May 2005, the Veteran underwent a VA examination. At that time, he stated that since his in-service left shoulder surgery, he had experienced chronic pain in his left shoulder with two subsequent dislocations in 1990 and 1999. The Veteran noted that his pain increased with increased activity, such as working with his left arm in an overhead position. According to the Veteran, his usual occupation was as a carpenter but that due to his left shoulder disability, he was working less. The Veteran reported that he was left-hand dominant and that the use of his left hand for carpentry purposes caused some discomfort. Upon physical examination, in regard to range of motion of the Veteran's left shoulder, forward flexion was to 160 degrees; abduction was to 120 degrees; external rotation was to 15 degrees; and internal rotation was to 60 degrees. The Veteran had a positive apprehension sign and mild impingement. He had no instability and motor strength was 5/5. X-rays of his left shoulder were reported to show one screw in place, anteriorly, with mild inferior glenohumeral degenerative changes. No subluxation, fracture, or dislocation was seen. Following the physical examination and a review of the Veteran's x-rays, the examiner diagnosed the Veteran as status post stabilization procedure of the left shoulder secondary to recurrent dislocations, with mild to moderate degenerative changes. According to the examiner, the Veteran would likely have pain with activities requiring significant use of his left hand, which was his dominant hand. The examiner noted that the Veteran's most symptomatic condition in regard to his left shoulder was pain, less likely to be impacted by fatigue, weakness, or lack of endurance. The examiner opined that if would be difficult for the Veteran to gain substantial employment as a carpenter due to his left shoulder disability. The Veteran could gain employment if he was able to perform activities that included light duty of the left upper extremity. According to the examiner, there was no pain on range of motion, although pain could further limit function as described above. VA Medical Center (VAMC) outpatient treatment records, dated from May 2005 to March 2010, show intermittent treatment for the Veteran's service-connected left shoulder disability. The records reflect that in March 2006, the Veteran stated that he had pain in his left shoulder. He said on a scale of 1 to 10, his pain level was a 3. A VA examination was conducted in May 2006. At that time, the examiner stated that he had reviewed the Veteran's claims file. The examiner indicated that according to the Veteran, he had pain in his left shoulder on a daily basis, with flare-ups three to four times a week. He worked as a carpenter and was limited to only doing finishing work, which had become increasingly more difficult. The Veteran was left hand dominant. He noted that his range of motion was decreased due to his left shoulder disability, and that the pain from his left shoulder would wake him up in the middle of the night. According to the Veteran, he also had numbness radiating down his left upper extremity, and his grip strength had decreased to the point where he was unable to handle his tools. He noted that he was also limited in terms of what he could do around the house and that he could not do heavy lifting, and light chores were becoming more difficult. The Veteran stated that he also had difficulty dressing and that he could not reach behind himself with his left upper extremity to put on his shirt. He indicated that he had been prescribed anti-inflammatories, as well as pain medication. The pain medication made him "woozy" and the anti-inflammatories had helped him only minimally. He recently had a cortisone injection which relieved his pain but did not help with his range of motion. The physical examination showed that the Veteran was tender to palpation throughout his rotator cuff and over his AC joint. There was no erythema and there were no skin changes. Range of motion was significantly limited. Forward flexion was to 80 degrees, with pain beginning at 45 degrees; abduction was to 60 degrees with pain beginning at 45 degrees and persisting until 60 degrees; internal rotation was to 10 degrees with pain throughout; and external rotation was to 10 degrees with pain throughout. With external rotation, the Veteran had apprehension and felt as if his shoulder could dislocate. Repetitive range of motion of his left shoulder did not limit arch of motion but did increase pain and caused fatigability. Crepitus was felt throughout the glenohumeral joint. The Veteran had a positive drop arm sign. Motor strength was 4/5. Sensation was intact to light touch. X-rays of the left shoulder showed moderate to severe arthritis of the AC joint and glenohumeral arthritis. Following the physical examination and a review of the x-rays, the examiner diagnosed the following: (1) glenohumeral arthritis, (2) adhesive capsulitis, (3) arthritis of the left shoulder AC joint, and (4) anterior shoulder instability. According to the examiner, the Veteran had pain with range of motion of the left shoulder which could further limit function after using his shoulder all day and while working. In a September 2006 opinion, a VA examiner stated that with regard to the Veteran's glenohumeral arthritis, adhesive capsulitis, AC joint arthritis, and anterior shoulder instability, the aforementioned conditions were caused by the Veteran's in-service traumatic anterior shoulder dislocation. According to the examiner, the Veteran's injury led to his developing degenerative changes in his left shoulder. In a private medical statement from S.S.H., D.O., dated in September 2006, Dr. H. stated that he had recently evaluated the Veteran. In regard to range of motion of the Veteran's left shoulder, abduction was to 15 degrees; flexion was to 20 degrees; extension was to 5 degrees; and rotation was to 0 degrees. According to Dr. H., the aforementioned ranges of motion were consistent with adhesive capsulitis. In February 2008, the Veteran underwent a VA neurological examination. At that time, the examiner stated that the Veteran's grip strength of his dominant left hand was decreased when compared to his right. Effort was approximately 4/5 when compared to 5/5 of the right upper extremity. A VA joints examination was conducted by J.L., M.D., in February 2008. At that time, Dr. L. stated that he had reviewed the Veteran's claims file. Dr. L. indicated that according to the Veteran, his pain level in his left shoulder was a 7 or 8/10. The Veteran noted that he had daily flare-ups when his pain level increased to a 9 or 10/10. He reported that he had very occasional radiation down the upper arm only. Repetitive activities aggravated his left shoulder disability. The Veteran stated that he had weakness and numbness in the left upper extremity. He indicated that he was a carpenter but that due to his left shoulder disability, he had not really worked since 1999. In regard to activities of daily living, he could do basic care type of activities and shopping; however, any sort of laborious activity, such as yard work, was difficult. The physical examination showed that the Veteran was tender to palpation anteriorly over the shoulder joint, as well as over the AC joint. In regard to range of motion of the left shoulder, forward flexion was to 45 degrees; abduction was to 45 degrees; internal rotation was to 25 degrees; and external rotation was to 15 degrees. With external rotation, the Veteran had apprehension. Repetitive range of motion of his left shoulder did not limit arch of motion but did increase pain and caused fatigability and additional limitation. Crepitus was felt throughout the glenohumeral joint. The examiner diagnosed the following: (1) glenohumeral arthritis, moderate to severe, (2) adhesive capsulitis, moderate (3) arthritis of the left shoulder AC joint, moderate to severe, and (4) anterior shoulder instability. According to the examiner, the Veteran had pain with range of motion of the left shoulder which could further limit function after using his shoulder all day and while working. A VA report shows that in February 2008, the Veteran underwent an electromyography (EMG). The EMG was interpreted as showing no definite electrophysiological evidence of a median neuropathy at the wrist on either side as the low amplitudes of the median sensory nerve action potentials were of uncertain clinical significance. The EMG was also reported to show no electrophysiological evidence of an ulnar neuropathy on either side. The normal sural sensory nerve action potential amplitudes were electrophysiological evidence against the diagnosis of an underlying polyneuropathy. In an April 2008 opinion, a VA examiner stated that a review of the February 2008 EMG showed that the nerve conduction was normal from the periphery to the spinal cord. In a lay statement from Mr. J.M., dated in August 2008, Mr. M. stated that he had helped the Veteran with simple tasks such as cleaning gutters and weed cutting. According to Mr. M., he had observed the Veteran's limited range of motion of his left shoulder. In March 2010, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. At that time, he stated that due to his left shoulder disability, he was not able to perform the tasks he needed to do as a carpenter. The Veteran indicated that he last worked as a carpenter in approximately 1999. He noted that he had chronic pain in his left shoulder, and weakness and numbness in his left arm. In an October 2010 decision, the Board denied the Veteran's claim of entitlement to service connection for a chronic disability of the left hand, wrist, and elbow, manifested by pain, numbness, and loss of strength, to include as secondary to the service-connected left shoulder disability. At that time, the Board recognized that the evidence of record showed that the Veteran had pain, numbness, and loss of grip strength in his left wrist, hand, and elbow; however, there was no chronic disability in the wrist, elbow, or hand, with competent medical assessments documenting any neuropathy or other disability. The Board also remanded the issue of entitlement to an increased rating for the left shoulder disability. The Board indicated that the Veteran had made a contention regarding the credibility of the examiner from his February 2008 VA joints examination, Dr. J.M. Specifically, the Veteran's spouse had alleged that Dr. M. moved the Veteran's arm against his will, and that the forced movement caused the Veteran to experience great pain. In essence, it was her contention that the results of the 2008 VA examination did not accurately reflect the Veteran's true range of motion. Thus, the Board remanded this case and directed the RO to schedule the Veteran for a new VA examination, with an examiner other than the one who had conducted the February 2008 VA joints examination, for the purposes of determining the current severity of the Veteran's service-connected left shoulder disability. Pursuant to the October 2010 remand, the Veteran underwent a VA joints examination in March 2011 that was conducted by S.H., M.D. At that time, Dr. H. stated that according to the Veteran, his left shoulder pain was an 8/10 on a daily basis. The Veteran indicated that he had flare-ups on a monthly basis that were associated with over-the-head activity. The physical examination showed that the Veteran had 5/5 strength of the finger flexors and extensors, wrist flexors and extensors, biceps, triceps, and deltoid. In regard to his left upper extremity, the Veteran's sensation was intact to light touch in the median, radial, ulnar, and axillary nerve distributions. He had an excellent radial pulse. The Veteran had a well-healed scar over the anterior aspect of his left shoulder that was flat and nontender to palpation. In regard to range of motion of the left shoulder, abduction was to 90 degrees without any pain; however, the Veteran could not abduct beyond 90 degrees due to exquisite pain. Flexion was to 90 degrees without any pain; however, beyond 90 degrees was exquisitely painful and the Veteran would not flex beyond that point. Internal rotation was to 20 degrees and beyond 20 degrees, the Veteran was in exquisite pain. External rotation was to 40 degrees without any pain; the Veteran could not rotate beyond 40 degrees. The Veteran had a negative impingement sign and a negative cross-over sign. He had an internal impingement sign and a positive apprehension sign. Repetition three times in all planes of motion involving the left shoulder increased the Veteran's pain. X-rays of the left shoulder showed mild to moderate osteoarthritis of the glenohumeral joint. Following the physical examination and a review of the Veteran's x-rays, the examiner diagnosed the Veteran as status post recurrent dislocations of the left shoulder with mild to moderate osteoarthritis of the glenohumeral joint. III. Analysis At the outset, the Board notes that under the laws administered by VA, a distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. In the instant case, because the record reveals that the Veteran is left-handed, the Veteran's left arm is considered the major upper extremity. Disability ratings are determined by the application of VA's SCHEDULE FOR RATING DISABILITIES (Rating Schedule) codified in 38 C.F.R. Part 4 (2011), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2011). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with the impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2011). 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 (2011). Where entitlement to compensation has already been established and an increase in the severity of the disability is at issue, as in this case, "the relevant temporal focus . . . is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mayfield, 21 Vet. App. 505, 509-10 (2007); see also Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In this regard, the Court has recognized that "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service- connected disability exhibits symptoms what would warrant different ratings." Hart, 21 Vet. App. at 509. In this case, the Veteran's service-connected post-operative residuals of a left shoulder dislocation are currently evaluated at the 30 percent level under Diagnostic Code 5301, which pertains to Muscle Group I. Under Diagnostic Code 5301, Muscle Group I corresponds to the extrinsic muscles of the shoulder girdle, specifically, the trapezius, levator scapulae, and serratus magnus. The affected function consists of upward rotation of the scapula, and elevation of the arm above shoulder level. A moderately severe impairment corresponds to a 30 percent rating in a dominant extremity, and severe impairment warrants a maximum 40 percent rating in a dominant extremity. 38 C.F.R. § 4.73, Diagnostic Code 5301 (2011). Under 38 C.F.R. § 4.56, governing the evaluation of muscle disabilities, an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. The type of injury associated with a moderately severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe muscle disability is a through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, sloughing of soft parts, and intermuscular binding and scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track and indications on palpation shows loss of deep fascia or muscle substance or soft flabby muscles in the wound area. Also, a demonstration that muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should demonstrate severe impairment. 38 C.F.R. § 4.56(d)(4). If present, the following are also signs of severe muscle disability: (a) X-ray evidence of minute multiple scattered foreign bodies; (b) adhesion of the scar; (c) diminished muscle excitability on electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile; or (g) induration or atrophy of an entire muscle following simple piercing by a projectile. Id. The Veteran maintains that his current rating does not adequately address the manifestations of his post-operative residuals of a left shoulder dislocation. He states that he has chronic pain in his left shoulder with limited range of motion. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. Symptoms, however, must be viewed in conjunction with the objective medical evidence of record. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Based upon the evidence of record, the Board finds that the characteristics or cardinal signs and symptoms of more than a moderately severe muscle injury are not demonstrated by the overall evidence of record. See 38 C.F.R. § 38 C.F.R. § 4.56. In consideration of the criteria for a higher rating under Diagnostic Code 5301, there is no competent medical evidence of the factors that indicate a severe disability of the muscles. For example, there is no competent evidence of a through and through or deep penetrating wound, shattering bone fracture, open comminuted fracture with extensive debridement, prolonged infection, sloughing of soft parts, or intermuscular binding and scarring. There is also no competent evidence indicating a missile track through one or more muscle groups. In addition, there are no indications of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Similarly, there is no evidence of any of the factors, set forth above, which indicate a severe muscle injury, such as visible or measurable atrophy, adhesion of the scar, or diminished muscle excitability on electrodiagnostic tests. Thus, the Board concludes that an evaluation in excess of 30 percent for post-operative residuals of a left shoulder dislocation is not warranted under Diagnostic Code 5301. The Board has also considered alternate diagnostic codes under which the Veteran's left shoulder disability may be rated but none provide for a higher evaluation. In this regard, degenerative or traumatic arthritis (established by X-ray findings) will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joints involved. When there is some limitation of motion, but which would be noncompensable under a limitation-of-motion code, a 10 percent rating may be assigned for arthritis of a major joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. For purposes of rating disability from arthritis, the shoulder is considered a major joint. 38 C.F.R. § 4.45(f). Disabilities of the shoulder and arm are rated under Diagnostic Codes 5200 through 5203. Normal ranges of upper extremity motion are defined by VA regulation as follows: forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5201 provides that limitation of motion of the major arm midway between the side and shoulder level warrants a 30 percent disability rating. Limitation of motion of the major arm to 25 degrees from the side warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. In this case, the Board recognizes that in a private medical statement from Dr. H., dated in September 2006, he stated that abduction of the Veteran's left shoulder was to 15 degrees. The Board, however, notes that in all of the other examinations that were conducted during this appeal, the Veteran's abduction was to at least 45 degrees. In the Veteran's March 2005 VA examination, abduction was to 120 degrees. In the May 2006 VA examination, abduction was to 60 degrees, albeit with pain beginning at 45 degrees. In the February 2008 VA examination, abduction was to 45 degrees. Moreover, in the Veteran's most recent VA examination, dated in March 2011, abduction was to 90 degrees. The Board recognizes that the Veteran has contended that the results of the 2008 VA examination did not accurately reflect his true range of motion; however, even if the Board excluded the results from the February 2008 examination, the September 2006 finding of abduction to 15 degrees is the lone exception when compared to the other examinations of record. Therefore, the Board does not find that the Veteran has limitation of motion of the left arm to 25 degrees from the side. Accordingly, an evaluation in excess of 30 percent for post-operative residuals of a left shoulder dislocation is not warranted under Diagnostic Code 5201. The Board has further considered whether an increased evaluation could be assigned on the basis of functional loss due to subjective complaints of pain, weakness, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45 (2011); see also DeLuca v. Brown, 8 Vet. App. 202, 204-205 (1995). In this regard, the Board recognizes that the Veteran has chronic pain in his left shoulder. In addition, repetitive range of motion increases his pain and causes fatigability and additional limitation. Moreover, he also has instability. A preponderance of evidence, however, is against a finding that the Veteran has any additional limitation of motion of the left shoulder or arm due to pain or flare-ups of pain, supported by objective findings, to a degree that would support a rating in excess of 30 percent (i.e., limitation of motion of the left arm that more nearly approximates to 25 degrees from the side). Further, there is no medical evidence of fatigability, weakness, or incoordination that results in such additional limitation of motion of the left arm. As stated above, with the exception of the September 2006 finding of abduction to 15 degrees, the remainder of the Veteran's examinations showed that his abduction was at least to 45 degrees. Therefore, the Board finds that the Veteran does not have limitation of motion of the left arm to 25 degrees from the side so as to warrant a 40 percent rating under Diagnostic Code 5201, even with consideration of the DeLuca criteria. The Board notes that with respect to other Diagnostic Codes, the Veteran does not have ankylosis of the scapulohumeral articulation (Diagnostic Code 5200) to support a higher rating under Diagnostic Code 5051. In addition, he has not been shown to have impairment of the humerus involving fibrous union, false flail joint or flail shoulder so as to warrant a rating in excess of 30 percent under Diagnostic Code 5202. Therefore, a higher rating is not available under the other Diagnostic Codes for the left shoulder disability. Furthermore, in regard to whether a separate compensable evaluation is warranted for a neurological disability related to the left shoulder disability, the Board notes that in a prior decision, the Board specifically denied the Veteran's claim of entitlement to service connection for a chronic disability of the left hand, wrist, and elbow, manifested by pain, numbness, and loss of strength, to include as secondary to the service-connected left shoulder disability. At that time, the Board recognized that the evidence of record showed that the Veteran had pain, numbness, and loss of grip strength in his left wrist, hand, and elbow; however, there was no chronic disability in the wrist, elbow, or hand, with competent medical assessments documenting any neuropathy or other disability. In this regard, the Board observes that the Veteran's February 2008 EMG was reported to be normal from the periphery to the spinal cord. Thus, there is no medical evidence of a neurological disability associated with or due to the left shoulder disability which warrants a separate compensable rating. In light of the above, the Board finds that there is a preponderance of evidence against the Veteran's claim for an evaluation in excess of 30 percent for the post-operative residuals of a left shoulder dislocation. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Extraschedular Rating Under 38 C.F.R § 3.321(b)(1), in exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be made. The governing norm in an exceptional case 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. See 38 C.F.R § 3.321(b)(1) (2011). Here, the rating criteria reasonably describe the Veteran's symptoms and provide for additional or more severe symptoms than currently shown by the evidence; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). As discussed above, the schedular criteria for a higher rating have not been shown. The record does not reflect that the Veteran has required any hospitalizations for his left shoulder disability. There is also no indication in the record that the left shoulder disability markedly interferes with his employment or daily activities, beyond what is contemplated in the rating schedule. In this regard, the Board recognizes that due to the Veteran's left shoulder disability, he had to stop working as a carpenter. The Board also recognizes that in the May 2005 VA examination report, the examiner stated that it would be difficult for the Veteran to gain substantial employment as a carpenter due to his left shoulder disability. The examiner, however, did not say that Veteran's left shoulder disability prevented him from obtaining and/or maintaining employment. In fact, he indicated that the Veteran could gain employment if he was able to perform activities that included light duty of the left upper extremity. In sum, there is no indication in the record that the average industrial impairment from this disability would be in excess of that contemplated by the 30 percent rating; it is not impractical to apply the regular schedular standards. Thus, a referral for an extra-schedular rating is not warranted. ORDER Entitlement to an evaluation in excess of 30 percent for post-operative residuals of a left shoulder dislocation, is denied. REMAND The Board observes that, although a claim for a TDIU rating was previously considered by the RO in a June 2005 rating decision, in light of the recent case Rice v. Shinseki, 22 Vet. App. 447 (2009), entitlement to TDIU is properly considered as part of the determination of the appropriate disability rating rather than as a separate claim. In this regard, since that adjudication, in particular at the time of the March 2010 Travel Board hearing, the Veteran reported that he had stopped working because of his service-connected left shoulder disability and, in essence, raised the claim for a TDIU. In addition, since the June 2005 rating action, service-connection has been granted for the Veteran's posttraumatic stress disorder (PTSD). At present, the Veteran is receiving a 50 percent disability rating for his PTSD, and his combined disability rating is 70 percent, effective from May 3, 2011. As such, the Board finds that a claim for TDIU, as due to the Veteran's service-connected left shoulder disability and/or PTSD, must be remanded to the RO for adjudication in light of this Board decision and in consideration of the criteria for a TDIU based on the provisions of 38 C.F.R. § 4.16 (2011). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should perform any additional development as necessary in order to adjudicate the Veteran's claim for TDIU pursuant to the provisions of 38 C.F.R. § 4.16 (2011). 2. After any necessary development has been completed to the extent possible, the record should again be reviewed. If the benefits sought on appeal remain denied, the Veteran and his representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter or 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 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. 2011). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs