Citation Nr: 1237011 Decision Date: 10/25/12 Archive Date: 11/08/12 DOCKET NO. 10-08 373 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for disease or injury of the prostate, to include as secondary to service-connected disease or injury. 2. Entitlement to an evaluation in excess of 10 percent for left shoulder impingment prior to September 28, 2010. 3. Entitlement to an evaluation in excess of 20 percent for left shoulder impingment from September 28, 2010. 4. Entitlement to an increased rating for left ulnar palsy, currently evaluated as 10 percent disabling. 5. Entitlement to an increased rating for lumbar spine strain, currently evaluated as 10 percent disabling. 6. Entitlement to a total rating based on unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney at law ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to June 1967. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from a June 2009 rating decision of the VA Regional Office in St. Louis, Missouri that denied service connection for prostatitis, denied increased ratings for lumbar spine strain, left ulnar palsy, and evaluation in excess of 10 percent for left shoulder impingment, and denied a total rating based on unemployability due to service-connected disability. During the pendency of the appeal, by rating decision in February 2012, the 10 percent disability evaluation for left shoulder impingement was increased to 20 percent, effective from September 28, 2010. Following review of the record, the issue of entitlement to service connection for a prostate disorder, to include as secondary to service-connected disease or injury, 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. The issue of entitlement to a total rating based on unemployability due service-connected disability will be deferred pending resolution of the former. FINDINGS OF FACT 1. The Veteran is right hand dominant. 2. Prior to September 28, 2010, left shoulder impingement was manifested by forward flexion to 150 degrees and evidence of articular pathology; the Veteran was able to lift the right arm beyond shoulder level. 3. Left shoulder impingment is manifested by arthritic changes, forward flexion to 110 degrees and abduction to 90 degrees with complaints of pain, stiffness, and limitation of motion without evidence of ankylosis, fibrous union, nonunion or loss of the humeral head; the Veteran is able to lift the right arm to shoulder level. 4. Left ulnar palsy is manifested by complaints of sensory impairment; no more than mild incomplete paralysis is demonstrated. 5. The Veteran does not have the functional equivalent of forward flexion of the thoracolumbar spine to 60 degrees or less, or muscle spasm or guarding. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for left shoulder impingment prior to September 28, 2010 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5201 (2012). 2. The criteria for an evaluation of 20 percent for left shoulder impingment are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5201 (2012). 3. The criteria for evaluation in excess of 10 percent for left ulnar palsy with history of dislocation are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); ); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8516 (2012). 4. The criteria for an evaluation in excess of 10 percent for lumbar spine strain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); ; 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet.App. 183 (2002). The notice requirements of the VCAA apply to all elements of a claim for a higher rating including: (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. See Dingess/Hartman v. Nicholson, 19 Vet.App. 473 (2006). Here, the duty to notify was satisfied prior to the initial decision on the claims by letter dated in March 2009 that addressed the required notice elements. The letter informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence. Notification that included information pertaining to a disability rating and an effective date for the award of compensation was also sent to the appellant at that time. Therefore, no further notice is needed under the VCAA. The Board finds that the necessary development has been accomplished and that appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet.App. 384. VA outpatient and private clinical records have been associated with the claims folder and carefully considered. The Veteran was afforded VA examinations in April 2009 and September 2010 that are determined to be adequate for rating purposes. Social Security records have been received and reviewed. His statements and those of his representative have been carefully considered. The Board thus finds that no further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the claim. See 38 U.S.C.A. § 5103A (a) (2); Dela Cruz v. Principi, 15 Vet.App. 143; Smith v. Gober, 14 Vet.App. 227 (2000); aff'd 281 F. 3d 1384 (Fed. Cir. 2002); see also Quartuccio v. Principi, 16 Vet.App. 183; Soyini v. Derwinski, 1 Vet.App. 540, 546 (1991) (2002). As such, the claims for increased ratings are ready to be considered on the merits. Law and Regulations - General Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2012). The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life and is based, as far as practicable, on average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.10 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2012). Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 U.S.C.A. § 4.45 (2012). The intent of the Rating Schedule is 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 (2012). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet.App. 589 (1995). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet.App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet.App. 119, 126 (2001). 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3 (2012). Factual Background A claim for increased ratings for service-connected disabilities was received in January 2009. The Veteran was afforded a VA joints examination in April 2009. It was noted that the right hand was dominant. He related that he had progressively worsening pain of the left shoulder, especially with weather changes, that interfered with sleep, and worsening numbness and tingling in the left arm. It was reported that he denied any problem with the left elbow. On examination of the left shoulder, the Veteran had positive stiffness, pain and reported flare-ups of severe joint pain, but had no deformity, giving way or instability. He denied incoordination, weakness, episodes of dislocation or subluxation, locking and effusion. Left shoulder flexion, abduction, internal rotation and external rotation were from 0 to 150 degrees, 0 to 125 degrees, 0 to 35 degrees, and 0 to 75 degrees, respectively. It was reported that there was objective evidence of pain following repetitive motion and that there was additional limitation after three repetitions of range of motion. Range of motion of left elbow flexion, extension, pronation, and supination was from 0 to 140, 0, 80, and 85 degrees, respectively. The Veteran denied pain following repetitive motion and additional limitation after three repetitions of range of motion. There was no evidence of joint ankylosis. An X-ray of the left shoulder was interpreted as showing no acute fracture/dislocation and no significant interval change since 2005. An X-ray of the left elbow disclosed no acute fracture or dislocation. The functional effects of left shoulder disability with neuropathy of the ulnar nerve were depicted as pain and problems with lifting and carrying, with severe effects on chores, shopping and exercise, moderate effects on recreation, traveling, dressing, bathing and driving, and a mild effect on feeding and grooming. The appellant complained of worsening symptoms related to ulnar nerve paralysis with symptoms of left arm numbness, tingling and pain that were lasting longer. It was noted that symptoms also included weakness, stiffness, and paresthesias. On motor examination, muscle strength was 5 and there was no motor impairment. Sensory function was normal in all aspects. All reflexes were 2+ and equal. It was reported that there was no muscle atrophy, no abnormal muscle tone or bulk, no abnormal movement and no joint affected by a nerve disorder. On evaluation of the lumbar spine, the Veteran complained of progressively increasing pain and decreased motion. He stated that he had constant daily moderate pain with weekly severe flare-ups, especially with weather changes. The appellant related that he rested and took Advil and used heat to alleviate symptoms. It was reported that during flare-ups of pain, he was unable to do anything. On examination of the spine, posture and head position were normal. The spine was symmetric. There was no spinal gibbous, kyphosis, listing, lumbar flattening, scoliosis, reverse lordosis, or ankylosis. The Veteran was noted to have some lumbar lordosis. There was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness. Muscle tone was normal. There was no atrophy. Reflexes were normal. The motor and sensory examinations were normal. Thoracolumbar flexion, extension, left lateral flexion, left lateral rotation, right lateral flexion, and right lateral rotation were from 0 to 85, 0 to 28, 0 to 26, 0 to 30, 0 to 32, and 0 to 34 degrees, respectively. There was no objective evidence of pain on active range of motion or pain following repetitive motions or additional limitations after repetitions of range of motion. It was reported that five views of the lumbar spine were taken that revealed small osteophyte formation on the vertebral bodies of L3, L4 and L5 but no acute fracture or subluxation was identified. The functional effects of low back were reported as pain and decreased mobility with severe effects on chores, shopping, exercise, and traveling, and moderate effects on recreation, traveling, dressing, bathing. Following examination, the diagnoses were left shoulder strain with C5-C6 radiculopathy, and minimal lumbar degenerative joint disease per MRI [magnetic resonance imaging]. VA outpatient records dating from April 2009 reflect that the Veteran had generalized complaints of low back pain and arthralgias. In May 2009, he was seen in physical medicine rehabilitation consultation for evaluation of chronic pain. Pertinent history was recited. The Veteran described pain as sharp and stabbing that was worse at the end of the day, especially after standing for long periods. The worst level of pain was depicted as 8 on a 10 scale (8/10) with 4-5/10 as the usual degree. He stated that pain was provoked by lifting over 10-12 pounds from the floor, awkward positioning when sitting down too fast, and changes in weather, especially the cold. Examination disclosed no gross bony abnormalities. The lordotic curve was well maintained. There were no paraspinal muscle spasms. The assessment was low back pain with mild radicular pain. Following imaging studies in August 2009 and on follow-up in September 2009, the diagnoses were left L5 radiculopathy and chronic low back pain. The Veteran underwent examinations for VA compensation and pension purposes in September 2010. He related that he had rheumatoid arthritis for which he was not service connected. On this occasion, he reported pain, stiffness and decreased speed of joint notion of the left shoulder, and instability, stiffness, pain, and decreased speed of joint notion of the left elbow. Left shoulder flexion, abduction, internal rotation and external rotation were from 0 to 110 degrees, 0 to 90 degrees, 0 to 50 degrees, and 0 to 70 degrees, respectively. It was reported that there was objective evidence of pain following repetitive motion but no additional limitation after three repetitions of range of motion. There was objective evidence of pain with active motion on the left side. Left elbow/forearm flexion, pronation, supination were from 0 to 145, 0 to 80, and 0 to 85 degrees, respectively. The Veteran denied pain following repetitive motion and additional limitation after three repetitions of range of motion. There was no evidence of joint ankylosis. An X-ray of the left shoulder was interpreted as showing mild degenerative changes of the acromioclavicular joint. An X-ray of the left elbow disclosed no definitive fracture or soft tissue calcification but mild degenerative changes and mild joint effusion. Following examination, the diagnosis was mild degenerative changes of the acromioclavicular joint of the left shoulder with impingment. The disability's impact on occupational activities was problems with lifting and carrying, decreased strength of the upper extremity and pain. The effects of the problem on the usual daily activities included preventing chores, shopping, exercise, sports, recreation and driving. The diagnoses pertinent to the left elbow were mild degenerative changes and mild effusion. The disability's impact on occupational activities was problems with lifting and carrying, decreased strength of the upper extremity and pain. The effects of the problem on the usual daily activities included preventing chores, shopping, exercise, sports, recreation and driving. On physical examination of the left ulnar nerve, the complaints were essentially the same as on the prior compensation examination. The motor evaluation and reflexes were normal in all respects. On sensory evaluation, the Veteran had decreased vibration sense, pinprick sensation, and light touch sensation in the lateral aspect of the hand and 4th and 5th fingers examination. There was no complaint of dysesthesias. It was reported that no joint was affected by the nerve disorder. Following examination, the pertinent diagnosis was left ulnar nerve palsy. It was noted that nerve dysfunction and paralysis were present but that neuritis and neuralgia were absent. The disability's impact on occupational activities was problems with lifting and carrying, and decreased strength in the upper extremity. On examination of the lumbar spine, it was reported that gait was antalgic. Inspection of other aspects of the spine was essentially the same as on the previous VA examination. On this occasion, thoracolumbar flexion, extension, left lateral flexion, left lateral rotation, right lateral flexion, and right lateral rotation were from 0 to 70, 0 to 20, 0 to 30, 0 to 30, 0 to 30, and 0 to 30 degrees with pain on active range of motion. The appellant reported pain with repetitive motion and but no additional limitations after repetitions of range of motion. An X-ray of the lumbar spine was interpreted as showing minimal osteoarthritis. Following examination, the diagnosis was mild degenerative joint disease of the lumbosacral spine. The functional effects of low back disability were reported as pain and decreased mobility, problems with lifting and carrying, and decreased strength in the lower extremity. It was opined that the problem affected all activities of daily living. Subsequently received were private clinical records dating from 2005 through 2010. Pertinent evidence dating from 2008 reflects left hand tingling in October 2008 with decreased grip strength, neuropathic pain, weakness in the left arm and a pins and needles sensation in the left upper extremity. The record reflects Veteran continued to seek treatment for low back pain. In January 2012, diagnoses following evaluation included generalized aches and pains, probably caused by rheumatoid arthritis, and back pain that is not localized to any particular area. It was noted that he did not complain of radiating pain and that the clinical examination was negative for radiculopathy. Legal Analysis 1. Entitlement to an evaluation in excess of 10 percent for left shoulder impingment prior to September 28, 2010 and in excess of 20 percent for left shoulder impingment from September 28, 2010. The service connected left shoulder disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5201 (2012). Hyphenated diagnostic codes are used when a rating requires use of an additional rating criteria to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.71a (2012). In this case, Diagnostic Code 5010 signifies an arthritis component of the disability. Diagnostic Code 5201 rates limitation of motion of the arm and provides that a 20 percent rating is warranted when motion is limited to shoulder level or to midway between the side and shoulder level for the minor arm; 20 percent when motion is limited midway between side and shoulder level for the minor arm; and 30 percent when motion is limited to 25 degrees from side for the minor arm. Id. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). For VA purposes, normal range of motion of the shoulder is forward extension and abduction from 0 to 180 degrees with 90 degrees being at shoulder level; internal rotation from 0 to 90 degrees; and external rotation from 0 to 90 degrees. See 38 C.F.R. § 4.71a, Plate I (2012) The Veteran was assigned a staged evaluation of 10 percent prior to September 28, 2010 and a 20 percent disability rating thereafter. The 10 percent evaluation would be compatible with periarticular pathology productive of painful motion. The 20 percent evaluation is consistent with limitation of motion to shoulder level. In order to warrant a higher evaluation, the evidence would have to reflect the functional equivalent of limitation of motion to shoulder level prior to September 28, 2010 and/or the functional equivalent of limitation of motion to 25 degrees from the side. See 38 C.F.R. § 4.7. The record reflects that when the Veteran was examined by VA in 2009 he referred to mild stiffness, progressive pain, lifting restrictions and carrying out activities of daily living. The evidence reflects that he retained significant range of motion of the left shoulder and was able to lift the left arm to 150 degrees. The ability to lift the arm to shoulder level is lifting it to 90 degrees. Therefore, left shoulder flexion far exceeded that required for a 20 percent rating in this regard which is the ability to lift an arm to no more than 90 degrees or to shoulder level. The evidence thus indicates that the appellant had articular and periarticular pathology at that time. The presence of periarticular pathology, limited motion, and pain on use is contemplated by 38 C.F.R. § 4.59 that is consistent with Diagnostic Codes 5003-5010, and provides for a 10 percent evaluation when limitation of motion is noncompensable but affected by painful motion. As such, the Board finds that the symptoms associated with service-connected left shoulder impingement did not more nearly comport with the criteria for a 20 percent disability evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5201 prior to September 28, 2010 and a 10 percent disability evaluation based on the presence of articular pathology was appropriate. The record reflects that when the appellant was examined by VA in 2010, he was shown to have further reduced left shoulder range of motion relative to the regulatory criteria, but functional left shoulder flexion shown to be from zero to 110 degrees. Therefore, he is able to lift the both arms above shoulder level. On this occasion, however, abduction was reduced to 90 degrees, and internal and external rotation was also substantially reduced evidencing a greater degree of disability. An X-ray of the left shoulder disclosed degenerative changes of the acromioclavicular joint that were not shown previously. The Veteran reported further compromise and functional loss of the left shoulder, and it was determined that the effects of the problem prevented a number of activities of daily living which were not previously noted Accordingly, the disability evaluation was increased to 20 percent as of the date of the VA examination. This is consistent with increased disability exhibited on that occasion with consideration of additional functional loss occasioned by pain. See DeLuca v. Brown, 8 Vet.A00. 202 (1995). The Board finds, however, that a 30 percent rating for the left shoulder is not warranted as the evidence clearly does not reflect that the left arm is limited to 25 degrees from the side. In determining the degree of functional impairment, the provisions of 38 C.F.R. §§ 4.40 and 4.45 are for consideration. The Board accepts that the appellant has a significant degree of functional impairment and pain as indicated above. When examined by VA over the course of the appeal period, it has been noted that there is evidence of left shoulder impingment and pain on motion. Range of motion is reduced with reported pain, stiffness, weakness and activity restrictions. However, neither the lay nor the medical evidence reflects the functional equivalent of symptoms required for an evaluation in excess of 10 percent prior to September 28, 2010 and 20 percent thereafter when all of the complaints and findings are considered. Left shoulder flexion and abduction do not impede the ability to lift the arms to shoulder level. The Board thus finds that the left shoulder symptoms displayed throughout the appeal period are contemplated by the 10 percent disability prior to September 28, 2010 and the 20 percent disability evaluation in effect under 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board must also consider whether any alternative diagnostic code serves as a basis for higher ratings for the service-connected left shoulder disability prior to and after September 28, 2010. However, the evidence discloses no ankylosis of the scapulohumeral joint, malunion or nonunion, or dislocation or subluxation of the clavicle or scapula by clinical report or lay assertion. Therefore, 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203 do not provide for higher evaluations for left shoulder disability prior to or after September 28, 2010. The Veteran is competent to report symptoms of increased left shoulder disability and the Board has considered the lay evidence in this regard. However, the clinical findings of the skilled clinical professionals on VA examination are more probative and credible when all of the lay and objective evidence is considered. As such, the Board finds that the evidence does not support a rating higher than 10 percent for left shoulder impingment prior to September 28, 2010 and more than the current disability rating of 20 percent in this regard. See Hart v. Mansfield, 21 Vet.App. 505 (2007). The preponderance of the evidence is against the claims and they are denied. 38 U.S.C.A. § 5107(b); Gilbert v Derwinski, 1 Vet.App. 49 (1990). 2. Increased rating for left ulnar palsy. Pertinent Regulation 38 C.F.R. § 4.124a, Diagnostic Code 8516 provides that mild incomplete paralysis of the ulnar nerve is rated 10 percent disabling on the major side and 10 percent on the minor side. Moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side. Severe incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side. Complete paralysis of the ulnar nerve, that includes "griffin claw" deformity due to flexor contraction of ring and little fingers, very marked atrophy in dorsal interspace and thenar and hypothenar eminences, loss of extension of ring and little fingers, inability to spread the fingers (or reverse), inability to adduct the thumb, and weakened flexion of wrist, is rated 60 percent disabling on the major side and 50 percent on the minor side. Id. When involvement is only sensory, the rating should be for the mild, or at most, moderate degree. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.124 (2012). The Veteran is currently in receipt of a 10 percent evaluation for mild incomplete paralysis of the minor ulnar nerve. See 38 C.F.R. § 4.7. In order to receive an increased evaluation, it must be shown that the evidence approximates at least moderate incomplete paralysis of the ulnar nerve. In determining whether the degree of left ulnar paralysis, Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence to the end that decision will be equitable and just. See 38 C.F.R. § 4.6 (2012). Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104(West 2002); 38 C.F.R. § 4.2 (2012). The Board observes that over the course of the appeal, the appellant has reported progressively worsening numbness, paresthesias, ant dysesthesias, etc., related to left ulnar nerve disability. The record reflects that although he appears to have experienced some acute symptoms in October 2008 and was treated for complaints that included decreased grip strength, neuropathic pain, weakness in the left arm and a pins and needles sensation, VA examination in April 2009 disclosed that sensory and motor function was normal in every aspect. When examined by VA September 2010, the sensory examination revealed decreased vibration sense, pinprick sensation, and light touch sensation in the lateral aspect of the hand and 4th and 5th fingers examination, but no complaint of dysesthesias. It was reported that no joint was affected by the nerve disorder. Although it was found that nerve dysfunction and paralysis were present, it was noted that there was no neuritis or neuralgia. Motor, and reflex functions were normal. Thus, the clinical picture obtained over the course of the appeal reflects that neurological impairment affecting the left ulna nerve is almost entirely sensory and is no more than mild. In consideration of all of the relevant lay and medical evidence delineated above pertaining to the left ulnar nerve, the Board finds the disability picture does not support a finding that the Veteran's service-connected ulnar nerve disability more nearly approximates moderate incomplete paralysis for which a 20 percent disability rating may be conceded. As such, no more than a 10 percent disability evaluation is warranted under 38 C.F.R. § 4.124a, Diagnostic Code 8516. The Veteran is competent to report symptoms of increased ulnar nerve disability and the Board has considered the lay evidence in this regard. However, the clinical findings of the skilled clinical professionals on VA examination are more probative and credible. As such, the Board concludes that the preponderance of the evidence is against the claim for a higher rating for left ulnar palsy and the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v Derwinski, 1 Vet.App. 49 (1990). 3. Increased rating for lumbar spine strain. Law and Regulations Service connection is in effect for lumbar spine strain, evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board would point out that the Veteran's service-connected lumbar spine disorder does not currently encompass lumbar disc pathology under 38 C.F.R. § 4.71a, Diagnostic Code 5243 or rheumatoid arthritis. The appellant is always free to pursue a claim as to those matters if he so chooses. All diseases and injuries of the spine other than intervertebral disc syndrome are to be evaluated under the General Rating Formula for the spine (codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012)). Under the General Rating Formula for the spine, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or, muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar to 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 (See also Plate V) provides that for VA compensation purposes, normal forward flexion of the cervical 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 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension from zero to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion is 240 degrees for the thoracolumbar spine. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in the neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately except when there is unfavorable ankylosis of both segments which will be rated as a single disability. In evaluating the clinical findings pertaining to the lumbar spine, the evidence reflects that the Veteran has not had the functional equivalent of forward flexion of the thoracolumbar spine limited to 60 degrees or less for which a higher disability evaluation might be awarded. See DeLuca. Throughout the appeal period, flexion has not been shown to be less than 60 degrees as demonstrated by forward flexion to 85 degrees in April 2009 and 70 degrees in September 2010. No muscle spasm, tenderness, guarding or pain on palpation has been reported or confirmed on examination. Flexion of greater than 60 degrees and the absence of the absence or muscle spasm and/or guarding are contemplated by the 10 percent disability evaluation currently in effect and do not afford a basis for more than a 10 percent evaluation under Diagnostic Code 5237 for the lumbar spine. Additionally, the evidence does not reflect fixation of a spinal segment or ankylosis. Therefore, a higher rating is not warranted on these bases. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242 (2012). With respect to possibility of entitlement to an increased evaluation under 38 C.F.R. §§ 4.40, and 4.45 on the basis of functional loss due to pain and other impairment associated with motion, see DeLuca, 8 Vet.App. at 204-205, the appellant reports pain and states that some activities of daily living have been constrained. However, pain associated with motion is fully contemplated in the current 10 percent evaluation. There is no evidence indicating that pain, weakness, fatigue, or incoordination associated with motion results in the equivalent of flexion to less than 60 degrees. As such, a higher rating based on pain and functional loss is not warranted. The preponderance of the evidence is against the claim for a rating in excess of 10 percent for lumbar spine strain the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v Derwinski, 1 Vet.App. 49 (1990). Conclusion The Board recognizes that a layperson is competent to describe what comes to him or her through the senses. See Layno v. Brown, 6 Vet.App. 465 (1994). In this regard, the Veteran can assert that the symptoms associated with the left shoulder, low back and left ulnar disability are worse. The Federal Circuit has held that lay assertion is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. However, the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). To the extent that the appellant asserts that his service-connected left shoulder, low back and left ulna disorders are more severely disabling, the Board points out that the findings on the VA clinical examinations over the course of this appeal do not establish that he has more severe disability in each respect. The Board has carefully considered the appellant's contentions of pain, and functional loss. However, functional impairment is included in the current evaluations assigned. Even accepting his statements as true, this would not warrant a higher rating for reasons stated above. The Board concludes that the medical findings on examination are of greater probative value and fail to demonstrate that higher evaluations are warranted. In view of such, the Board finds that the currently assigned disability evaluations are appropriate. Finally, the Board has also considered whether higher ratings for service-connected left shoulder impingement, ulnar palsy and lumbar spine strain are warranted on an extraschedular basis. The potential application of 38 C.F.R. § 3.321(b)(1) (2012) has been considered. However, the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." There is no objective evidence demonstrating that the appellant's service-connected disabilities markedly interfere with employment beyond that contemplated by the rating schedule. There is no evidence showing that he has been frequently hospitalized due to his such symptoms. The evidence shows that the relative manifestations and the effects of the disability have been fully considered and are contemplated by the rating schedule. The Board finds that the ratings assigned are precisely that contemplated for these disabilities. See Thun v. Peake, 22 Vet.App. 111 (2008). The Board thus concludes that the Veteran has not demonstrated such a degree of disability to render impractical the application of the regular rating schedule standards. In the absence of such factors, the criteria for referral for an extraschedular rating pursuant to § 3.321(b) (1) are not met. See Bagwell v. Brown, 9 Vet.App. 337 (1996); Shipwash v. Brown, 8 Vet.App. 218 227 (1995). ORDER An evaluation in excess of 10 percent for left shoulder impingment prior to September 28, 2010 is denied An evaluation in excess of 20 percent for left shoulder impingment is denied. An evaluation in excess of 10 percent for left ulnar palsy with history of dislocation is denied. An evaluation in excess of 10 percent for lumbar spine strain is denied. REMAND The Veteran asserts that he has a prostate disorder that is of service onset or is secondary to service-connected disability, specifically a back disorder. Service treatment records reflect that he was treated for balanitis in February 1966 and gonoccocal urethritis in June of that year. In private clinical reports dated in June and October 1998, it was recorded that there a medical history positive for a prostate problem since the 1970s for which he had been seen by "many urologists." In a statement dated in March 1999, the appellant related that he had been seen by a urologist for a number of years for a prostate problem. The Veteran has not had a VA examination for a prostate disorder and there is no competent or probative opinion in the record that addresses whether it is related to an incident of service or a service-connected disorder. The Court of Appeals for Veterans Claims (Court) held in McLendon v. Nicholson, 20 Vet.App. 79, 83 (2006) that under the VCAA, VA is obligated to provide an examination where the record contains competent evidence that the claimant has a current disability, the record indicates that a disability or signs or symptoms of disability might be associated with active service, and the record does not contain sufficient information to make a decision on a claim. 38 U.S.C.A. § 5103A. The threshold for getting an examination under the VCAA is low. McLendon. With these factors in mind and upon further review of the record, the Board finds that a VA examination and opinion are indicated in this matter pursuant to VA's duty to assist in order to render a fully informed appellate decision. See Hyder v. Derwinski, 1 Vet. App. 221, (1991); Green v. Derwinski, 1 Vet.App. 121, 124 (1991). Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and request that he provide authorization identifying the names and addresses of all providers who treated him for a prostate disorder beginning immediately after discharge from service and continuing. After securing the necessary releases, the RO should request this information. 2. Following a reasonable time for receipt of information requested above, schedule the Veteran for a VA examination by an appropriate examiner. All indicated tests and studies should be performed, and clinical findings should be reported in detail. The claims file should be made available to the examiner for review prior to examination. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence and physical examination, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) a) the Veteran has a current prostate disorder related to symptoms in service or b) whether a prostate disorder is secondary to or has been aggravated by a service-connected disability, either singly or in the aggregate, including the low back (See 38 C.F.R. § 3.310(a) (2012)), or has been or is made chronically worse by service-connected disabilities, including the low back. See Allen v. Brown; 7 Vet.App. 439 (1995). In formulating the medical opinion, the examiner is asked to consider that the term "at least as likely as not" does not mean within the realm of possibility, rather that the weight of the medical evidence both for and against the conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against causation. The examination report must include well-reasoned rationale for all opinions and conclusions provided. 3. After taking any further development deemed appropriate, re-adjudicate the remaining issues on appeal, to include a total rating based on unemployability. If a benefit is not granted, provide the appellant and his representative a supplemental statement of the case before the case is returned to the Board. The appellant 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 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. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans Appeals Department of Veterans Affairs