Citation Nr: 1305463 Decision Date: 02/14/13 Archive Date: 02/21/13 DOCKET NO. 09-07 094 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder. 2. Entitlement to service connection for posttraumatic stress disorder. 3. Entitlement to an initial compensable disability rating for residuals of a right elbow fracture with pain. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from February 2003 to April 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky granted service connection for residual right elbow pain after a fracture, assigning a noncompensable evaluation effective August 27, 2007; and denied service connection for posttraumatic stress disorder (PTSD), chronic sinusitis, and irritable bowel syndrome (IBS). In July 2008, the Veteran submitted a notice of disagreement and subsequently perfected his appeal in February 2009. The Board notes that the Veteran originally filed a claim of entitlement to service connection for PTSD. Although not expressly claimed by the Veteran, the Board is expanding his original claim to include all acquired psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness; he filed a claim for the affliction his mental condition, whatever it is, causes him). Accordingly, the issue has been recharacterized and separated into two distinct issues, as are annotated on the preceding cover page. In January 2012, the Board denied the Veteran's claims of entitlement to service connection for chronic sinusitis and IBS and a compensable initial rating for residuals of a right elbow fracture with pain and remanded his claim for service connection for a psychiatric disorder, to include PTSD, to the Appeals Management Center (AMC) for further evidentiary development, including asking the Veteran to provide releases of information for outstanding private psychiatric treatment records, scheduling him for a VA examination, and readjudicating the case in a supplemental statement of the case (SSOC). The Board is obligated by law to ensure that the AMC complies with its directives. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AMC sent the Veteran a letter in January 2012 asking him to provide a release of information for any relevant private treatment records and afforded him a VA examination in February 2012. The AMC did not readjudicate the Veteran's claim or provide an SSOC. With regard to the Veteran's claim for service connection for an acquired psychiatric disorder other than PTSD, the Board has granted this claim as discussed in detail below. Therefore, any failure to complete this remand directive is irrelevant and does not prejudice the Veteran. With regard to the Veteran's claim for service connection for PTSD, the Board finds that the AMC has not complied fully with the January 2012 remand directives, as discussed more fully below. As such, this claim must be remanded yet again. Stegall, supra. The Veteran appealed the Board's January 2012 denial of an initial compensable evaluation for a right elbow disability to the United States Court of Appeals for Veterans Claims (Court). In August 2012, the Court issued an order granting a August 2012 joint motion to remand (JMR) the appeal to the Board. The appeal was returned to the Board for action consistent with the August 2012 JMR and Court order. The issue of entitlement to service connection for PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. The Veteran's currently diagnosed psychosis NOS is the result of his active duty service. 2. The Veteran's service-connected residuals of a right elbow fracture with pain are manifested by painful motion during flare ups, tenderness on palpation, with motion limited to no worse than 10 degrees of extension, 145 degrees of flexion, 80 degrees of pronation, and 85 degrees of supination, and no evidence of ankylosis or impairment of the radius or ulna. CONCLUSIONS OF LAW 1. The Veteran's psychosis NOS was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 2. The criteria for the assignment of an initial disability rating of 10 percent, but no higher, for residuals of a right elbow fracture with pain have been met for the entire period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.59 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board 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. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claim for service connection for an acquired psychiatric disorder, other than PTSD, this claim is being granted, as discussed in further detail herein. As such, any error related to the VA's duties to notify and to assist the Veteran is moot with regard to this issue. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the Veteran's claim for an initial compensable evaluation for his right elbow disability, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio at 187. Further, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Here, by the March 2008 rating action, the RO granted service connection for residuals of a right elbow fracture with pain and assigned a noncompensable disability rating. Following receipt of notification of that determination, the Veteran perfected a timely appeal of the noncompensable rating assigned. Clearly, based on this evidentiary posture, the Veteran's claim for a higher rating is based on his disagreement with the assignment of the specific evaluation following the grant of service connection for this disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007). Thus, no further VCAA notice with respect to this initial compensable rating issue is required. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records, and VA examination reports are in the file. At no time has he referenced any private or other outstanding treatment records that he wanted VA to obtain or that he felt were relevant to the claim. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with a VA examination for his right elbow disability most recently in May 2009. That examiner reviewed the Veteran's medical records, obtained a thorough history, and provided a thorough physical examination, including the appropriate range of motion testing. The May 2009 examination is adequate for determining the disability rating for the Veteran's service-connected right elbow disability. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, there is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected right elbow disability since he was last examined. 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Thus, the Board finds that a new VA examination is not necessary at this time. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims A. Acquired Psychiatric Disorder The Veteran claims that he has a psychiatric disorder (e.g., PTSD) as a result of exposure to riots, gunfire, and IED explosions while serving in Iraq. As noted above, his claim has been expanded to include all currently diagnosed psychiatric disorders, and the issue of PTSD specifically has been remanded below. Here, the Board will only address acquired psychiatric disorders other than PTSD. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for a disability, there must be (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). The medical evidence of record reflects that the Veteran has been diagnosed with several psychiatric disorders, including anxiety NOS, depression NOS and depressive disorder, paranoid and delusional disorder, and bipolar disorder with psychotic features. The February 2012 VA examiner diagnosed him with psychosis NOS. As such, the first element of Hickson is met. Service treatment records are negative for any diagnosis of a psychiatric disorder in service. However, the separation report of medical history shows self-reported psychiatric symptoms, including nervous trouble, frequent trouble sleeping, past history of counseling, and depression or excessive worry. Also, a March 2004 post-deployment health assessment indicates that the Veteran felt in great danger of being killed while deployed in Iraq, and a March 2005 record shows an appointment with psychiatry. Finally, the Veteran's personnel records show a pattern of misconduct during his later service, including domestic violence. The February 2012 VA examiner concluded that these acts of misconduct may have been early signs of psychiatric symptomatology. As these findings support in-service psychiatric complaints, the second element of Hickson can be conceded. The remaining question is whether a medical nexus exists between the Veteran's current psychiatric disability, other than PTSD, and his military service. At the February 2012 VA examination, the examiner diagnosed psychosis NOS; concluded that the DSM-IV diagnostic criteria for a diagnosis of PTSD were not met; and opined that the psychosis NOS was at least as likely as not related to service. To support his conclusion, the examiner pointed out the Veteran's pattern of misconduct in service and concluded that these acts may have been precursors to the later onset of his disabling psychiatric problems. In addition to the February 2012 VA examination report, the VA treatment records include records showing treatment for various psychiatric diagnoses. However, none of these records relate the Veteran's psychiatric problems to service. Finally, the Veteran submitted a letter from his mother, a nurse practitioner, in October 2012. She indicated that the Veteran suffered from disabling emotional and mental problems and that she believed that these problems were related to his military service. As a nurse practitioner, the Veteran's mother is presumed competent to make such a statement about the etiology of a psychiatric illness. In addition to the medical evidence, including his mother's statement, the Veteran has submitted personal statements indicating that he has experienced psychiatric symptoms, including depression and anxiety, since service. The Board notes that the Veteran is competent to offer a description of symptoms, such as feeling depressed and anxious, that he has experienced since service, and to describe a continuity of such symptoms since service. A layperson, such as the Veteran is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom; Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to report that he has experienced psychiatric symptoms, including depression and anxiety, since service. Although he is not competent to link these symptoms to his service, the February 2012 VA examiner and his mother are competent and have provided such a link. In light of the February 2012 examiner's positive nexus opinion and the Veteran's mother's positive opinion, the lack of sufficiently probative evidence to contradict these opinions, and the lay evidence reporting continuous psychiatric symptoms since service, the Board finds that the evidence is, at minimum, in equipoise regarding the question of whether the Veteran's current acquired psychiatric disorder, other than PTSD, is related to his active duty service. As such, the Board will give the Veteran the benefit of the doubt, and conclude that service connection for a psychosis NOS is warranted. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Right Elbow The Veteran's service-connected residuals of a right elbow fracture with pain has been initially evaluated as 0 percent disabling under Diagnostic Code 5209. He seeks a higher initial evaluation. In this regard, the Board notes that disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The Veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2012). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing him claim when his disability may have been more severe than at other times during the course of his appeal. Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Under Diagnostic Code 5209, a 20 percent evaluation is assigned for an elbow joint fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius of the major arm. A 60 percent evaluation is assigned for other impairment of flail joint of the elbow of the dominant arm. See 38 C.F.R. § 4.71a, Diagnostic Code 5209 (2012). Diagnostic Code 5206 provides the rating criteria for limitation of flexion of the forearm; Diagnostic Code 5207 provides the rating criteria for limitation of extension of the forearm; Diagnostic Code 5208 provides the rating criteria for limitation of flexion and extension of the forearm; and Diagnostic Code 5213 provides the rating criteria for impairment of supination and pronation. Normal range of motion of the forearm is from 0 degrees of extension to 145 degrees of flexion, from 0 to 80 degrees of pronation, and 0 to 85 degrees of supination. 38 C.F.R. § 4.71a, Plate I (2012). Under Diagnostic Code 5206, a noncompensable evaluation is assigned for flexion of the major forearm limited to 110 degrees. A 10 percent evaluation is assigned for flexion of the major forearm limited to 100 degrees. A 20 percent evaluation is assigned for flexion of the major forearm limited to 90 degrees. A 30 percent evaluation is assigned for flexion of the major forearm limited to 70 degrees. A 40 percent evaluation is assigned for flexion of the major forearm limited to 55 degrees. A 50 percent evaluation is assigned for flexion of the major forearm limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206 (2012). Under Diagnostic Code 5207, a 10 percent evaluation is assigned for extension of the major forearm limited to 45 or 60 degrees. A 20 percent evaluation is assigned for extension of the major forearm limited to 75 degrees. A 30 percent evaluation is assigned for extension of the major forearm limited to 90 degrees. A 40 percent evaluation is assigned for extension of the major forearm limited to 100 degrees. A 50 percent evaluation is assigned for extension of the major forearm limited to 110 degrees. 38 C.F.R. § 4371a, Diagnostic Code 5207 (2012). Under Diagnostic Code 5208, a 20 percent evaluation is assigned for flexion of the major forearm limited to 100 degrees and extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208 (2012). Under Diagnostic Code 5213, a 10 percent evaluation is assigned for limitation of supination of the major arm to 30 degrees or less. A 20 percent evaluation is assigned for limitation of pronation of the major arm with motion lost beyond the last quarter of arc and the hand not approaching full pronation or for loss of bone fusion of the major arm with the hand fixed near the middle of the arc or moderate pronation. A 30 percent evaluation is assigned for limitation of pronation of the major hand with motion lost beyond the middle of the arc or for loss of bone fusion of the major arm with the hand fixed in full pronation. A 40 percent evaluation is assigned for loss of bone fusion of the major arm with the hand fixed in supination or hyperpronation. 38 C.F.R. § 4.71a, Diagnostic Code 5213 (2012). Additionally, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, in claims for increased ratings for musculoskeletal disabilities where the veteran has a noncompensable rating and complains of pain on motion, the veteran is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012); Burton v. Shinseki, 25 Vet. App. 1 (2011) (painful motion under 38 C.F.R. § 4.59 does not require arthritis for a minimum rating for the specific joint). As referenced above, the Veteran most recently underwent a VA examination for his right elbow disability in May 2009. At that time, he complained of pain in his right elbow twice weekly for a couple of hours that was relieved with change in position and massage, stiffness, tenderness, decreased speed of joint motion, affected motion of the joint, and moderate weekly flare ups with no deformity, instability, weakness, incoordination, episodes of dislocation of subluxation, locking episodes, effusions, or other symptoms. He indicated that his right hand was his dominant hand. He reported that, when his elbow was sore, it hurt to perform range of motion movements. The examiner observed mild point tenderness over the proximal ulna posteriorly and recorded range of motion measurements of 0 degrees of extension, 145 degrees of flexion, 80 degrees of pronation, and 85 degrees of supination, with no objective evidence of pain on motion or additional limitation of motion or objective evidence of pain after repetitive motion. He did not observe any joint ankylosis or popping or dislocation with range of motion against pressure. X-rays were negative for any acute abnormalities. The examiner diagnosed the Veteran with residual right elbow pain status post fracture of the right radial head and concluded that his right elbow disability resulted in no effects on feeding, bathing, dressing, toileting, or grooming, mild effects on chores, shopping, sports, recreation, traveling, and driving, and severe effects on exercise. The Veteran was previously examined in February 2008. At that time, he complained of pain with no effect on motion of the right (dominant) elbow. The examiner observed no abnormalities of the right elbow, including no deformity, angulation, loss of bone or part of bone, false joint, malunion, nonunion, or tenderness on palpation. He recorded range of motion measurements of 150 degrees of flexion, 10 degrees of extension, 90 degrees of pronation, and 90 degrees of supination with no loss of motion with repetitive movement. X-rays findings were negative for the right elbow. The examiner diagnosed the Veteran with residual right elbow pain after fracture and concluded that his right elbow disability had no effects on traveling, feeding, bathing, dressing, toileting, and grooming, mild effects on shopping and recreation, and moderate effects on chores, exercise, and sports. The medical evidence of record does not establish that the Veteran's service-connected right elbow disability warrants a compensable disability rating under his currently assigned Diagnostic Code 5209 at any point throughout the appeals period. Notably, there is no evidence of any deformity or ununited fracture of the head of the radius. However, although the Veteran is not entitled to a compensable rating under his currently assigned diagnostic code, the Board has considered all additional relevant diagnostic codes and regulatory provisions to determine whether he may be entitled to a compensable evaluation under an alternative diagnostic code or regulatory provision. Although the medical evidence does not support a finding that the Veteran's flexion is limited to 100 degrees or less or that his extension is limited to 45 degrees or more to warrant a compensable rating based on limitation of flexion or extension, the Board acknowledges the provisions of 38 C.F.R. § 4.59 referenced above. Under this provision, the Veteran is entitled to the minimum compensable evaluation for the right elbow joint based on his complaints of painful motion. The Board notes that neither VA examiner noted or observed objective evidence of painful motion and that the only findings of painful motion were the Veteran's subjective reports. However, affording the Veteran the full benefit of the doubt, the Board finds that he does suffer from painful motion and that the minimal compensable evaluation, 10 percent, is appropriate for his right elbow disability. However, although a compensable initial rating is warranted, the evidence of record does not reflect that the Veteran's right elbow disability would meet the criteria for a rating in excess of 10 percent at any point throughout the appeals period. Specifically, there is no evidence of compensable limitation of extension, flexion, pronation, or supination to warrant an increased rating under the rating criteria for limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5206-5208, 5213 (2012). As such, a rating in excess of 20 percent is not warranted. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2012); see also DeLuca, supra. Significantly, the Veteran did not complain of increased pain or other limitations while performing repetitive range of motion testing at his VA examinations. Although the examiner noted some mild to severe functional effects in the areas of chores, shopping, sports, recreation, traveling, and driving, and exercise, there is no indication that these mostly mild to moderate effects rise to a level of severity to exceed that already being compensated by the Veteran's painful motion rating under 38 C.F.R. § 4.59. Notably, the Veteran has not claimed that his right elbow disability is the cause of his unemployment or that it results in any problems with his schooling. Further, while the VA examiner noted the Veteran's complaints, there is no objective evidence of additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of the right elbow due to limitation of motion, other than that already recognized by the Veteran's currently assigned 10 percent evaluation. As such, an increased rating under DeLuca is not warranted. Additionally, there is no indication that the Veteran's right elbow disability warrants an increased rating under any other diagnostic code relating to the elbow or forearm. The claims folder contains no medical evidence indicating that the Veteran's right elbow disability is manifested by ankylosis, impairment of the ulna or radius, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5205, 5210-5212. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205, 5210-5212 (2012). Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's right elbow symptomatology warranted other than the currently assigned disability ratings throughout the appeal period. As such, assignment of staged ratings is not warranted. See Fenderson, supra. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected right elbow disability, the evidence of record does not reflect that his disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 10 percent disability rating contemplate his complaints of painful motion during flare ups. His complaints of pain and limited range of motion due to pain are also adequately contemplated by the rating schedule. Notably, 38 C.F.R. §§ 4.40 and 4.45 adequately contemplate any functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of the joint. Although the Veteran's right elbow disability did not warrant a compensable evaluation under the rating criteria, 38 C.F.R. § 4.59 allowed for a compensable evaluation in contemplation of his painful motion. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected right elbow disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. For all the foregoing reasons, the Board finds that a rating of 10 percent for residuals of a right elbow fracture with pain is appropriate for the entire period on appeal. In reaching this conclusion, the Board has applied the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a psychosis NOS is granted. Entitlement to a disability rating of 10 percent, but not higher, for residuals of a right elbow fracture with pain is granted for the entire period on appeal, subject to the laws and regulations governing the award of monetary benefits. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of his claim of entitlement to service connection for PTSD. The Board is cognizant of the fact that this claim has been in adjudicative status since 2007, and that it has been remanded in the past. The Board wishes to assure the Veteran that it would not be remanding his claim again unless it was essential for a full and fair adjudication. After the Board's January 2012 remand, the AMC provided the Veteran with a February 2012 VA psychiatric examination but did not then readjudicate this claim or provide him and his representative with an SSOC. Under 38 C.F.R. § 19.31(c), the AMC is to issue an SSOC when, pursuant to a Board remand, it develops evidence or cures a procedural defect. The only exceptions allowed for by the regulation are if: (1) the only purpose of the remand is to assemble records previously considered by the agency of original jurisdiction and properly discussed in a prior statement of the case (SOC) or SSOC, or (2) the Board specifies in the remand that a SSOC is not required. 38 C.F.R. § 19.31(c) (2012). In this case, the AMC developed further evidence in the form of a VA psychiatric examination. Further, neither of the above-mentioned exceptions is met, as the new evidence has not been previously considered and discussed in an SOC or SSOC and the Board remand did not specify that an SSOC was not required. Rather, the Board remand explicitly directed the AMC to readjudicate the claim and provide the Veteran and his representative with a Supplemental Statement of the Case. See Board remand, January 2012. As the AMC has failed to issue an SSOC, the Board finds that the AMC did not fully comply with the January 2012 remand directives. As such, this claim must be remanded in order to comply with the January 2012 Board remand. See Stegall, supra. Accordingly, the case is REMANDED for the following action: After completing any notification or development deemed necessary, the Veteran's claim of entitlement to service connection for PTSD should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter 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 or the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs