Citation Nr: 1306325 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 09-04 899 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for residuals of a left shoulder injury. 2. Entitlement to service connection for a major depressive disorder. 3. Entitlement to service connection for peripheral arterial occlusive disease of right thigh with scar. 4. Entitlement to an initial disability rating in excess of 20 percent for a right shoulder strain. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from March 1980 to May 1985. These matters come to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision that, in pertinent part, denied service connection for residuals of a left shoulder injury, for a major depressive disorder, and for peripheral arterial occlusive disease of right thigh with scar; and granted service connection for a right shoulder strain evaluated as 20 percent disabling effective July 12, 2007. The Veteran timely appealed each denial of service connection, and for a higher initial disability rating for a right shoulder strain. The record reflects that the Veteran failed to appear for a hearing scheduled in August 2012. Under these circumstances, the Veteran's request for a hearing is considered withdrawn. See 38 C.F.R. § 20.700 (2012). In the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans' Claims (Court) held, in substance, that every claim for a higher evaluation includes a claim for TDIU where the Veteran claims that her service-connected disabilities prevent her from working. In this case, the Board notes that the Veteran has put forth statements indicating that she believes her service-connected right shoulder strain renders her unemployable. Accordingly, in light of the holding in Rice, the Board has characterized the issues on appeal so as to include a claim for entitlement to TDIU. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of her Virtual VA file. The issues of service connection for pes planus and for diabetes mellitus have been raised by the record (August 2008 and January 2009 correspondence), but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to a 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. FINDINGS OF FACT 1. The Veteran does not have residuals of a left shoulder injury that are related to a disease or injury during active service, or otherwise related to a service-connected disability; and arthritis of the left shoulder was not manifested to a compensable degree within the first post-service year. 2. The Veteran's major depressive disorder has not been satisfactorily disassociated from her active service. 3. Chronic symptoms of peripheral arterial occlusive disease were not exhibited in service; organic heart disease, a cardiovascular disease, or hypertension were not manifested to a compensable degree within the first post-service year; and current peripheral arterial occlusive disease of right thigh with scar is not otherwise related to service or to a service-connected disability. 4. Throughout the course of the rating period on appeal, the Veteran's right shoulder disability has been manifested by constant pain and functional loss of the right (major) arm which more nearly approximates limited arm motion to shoulder level; arm motion limited to midway between side and shoulder level and ankylosis have not been demonstrated. CONCLUSIONS OF LAW 1. Residuals of a left shoulder injury were not incurred or aggravated in service; and are not proximately due to, or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2012). 2. A major depressive disorder was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. Peripheral arterial occlusive disease of right thigh with scar was not incurred or aggravated in service; and is not proximately due to, or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2012). 4. The criteria for an initial disability rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). The Veteran's claim for a higher initial disability rating for a right shoulder strain arises from her disagreement with the initial evaluation assigned, following the grant of service connection. Courts have held that once service connection is granted, the claim is substantiated; additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Through August 2007 and June 2010 letters, the RO notified the Veteran of elements of service connection, the evidence needed to establish each element, and evidence of increased disability. These documents served to provide notice of the information and evidence needed to substantiate the claims. VA's letters notified the Veteran of what evidence she was responsible for obtaining, and what evidence VA would undertake to obtain. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA informed her that it would make reasonable efforts to help her get evidence necessary to support her claims, particularly, medical records, if she gave VA enough information about such records so that VA could request them from the person or agency that had them. In each letter, the RO specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims on appeal, reports of which are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). As will be discussed below, there is neither evidence of pertinent disability in service, nor competent medical evidence suggesting a relationship between the Veteran's current peripheral arterial occlusive disease of right thigh with scar and service; and the Board finds the Veteran's report of a continuity of symptomatology of right leg and foot pain not credible. Based on the facts of this case, VA has no duty to provide further VA examination or obtain medical opinions, even under the low threshold of McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Moreover, the RO provided the Veteran with appropriate VA examinations; and there is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected right shoulder strain since she was last examined. The Board finds the examination reports to be thorough and adequate upon which to base a decision with regard to this claim. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Service Connection Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to the showing of chronic disease, there must be a combination of sufficient manifestations to identify the disease entity and sufficient observation at the time, as distinguished from isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303 (2012). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (non-precedential). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). Lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time. 38 U.S.C.A. § 1111. In this case, the Veteran did not report; and no examiner had found, any physical defects or diseases other than decreased visual acuity and refractive error, at the time of pre-enlistment in September 1979. Service connection may also be presumed, for certain chronic diseases, such as arthritis or psychoses or hypertension, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. 3.307, 3.309 (2012). Any disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b) (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A. Residuals of a Left Shoulder Injury Service treatment records do not reflect any findings or complaints of left shoulder injury or disability. Here, there is no evidence of arthritis of the left shoulder manifested to a compensable degree within the first post-service year, and no basis to presume its onset in service. The Veteran also did not report any left shoulder problems or complaints during a May 2008 VA (contract) examination, The report of the May 2008 VA (contract) examination reflects that the Veteran reported injuring both shoulders when someone fell upon her in boot camp during active service in 1980. The Veteran was hospitalized for two-to-three days at the time; and she currently reported that the left shoulder improved nicely without any prolonged problems. Examination in May 2008 revealed no ankylosis of either shoulder, and normal range of motion of the left shoulder. There was no pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use of the left shoulder. X-rays taken of the left shoulder were negative. No residuals of a left shoulder injury were found. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The May 2008 VA (contract) examiner reviewed the Veteran's medical history and completed a comprehensive examination, but did not diagnose a left shoulder disability. The report of that examination weighs against a finding of current residuals of a left shoulder injury. The Board finds the May 2008 VA (contract) examination report is factually accurate, fully articulated, and contains sound reasoning; it is afforded significant probative value. The Board has considered the Veteran's statements regarding a left shoulder injury as being among her current disabilities. However, the Board finds the conclusions of the VA (contract) examiner, which are based on the results of clinical evaluation, and supported by rationale, to be more probative than references made by the Veteran. X-ray evidence of arthritis of the left shoulder is not documented in the claims file, and there is no medical evidence that any degenerative process or residuals are in any way related to service or to a service-connected disability. Hence, a basis for compensation is not established. The Board finds a clear preponderance of the evidence is against a finding that the Veteran currently has residuals of a left shoulder injury. Therefore, there is no basis for a grant of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Caluza v. Brown, 7 Vet. App. 498, 505 (1995) (recognizing that "[a] service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability"). Here, the evidence weighs in favor of the conclusions made by the VA (contract) examiner in May 2008. The Veteran is not shown to have the medical expertise to diagnose a left shoulder disability. Lastly, while there likely were manifestations of left shoulder pain in service, the competent evidence fails to link residuals of a left shoulder injury with injury or disease in active service, or establish the onset of arthritis of the left shoulder in active service or within the first post-service year. Because the competent evidence does not link residuals of a left shoulder injury to active service or to a service-connected disability, the weight of the evidence is against the claim. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for residuals of a left shoulder injury. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Major Depressive Disorder The Veteran contends that the onset of her current major depressive disorder was during active service aboard the U.S.S. Lexington (AVT 16). She reported that she had no prior psychiatric problems; and that she awoke in sick bay during active service after becoming scared from witnessing a scene of two women in intimate activities. The Veteran reported that she still had nightmares and anxiety since her discharge from active service, and that she continued to receive psychiatric care. The Veteran is competent to testify on factual matters of which she has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Service treatment records show that the Veteran was treated in October 1980 due to uncontrollable crying, and had reported witnessing two women in intimate activities; and that she refused to talk, but nodded "no" to having been injured, and "yes" to being threatened, then "they're gonna come after me." The Veteran was admitted and sedated. The assessments were situational reaction and hysteria. Post-service records include private treatment records, dated in May 2004, showing hospitalization and an Axis I diagnosis of major depression. In February 2005, the Veteran was so severely depressed that she again needed inpatient treatment. Records also show inpatient treatment in April 2005. In October 2005, one psychiatrist noted that the Veteran had been his patient for several years; and that the Veteran suffered from severe depression and anxiety disorders. Additional records, dated in April 2007, show that the Veteran had been on heavy medication and therapies for a significant psychiatric psychotic illness for several years, which rendered her depressed. Diagnoses in January 2008 included severe depression, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and seizure disorders. During a May 2008 VA (contract) examination, the Veteran reported that she had been psychiatrically hospitalized five or six times; and that her first psychiatric hospitalization occurred in the 1980's. She reported being suicidal on several occasions, and had taken overdoses of pills. The Veteran reported that she cried practically daily, and felt depressed "all of the time." She reported receiving outpatient psychotherapy intermittently since at least the 1980's. The Veteran is competent to testify as to her experiences in service and since. Military personnel are competent to testify as to their observations. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Following examination in May 2008 and review of treatment records, the examiner opined that the Veteran suffered from two psychiatric disorders. The primary psychiatric disorder was major depression, recurrent, severe, with psychotic features; and anxiety was part of her depression. The second diagnosis was alcohol abuse, in sustained full remission. The examiner also found that the Veteran did not suffer from most symptoms of PTSD, although presumably exposed to traumatic events. Her symptoms were consistent with a diagnosis of major depression. The examiner opined that the Veteran's mental health symptoms arose during the time she served in active service; however, there was no clear precipitant for her depression that was caused by active service. In support of the opinion, the examiner reasoned that the treatment records correlate with the diagnosis of major depression. Records received from the Social Security Administration in April 2010 also reflect additional inpatient treatment and diagnosis of major depression, with onset following the death of certain family members. In November 2010, the Veteran's husband reported that the Veteran did suffer PTSD in active service; and that she now was treated regularly for depression. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Here, the Veteran's pre-enlistment examination and report of history was negative for psychiatric disability; therefore, she is presumed sound at entry in March 2008. Service treatment records reflect further that she received treatment during service due to uncontrolled crying, and after examination, diagnoses of situational reaction and hysteria were rendered. The Veteran has reported that her symptoms of depression and anxiety have continued intermittently after service, and that she was psychiatrically hospitalized several times over the years. She reportedly was involved with psychotherapy in the past, and currently received treatment from a psychiatrist every two months. The available medical evidence demonstrates more than a two decade gap in time from when the Veteran separated from service and when she was hospitalized for psychiatric symptoms. In Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006), the Federal Circuit Court indicated that, where lay evidence provided is competent and credible, the absence of contemporaneous medical documentation during service or since, such as in treatment records, does not preclude further evaluation as to the etiology of the claimed disorder. In this case, the Veteran is competent to report what has occurred since service because her statements are regarding her first-hand knowledge of factual matters, that is, the symptoms that the Veteran experienced from the time of her separation forward. Furthermore, the Board finds that the Veteran is credible in this regard. The available treatment records indicate a longstanding history of symptomatology. Also, the Veteran's statements are consistent with findings of a recurrent major depressive disorder by both the May 2008 VA (contract) examiner and by the Social Security Administration in April 2010. Most significantly, however, resolving all doubt in favor of the Veteran in the interpretation of the medical opinion of the May 2008 VA (contract) examiner, the Board must find that the Veteran's current psychiatric disorder was initially manifested in service. As noted above, the examiner opined that the Veteran's mental health symptoms arose during the time she served in active service. Although the examiner was not able to identify a clear precipitant for the Veteran's depression that was caused by active service, he did not satisfactorily disassociate that depression from service. Accordingly, the Board finds that the lay statements of record support a finding of continuity of symptomatology of depression since active service. When considering the service treatment records, the competent and credible lay statements, the opinion by the May 2008 VA (contract) examiner, and the post-service medical evidence substantiating the Veteran's claim; and resolving all reasonable doubt in her favor, the Board finds that a major depressive disorder had its onset in active service. See 38 C.F.R. § 3.102 (2012). C. Peripheral Arterial Occlusive Disease of Right Thigh with Scar Service treatment records do not reflect any findings or complaints of arterial occlusive disease or hypertension. The Veteran did report pain in her legs when she lifted them in January 1982. At that time, the Veteran was being treated for urinary tract infection and irregular menses; her blood pressure readings were within normal limits. There was no treatment for peripheral arterial occlusive disease in service. Here, there is no evidence of organic heart disease or cardiovascular disease or hypertension manifested to a compensable degree within the first post-service year, and no basis to presume their onset in service. The Veteran also reported experiencing pain and numbness in the right leg and foot problems starting approximately in 2006. Post-service private records, dated in June 2007, include a right ankle/brachial index that was consistent with findings of moderate degree of peripheral vascular disease. In September 2007, the Veteran was hospitalized and underwent right femoral endarterectomy with saphenous vein patch angioplasty. Private treatment records show that, approximately six hours post-operatively in September 2007, the Veteran complained of acute onset of pain from approximately mid-thigh downward, and was taken urgently to the operating room for additional surgical procedures. Also in September 2007, the Veteran contended that she hurt her right leg and foot during active service and was treated while aboard the U.S.S. Lexington (AVT 16); and that she now had ongoing treatment by a vascular and transplant specialist, and had undergone surgery in August 2007. During a May 2008 VA (contract) examination, the Veteran reported that she began experiencing pain and numbness in the right leg and foot approximately two years ago; and that she ultimately was diagnosed as having peripheral arterial occlusive disease. She described the surgery, dilatation, and stenting of the left leg artery in order to improve circulation; and reported having no further pain in the leg and foot since that time. Doppler studies performed earlier in 2008 were relatively normal. The Veteran reportedly took medication to improve her circulation problem, and used a walking cane since her surgery in 2007. Following examination in May 2008, the diagnosis was peripheral arterial occlusive disease of right thigh with scar, which was based upon subjective factors of history and objective factors of surgery. In an addendum to the examination report, the examiner explained that the Veteran's peripheral arterial occlusive disease was continuing and never resolved; and that surgery did improve the condition. The Veteran is competent to offer statements of first-hand knowledge that she experienced right leg and foot pain both in-service and post-service; however, her statements to this effect are not credible. The Board finds it unlikely that she had peripheral arterial occlusive disease in active service because it was never detected on examination. It is also unlikely that peripheral arterial occlusive disease was present for such an extended period post-service without complaints or detection. The first evidence of pertinent disability is more than 20 years after discharge, with no mention of a 20-year history of unreported symptoms. Thus, the Board finds the evidence with regard to the Veteran's report of a continuity of symptomatology in-service and post-service not credible. McLendon, 20 Vet. App. at 82. As a lay person, the Veteran is not competent generally to render a probative opinion on a medical matter, such as the onset of peripheral arterial occlusive disease, or of medical diagnosis or causation. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Peripheral arterial occlusive disease is not a disease readily diagnosed by even trained clinicians without medical testing. As noted above, the duty to assist is not invoked, where no reasonable possibility exists that such assistance would aid in substantiating the claim. See 338 U.S.C.A. § 5103A(a)(2). Hence, a clear preponderance of the evidence is against a finding that the Veteran has peripheral arterial occlusive disease that either had its onset during service or is related to her active service or to a service-connected disability. Thus, service connection for peripheral arterial occlusive disease of right thigh with scar is not warranted. III. Higher Initial Disability Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012). Degenerative arthritis established by X-ray findings will be rated on the basis of 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 10 percent evaluation is assignable 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. As noted above, the Veteran is competent to testify on factual matters of which she has first-hand knowledge. Washington, 19 Vet. App. at 368. She is also competent to report symptoms of right shoulder pain. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe her symptoms and their effects on employment or daily activities. Service connection has been established for a right shoulder strain. The RO evaluated the Veteran's disability as 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5201, based on painful motion of the right shoulder. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. In the instant case, the Veteran is right-handed; hence, her right shoulder is considered her major upper extremity. Under Diagnostic Code 5201, a 20 percent evaluation is warranted for motion of the major arm limited to shoulder level. A 30 percent rating is assignable for motion of the major arm limited to midway between the side and shoulder level. A maximum 40 percent rating is assignable for the major upper extremity, when motion is limited to within 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The standard ranges of motion for shoulder abduction and forward elevation (flexion) are 180 degrees. 38 C.F.R. § 4.71, Plate I. The report of a May 2008 VA (contract) examination shows complaints of decreased ranges of motion in the right shoulder and continued pain, described as constant and increasing with activity. Examination at that time revealed weakness and tenderness of the right shoulder. Range of motion of the right shoulder was to 90 degrees on flexion; to 90 degrees on abduction; to 90 degrees on external rotation; and to 45 degrees on internal rotation. Pain was noted at the extremes of motion. The examiner also noted pain, fatigue, weakness, and lack of endurance after repetitive motion of the right shoulder; there was no incoordination. Maximum impact was due to pain, without additional degrees of limited motion. X-rays taken of the right shoulder were negative. The examiner noted that the Veteran had quit her job as a cashier in February 2005 because of problems with her right shoulder, arm, and hand. During an April 2011 VA examination, the Veteran reported the following symptoms: weakness, stiffness, lack of endurance, fatigability, tenderness, and pain. She did not experience swelling, heat, redness, giving way, locking, deformity, drainage, effusion, subluxation, or dislocation. She reported flare-ups of right shoulder pain occurring as often as three times per day, and lasting each time for two hours; and that the flare-ups were precipitated by physical activity, and relieved by anti-inflammatory medication. The Veteran described pain with overhead activity and limited motion of the joint during flare-ups, and that treatment required physical therapy. Her right shoulder strain had not resulted in any incapacitation during the past 12 months. Examination of the Veteran's right shoulder in April 2011 revealed objective evidence of tenderness; and no evidence of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, or drainage. There was neither subluxation nor ankylosis of the right shoulder joint. Range of motion of the right shoulder was to 180 degrees on flexion, with pain at 180 degrees; to 180 degrees on abduction, with pain at 180 degrees; and to 90 degrees on internal and external rotation, with pain from 90 degrees. There was no loss of motion following repetitive use. X-rays revealed degenerative arthritic changes. The diagnosis was changed from a right shoulder strain to rotator cuff degeneration with narrowing of the acromioclavicular joint. Functional impairment noted by the examiner included right shoulder pain with overhead activities. In this case, throughout the appellate period, the evidence shows that the Veteran's motion of the right arm has been limited by pain and weakness, resulting in some functional impairment with overhead activities. The Veteran also has reported constant pain and daily flare-ups in the right shoulder, and that such pain limits her movement. Taking into account her lay assertions, particularly with respect to functional loss resulting from pain and other symptoms as contemplated by Deluca, the Board concludes that these symptoms approximate the criteria for the currently assigned 20 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5201. The disability has been symptomatic and results in some dysfunction at shoulder level. The evidence has not shown that the Veteran's motion of the right arm is limited to 25 degrees from her side during any examination. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2012). Nor is there evidence of ankylosis of the right shoulder or arm. The Veteran can still move his right shoulder and arm, although limited by pain. Even with consideration of functional factors, the Board finds that the Veteran's right shoulder disability has not meet or approximated the criteria for an initial disability evaluation in excess of 20 percent under Diagnostic Code 5201 at any time. Accordingly, staged ratings, pursuant to Fenderson, supra, are not indicated. Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluation assigned for the Veteran's service-connected right shoulder disability is adequate in this case. Specifically, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected disability. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 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). For the foregoing reasons, an initial disability evaluation in excess of 20 percent for the Veteran's right shoulder disability is not warranted. (CONTINUED ON NEXT PAGE) ORDER Service connection for residuals of a left shoulder injury is denied. Service connection for a major depressive disorder is granted. Service connection for peripheral arterial occlusive disease of right thigh with scar is denied. An initial disability evaluation in excess of 20 percent for a right shoulder disability is denied. REMAND A request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Hence, the Veteran's claim for an initial disability rating in excess of 20 percent for a right shoulder disability includes consideration of whether a TDIU is warranted under the provisions of 38 C.F.R. § 4.16. The critical question is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of her service-connected disabilities. Service connection has been established for a right shoulder strain, rated as 20 percent disabling; and for right carpal tunnel syndrome, rated as 10 percent disabling, and in this decision for depression which is not yet rated. In awarding a TDIU, consideration is given to the Veteran's background, including her employment and educational history. Records show that the Veteran no longer maintains steady employment. She last worked full-time as a cashier in 2005. Her level of education and any continuing training are not indicated. The Board notes that the RO denied the Veteran's claim for TDIU benefits in July 2010. Since then, as shown above, service connection has been established for additional disabilities, to include a major depressive disorder. VA has the duty to supplement the record by obtaining an examination which includes an opinion on what effect the Veteran's service-connected disabilities has on her ability to work. See Friscia v. Brown, 7 Vet. App. 294 (1994) (holding in the case of a claim for TDIU, that VA has a duty to obtain medical opinions as to employability). In this case, there is no opinion of record regarding the Veteran's ability to obtain or maintain any gainful employment that takes into account solely her service-connected disabilities. While the further delay of this case is regrettable, due process considerations require such action. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an appropriate VA examination to obtain an opinion as to the impact of the service-connected disabilities on the Veteran's ability to work. The Veteran's claims file, to include a complete copy of this REMAND, must be provided to the examiner(s) designated to examine the Veteran, and the examination report(s) should note review of the file. The examiner(s) should interview the Veteran as to her employment and education history. The examiner(s) should provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the service-connected right shoulder disability; right carpal tunnel syndrome; and major depressive disorder, preclude employment consistent with the Veteran's education and occupational experience, without taking into account her age or any nonservice-connected disability. The examiner(s) should set forth a rationale for the conclusions reached. 2. After ensuring that the requested actions are completed, the RO or AMC should re-adjudicate the claim on appeal. If the benefits sought are not fully granted, the RO or AMC must furnish a supplemental statement of the case (SSOC), before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and her representative until they are notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of her claim. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter that 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). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs