Citation Nr: 1306574 Decision Date: 02/26/13 Archive Date: 04/10/13 DOCKET NO. 08-14 326 DATE FEB 26 2013 On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for diabetes mellitus. 2. Entitlement to an evaluation in excess of 10 percent for the service-connected residuals of right shoulder dislocation. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant; his wife INTRODUCTION The Veteran served on active duty from June 1986 to June 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which denied entitlement to the benefits currently sought on appeal. The Veteran appeared before a Veterans Law Judge in April 2012 at a Travel Board hearing at the RO to present testimony in conjunction with his appeal. Unfortunately, the recording equipment malfunctioned, and no transcript was created of that proceeding. Accordingly, the Board offered the Veteran an additional hearing, which he accepted. In December 2012, he and his wife appeared before the undersigned Veterans Law Judge in a videoconference hearing. The transcript of the proceeding is of record. In May 2012, the Veteran submitted additional medical evidence, with a waiver of RO jurisdiction over that evidence. That has been associated with the claims folder. The Veteran indicated in his December 2012 hearing that he believed the issue of service connection for his neck disability was on appeal. A review of the record, however, reflects that the Veteran's claim for service connection for a neck disability was denied in a December 1998 rating decision. The Veteran submitted a notice of disagreement in October 1999. The RO issued a statement of the case in August 2000. The Veteran had 60 days from the date of the mailing of that statement of the case to file a substantive appeal to the Board in that matter. He did not file a substantive appeal; therefore, the issue is not before the Board. During the Veteran's December 2012 hearing, he raised the issues of entitlement to service connection for a neck disability (to reopen a previously denied claim), and for service connection for depression and carpal tunnel disorder as secondary to the service-connected shoulder disability. These issues have not been adjudicated by the Agency of Original Jurisdiction -2- (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Diabetes mellitus was first manifested many years after the Veteran's service and has not been medically related to his service. 2. Prior to May 17,2012, the Veteran's service-connected right shoulder disability manifested by full flexion, with intermittent pain and little functional loss. 3. Since May 17,2012, the Veteran's service-connected right shoulder disability has manifested by significant functional loss, as evidenced by flexion and abduction limited to between 15 and 20 degrees due to pain. CONCLUSIONS OF LAW 1. Diabetes mellitus was not incurred or aggravated in the Veteran's active duty service, nor may it be so presumed. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Prior to May 17,2012, the criteria for a rating in excess of 10 percent for residuals of right shoulder dislocation are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159,4.1-4.14, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5203 (2012). 3. Since May 17, 2012, the criteria for a 40 percent rating for residuals of right shoulder dislocation are met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5201 (2012). -3- REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in September and November 2006, the agency of original jurisdiction (AOJ) satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the notice informed the Veteran of information and evidence necessary to substantiate the claims for service connection and for an increased rating, and of the relative burdens of VA and the Veteran, relating the information and evidence that VA would seek to provide and that which he was expected to provide. The notice also informed the Veteran of information and evidence that governs the initial assignment of a disability evaluation and the regulations regarding the effective date of the establishment of service connection. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available post-service treatment records have been secured. The Veteran has been medically evaluated in conjunction with both claims and a medical opinion has been sought in conjunction with his service connection claim. The Veteran has also submitted a Disability Benefits Questionnaire from his treatment provider with respect to his shoulder disability. In short, the duty to assist has been fulfilled. Diabetes Mellitus The Veteran seeks service connection for diabetes mellitus, which he contends initially manifested in service. Specifically, he contends that he was pressured to go to enlisted clubs and consume alcohol, which ultimately led to his diabetes mellitus. He has testified that he felt fatigued on several occasions in service and sought treatment; however, no diagnosis was made. -4- Generally, in order to establish direct service connection, three elements must be established. There must be medical evidence of a current disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999) and Davidson v. Shinseki, 581 F.3d 1313,1316 (Fed. Cir. 2009). Service connection may also be granted for chronic disease, such as diabetes mellitus, when it is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). As provided by 38 U.S.C.A. § 1154(a), VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. With specific regard to lay evidence, the type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). For example, lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, the layperson is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372,1377 (Fed. Cir. 2007). Regarding nexus, although without describing specific situations, the Federal Circuit also has explicitly rejected the view that medical evidence is necessarily required when the determinative issue is etiology. See id., at 1376-77. In short, the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The evidence establishes that the Veteran is currently treated for diabetes mellitus. Specifically, post-service records confirm that the Veteran was seen by his family doctor in December 2004 for "new onset uncontrolled [diabetes mellitus]," after -5- experiencing urinary frequency and excessive thirst. Subsequent records document treatment for the disability. The diagnosis was confirmed on VA examination in January 2007. Thus, the first element of service connection (current disability) is established. Service treatment records confirm that in September 1993, the Veteran underwent initial active duty weight control counseling. A November 1993 lab report documenting cholesterol and glucose show a glucose reading of 101, which was noted to be within the normal range of 75 to 110. A September 1994 clinical record documents a self-referral to the clinic to address alcohol dependence, at which time he noted his first drink (whisky) at age 14, and that he had continued to drink since, frequently to excess. A January 1995 service treatment record documents that the Veteran was concerned with being fatigued and having chronic red eyes. A urinalysis showed a glucose level of 112, just over the normal range of 75 to 110. In February 1995, the Veteran was seen for a follow up appointment for fatigue. He reported decreased fatigue at that time. A urinalysis was noted to be normal. Additional follow up lab work in June 1995 showed a glucose level of 90. The remainder of the service treatment records are negative for glucose readings, or complaints commonly associated with diabetes mellitus. On this evidence, the Board finds that there are sufficient in-service findings, when coupled with the Veteran's lay statements, to move forward with the analysis. With respect to the final element of service connection, that of nexus, the Board notes that there are two medical opinions of record. First, the Veteran's treating physician at the Lakewood VA Medical Center clinic submitted a September 2006 statement that indicates that he had been treating the Veteran since September 2005. He noted the Veteran's diagnosis of diabetes mellitus, which had been diagnosed in approximately September 2004. He reviewed the Veteran's current treatment for the disability. He then indicated a brief review of the Veteran's labs in service, that of 101 in November 1993 and 112 in January 1995. He noted that the lab results did not note whether the testing had been done after fasting. He then stated that, "[i]f fasting, these values ... would have been considered in the normal range based -6- on the criteria at that time, but abnormal if based on today's criteria." He went on to state that if it was a fasting test, this "would likely represent impaired glucose tolerance." He concluded that it was "quite possible" that the Veteran's diabetes mellitus "could have a Service Connection." He then recommended review by an authorized committee. On the basis of this opinion, the Veteran was scheduled for a VA examination by an authorized physician, trained in providing disability examinations. He underwent this exam in January 2007. The physician reviewed the Veteran's file, to include his service treatment records, his post-service diagnosis, and the September 2006 opinion by the Veteran's treating physician. The reviewing physician found it important to realize that unless one knows the specific format of the test conducted (e.g., whether fasting or not), one cannot precisely say what the level itself means. He opined that, based on the lack of development of any diabetes from 1993 until "recent times" (when the Veteran was diagnosed in 2004), the in-service readings did not represent impaired glucose tolerance nor diabetes mellitus. He concluded that the he did not find a relationship between the levels of glucose in the 1990's and the present diagnosis of diabetes mellitus. The Board must weigh the evidence to determine whether service connection is warranted. 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. The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The standard by which VA generally determines service connection is whether a current disability is "as likely as not" related to service. That standard does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Furthermore, evidence favorable to the Veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service is insufficient to -7- establish service connection. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). In this case, the 2006 opinion found that it was "quite possible" that a relationship "could" exist. The opinion is based on a speculation that the test conducted in service was done while fasting. The Board finds that this opinion merits little weight in light of the language used. Although the 2007 opinion was also rendered in light of the unknown nature of the in-service lab results, the physician provided a reasoned conclusion with strong, definitive language. In particular, even without knowing for certain whether the in-service results were indicative of diabetes mellitus in their own right, the physician found very probative the fact that a diagnosis was first rendered for more than 10 years after those initial readings. As this physician went beyond speaking in possibilities and what could be, based on his expert review, and in context of the entire record, the Board accords the 2007 opinion more weight, finding against service connection. To the extent that the Veteran has offered his own lay statements linking his diabetes mellitus to his period of active duty service, the Board finds that he is not competent to render such an opinion. In particular, diabetes mellitus is a complex disability of the endocrine system, which is quite different from a broken arm or dislocated shoulder, both of which are capable of lay determination. He does not have the expertise to opine as to the origins of such a complex disability. His statements concerning his symptoms are competent, and have been considered by the competent medical professionals who have reviewed his case. However, his statements concerning the etiology of his disability are not competent, and therefore are accorded no weight in the discussion of nexus. Alternatively, with respect to the presumption of service connection for chronic diseases, the Board notes that the Veteran separated from service in 1995. His first documented diagnosis of diabetes mellitus is in 2004. Therefore, the presumption does not apply, as the disease was not manifested to a compensable degree within one year of separation. -8- In short, the Board finds that the preponderance of the evidence is against the Veteran's claim; therefore, the benefit of the doubt provision does not apply. Service connection for diabetes mellitus is not warranted. Right Shoulder The Veteran seeks a higher disability evaluation for his service-connected right shoulder disability. Such evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. 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. 38 C.F.R. § 4.21. When a question arises as to which of two ratings applies under a particular diagnostic code (DC), the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the current level of disability is of primary concern in a claim for an increased rating; and the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 1 Vet. App. 55 (1994). That being said, given unintended delays during the appellate process, VA's determination of the "current level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending. In those instances, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection was established for residuals of right shoulder dislocation by rating decision in February 1996 and was evaluated as 10 percent disabling under -9- 38 C.F.R. § 4.71a, DC 5299-5203. That rating is currently in effect, and the Veteran seeks a higher evaluation, based on an August 2006 claim. The Board notes that residuals of right shoulder dislocation is not a listed disability in the rating schedule. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). According to the policy in the schedule, when a disability is not specifically listed, the Diagnostic Code will be "built up," meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27 (2012). For example, Diagnostic Code 5299 is used to identify unlisted musculoskeletal disabilities. In this case, the Veteran's shoulder disability has been rated analogously to DC 5203, which establishes the criteria for impairment of the clavicle or scapula. It provides that malunion of the clavicle or scapula may be assigned a 10 percent rating, or may be rated based on impairment of function of the contiguous joint. Nonunion of the clavicle or scapula without loose movement warrants a 10 percent evaluation. Nonunion of the clavicle or scapula with loose movement shall be assigned a 20 percent rating. In cases of clavicular or scapular impairment, with dislocation, a 20 percent rating is warranted where either the major or minor arm is involved. The assignment of a particular diagnostic code to evaluate a disability is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 1 Vet. App. 411, 414 (1995). Therefore, the Board will explore all potentially relevant diagnostic codes. -10- The movement of the shoulder and arm joint is covered in the regulations by 38 C.F.R. § 4.71a , DCs 5200-5203. These DCs distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. § 4.69 (2012). The medical evidence, such as the May 2012 VA DBQ, shows that the Veteran is right-handed. Therefore, the criteria referencing the major extremity are for consideration here. DC 5201 provides that limitation of motion of the arm is rated as follows for the major extremity: A 20 percent rating is warranted for limitation of motion at the shoulder level (e.g., flexion to 90 degrees). A 30 percent rating is warranted for limitation of motion of the arm midway between the side and shoulder level (e.g., flexion between 25 to 90 degrees). A 40 percent rating is warranted for limitation of motion of the arm to 25 degrees from the side. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. §4.71, Plate I (2012). Under DC 5202, for impairment of the humerus in the major arm: A 20 percent rating is warranted when there is malunion, with moderate deformity, while a 30 percent rating is warranted when there is malunion with marked deformity. A 20 percent rating is warranted for recurrent dislocations of the major arm at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at shoulder level; when there are frequent episodes and guarding of all arm movements, a 30 percent rating is warranted. A 50 percent rating is warranted for fibrous union of the major arm. A 60 percent rating is warranted for nonunion (false flail joint) of the major arm. A maximum 80 percent rating is warranted for loss of head (flail shoulder) of the major arm. Notably, DC 5200 requires anklyosis of the joint, meaning it is fixed and without motion. As the Veteran retains some motion in his shoulder joint, this DC is inapplicable. The Veteran's claim for an increased rating was received in August 2006. He underwent a VA examination in October 2006, in conjunction with his claim. At -11- that time, the Veteran presented with complaints of intermittent pain in the acromioclavicular area. There was not constant pain. He indicated that he could not carry anything on that shoulder, and that he could not lie down on the right side. Those activities would result in pain at a level of 8 on a scale of 10. Otherwise, he was able to drive, and could use his right shoulder and work above his head when necessary. He denied any dislocations, and denied any weakness or instability. There had been no significant flares of pain that would last any length of time. Objective examination revealed full range of motion on flexion, that is from zero to 180 degrees. This was accomplished without pain. He also had full range of abduction and external rotation. Internal rotation was limited to 50 degrees out of 90. Muscle strength was normal, and there was no atrophy. Physically, there was a one centimeter step off at the acromioclavicular joint causing a slight asymmetry where the right shoulder is held lower than the left. An x-ray revealed that the distal fragment of the clavicle was displaced superiorly by 3 centimeters from the acromion. The Veteran submitted private treatment records from Family Care Southwest, dated from December 2004 to September 2006. These records are negative for complaints referable to the shoulder, and in fact, show no shoulder issue on his active problems list. He denied joint pain on several occasions. See records dated in September, October, and December 2004, and March and April 2006. Full range of motion of all joints was noted in April and September 2005. The record also contains VA outpatient clinical records, dated from September 2006 to November 2008. A January 2007 clinical note indicates that the Veteran was experiencing pain in his neck, which he felt was radiating into his shoulder. He also complained of pain in November 2007. In May 2012, the Veteran's treating physician at VA completed a Disability Benefits Questionnaire (DBQ) for the Veteran's shoulder. He recorded that the Veteran experiences flare ups twice per month, lasting two to three days. His muscles will tighten and he will be unable to move his shoulder due to pain. Initial -12- range of motion testing revealed that the Veteran's flexion was limited to 20 degrees out of 180. Pain began at 15 degrees. Abduction was similarly limited to 20 degrees by pain. The physician noted that the Veteran was unable to perform repetitive use testing due to pain; however, he then recorded post-repetitive testing range of motion, with flexion and abduction limited to 10 degrees. With respect to functional loss, the physician noted that the Veteran had less movement than normal on repetitive use, as well as pain and weakness. The Veteran was also noted to have pain on palpation and guarding. Strength testing was 2/5, demonstrating active movement only with gravity eliminated. It was specifically noted that the Veteran does not have anklyosis of the joint. Malunion and nonunion were specifically ruled out. It is clear to the Board on this evidence that the Veteran's shoulder disability has increased in severity during the appeal. In particular, the evidence prior to the May 17, 2012, DBQ demonstrates intermittent pain with little functional loss. The Veteran's flexion was repeatedly found to be normal. He had only occasional complaints of pain. His muscle strength was normal. As of the DBQ, however, there is significant limitation of motion with pain and functional limitations. Therefore, the Board finds that staged ratings are appropriate in this case. Each period is discussed below, in the context of all potentially relevant criteria. Prior to May 17, 2012 The Veteran's shoulder disability is rated at 10 percent under DC 5203, for impairment of the clavicle. Under that criteria, a higher rating requires nonunion of the clavicle with loose movement, or dislocations. Here, the evidence does not demonstrate that there is nonunion, or a failure of the ends of fractured bones to unite. Nor does the evidence demonstrate that the Veteran is experiencing dislocations, apart from the original injury. Therefore, a higher rating under DC 5203 is not warranted. Turning to the other potentially relevant DCs, a higher rating under DC 5201 requires flexion limited to 90 degrees. During the period under question, the -13- Veteran experienced full flexion to 180 degrees. See VA examination, dated in October 2006. A higher rating under DC 5201 is not warranted. DC 5202 allows for higher ratings for malunion with moderate or marked deformity, or recurrent dislocations. As noted above, the record does not show recurrent dislocations. Malunion is defined as union of the fragments of a fractured bone in a faulty position. The October 2006 x-ray of record shows that the distal fragment of the clavicle is displaced by three centimeters, and the concurrent physical examination of the Veteran's shoulder shows a one centimeter step off at the joint causing a slight asymmetry. Although this may be considered malunion, the Board finds that it is not indicative of moderate or marked deformity. Specifically, the examiner noted a one centimeter difference in appearance, characterizing it as slight. The Veteran has at no point argued that his shoulder is deformed in any way; nor have the records otherwise confirmed the same. Therefore, the Board finds that the higher ratings are not met under this code. In summary, the findings of record prior to May 17, 2012 more nearly approximate the 10 percent rating currently assigned, as opposed to any of the higher ratings offered by the DCs applicable to the shoulder joint. Since May 17, 2012 The evidence of record as of May 17, 2012 consists primarily of the DBQ submitted by the Veteran's treating physician at VA. That examination represents a significant shift in documented symptomatology for the Veteran's service-connected shoulder disability. In particular, it demonstrates significant limitation of motion with functional loss. As malunion and nonunion are specifically ruled out, the Board finds that the most appropriate DC to apply is DC 5201, limitation of motion of the arm. The Veteran's flexion was noted to be limited to 15 degrees by pain, and only reached as far as 20 degrees. His abduction was limited to 20 degrees. Under DC 5201, the maximum rating available is 40 percent, for limitation of motion of the arm up to 25 degrees from the side. This is compared to the full flexion or -14- abduction of 180 degrees. The Veteran's disability clearly meets this level as of the date of this examination. The only ratings higher than 40 percent for the shoulder are for when the evidence demonstrates false flail joint or flail shoulder. Those are not shown on exam. The Board has considered the Veteran's functional loss associated with not being able to move his shoulder more than to 15 to 20 degrees due to pain. However, in this instance, the Board finds that the rating specifically contemplates the loss of function, given that it is solely based on the inability to move the shoulder above 25 degrees. In sum, for the period beginning May 17, 2012, which represents the first objective, documented evidence of a worsening of symptoms, a 40 percent rating is warranted. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). 38 C.F.R. § 3.321(b)(1) applies when the rating schedule is inadequate to compensate for the average impairment of earning capacity for a particular disability. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the schedule addresses significant limitation of motion of the shoulder, which is the main symptom of the Veteran's disability. The competent evidence does not show that the disability at issue causes marked interference with employment. The Veteran has maintained his job as an information technology professional. The evidence does not show that the disability requires frequent hospitalizations, or otherwise produces impairment unrecognized by the schedule. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. (CONTINUED ON NEXT PAGE) - 15- ORDER Entitlement to service connection for diabetes mellitus is denied. Entitlement to an evaluation in excess of 10 percent for residuals of right shoulder dislocation, prior to May 17, 2012, is denied. Entitlement to a 40 percent evaluation for residuals of right shoulder dislocation, since May 17, 2012, is granted, subject to regulations applicable to the payment of monetary benefits. Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals -16-