Citation Nr: 1306944 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 09-15 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for radiculopathy of the bilateral upper extremities. 2. Entitlement to service connection for radiculopathy of the bilateral lower extremities. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial increased rating for thoracic degenerative disc disease with lumbar spondyloarthrosis, rated as 10 percent disabling prior to November 16, 2011 and 20 percent disabling thereafter. 5. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine with C3-6 herniated discs. 6. Entitlement to an initial increased rating for right shoulder tendonitis, rated as 10 percent disabling prior to November 16, 2011 and 20 percent disabling thereafter. 7. Entitlement to a rating in excess of 30 percent for headaches associated with degenerative disc disease of the cervical spine. 8. Entitlement to an initial rating in excess of 10 percent for left shoulder tendonitis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran had active military service from January 1985 to January 1988 and from February 2005 to January 2007. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from October 2007, January 2009, and August 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In April 2011, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. The Veteran also testified before a decision review officer (DRO) in April 2008. Transcripts of both hearings are of record. In December 2012, the Veteran requested a second videoconference hearing before the Board. VA regulations provide that a hearing on appeal will be granted upon request by the Veteran or the Veteran's representative. 38 C.F.R. § 20.700 (2012). In this case, the Veteran already requested and was provided a hearing before the Board in April 2011. During that hearing, the Veteran presented testimony regarding all the issues addressed in this decision. As the Veteran has already been provided a hearing on appeal, the Board finds that remand for another hearing is not warranted. The issues of entitlement to a rating in excess of 30 percent for headaches and an initial rating in excess of 10 percent for left shoulder tendonitis, 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 radiculopathy of the bilateral upper extremities. 2. The Veteran does not have radiculopathy of the bilateral lower extremities. 3. For the period prior to January 9, 2009, the Veteran's PTSD manifested mild symptoms with occupational and social impairment and an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. For the period beginning January 9, 2009, the Veteran's PTSD manifests moderate symptoms with occupational and social impairment and reduced reliability and productivity. 5. For the period prior to November 16, 2011, the Veteran's thoracic degenerative disc disease with lumbar spondyloarthrosis manifested forward flexion greater than 30 degrees, a combined range of motion greater than 120 degrees, localized tenderness, and a normal gait and normal spinal contour without incapacitating episodes requiring bed rest prescribed by a physician. 6. For the period beginning November 16, 2011, the Veteran's thoracic degenerative disc disease with lumbar spondyloarthrosis manifests forward flexion to 30 degrees without ankylosis or incapacitating episodes requiring bed rest prescribed by a physician. 7. The Veteran's thoracic degenerative disc disease with lumbar spondyloarthrosis has not resulted in neurological impairment of the bowel or bladder at anytime during the claims period. 8. For the period prior to March 23, 2011, the Veteran's cervical degenerative disc disease manifested limitation of flexion to 45 degrees and a combined range of motion to 299 degrees without incapacitating episodes requiring bed rest prescribed by a physician. 9. For the period beginning March 23, 2011, the Veteran's cervical degenerative disc disease manifests limitation of flexion to 20 degrees without incapacitating episodes requiring bed rest prescribed by a physician. 10. For the period prior to November 16, 2011, the Veteran's right shoulder tendonitis manifested painful noncompensable limitation of motion with flexion to 125 degrees and abduction to 120 degrees with full strength and no ankylosis or impairment of the humerus, clavicle, or scapula. 11. For the period beginning November 16, 2011, the Veteran's right shoulder tendonitis manifests painful limitation of motion with flexion to 115 degrees and abduction to 90 degrees without ankylosis or impairment of the humerus, clavicle, or scapula. CONCLUSIONS OF LAW 1. Radiculopathy of the bilateral upper extremities was not incurred or aggravated during service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Radiculopathy of the bilateral lower extremities was not incurred or aggravated during service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for an initial rating in excess of 30 percent for PTSD for the period prior to January 9, 2009 are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 4. The criteria for a rating of 50 percent, but not higher, for PTSD for the period beginning January 9, 2009 are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130. 5. For the period prior to November 16, 2011, the criteria for an initial rating in excess of 10 percent for thoracic degenerative disc disease with lumbar spondyloarthrosis are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 6. For the period beginning November 16, 2011, the criteria for a rating in excess of 20 percent for thoracic degenerative disc disease with lumbar spondyloarthrosis are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 7. For the period prior to March 23, 2011, the criteria for an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine with C3-6 herniated discs are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 8. For the period beginning March 23, 2011, the criteria for an increased 20 percent rating, but not higher, for degenerative disc disease of the cervical spine with C3-6 herniated discs are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5235-5243. 9. For the period prior to November 16, 2011, the criteria for an initial rating in excess of 10 percent for right shoulder tendonitis are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5003, 5200-5203. 10. For the period beginning November 16, 2011, the criteria for a rating in excess of 20 percent for right shoulder tendonitis are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5003, 5200-5203. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims The Veteran contends that service connection is warranted for radiculopathy of the upper and lower extremities associated with service-connected thoracic and cervical disc disease. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet.App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is also provided for a disability, which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). After review of the evidence of record, the Board finds that the Veteran does not have radiculopathy of the upper and lower extremities. Although service records document some treatment and findings of radiculopathy, the weight of the evidence establishes that the Veteran's in-service radiculopathy has resolved and he does not currently have the claimed disabilities. Service treatment records document multiple instances of treatment for disc abnormalities of the back and neck and contain some evidence of associated radiculopathy. In August 2005, the Veteran complained of numbness and tingling in his legs and feet and was diagnosed with a low back strain. Three months later, in October 2005, he was diagnosed with radiculopathy of both legs based on his complaints of paresthesia and numbness, though an October 2005 lumbar spine MRI did not indicate nerve compression. In contrast, an October 2005 X-ray of the cervical spine was indicative of a disc herniation deforming the left C7 nerve root. Examinations in December 2005 showed normal neurological findings of the upper and lower extremities, but the Veteran continued to complain of numbness and tingling in his arms and legs on the accompanying report of medical history. Similar findings were noted a year later during the Veteran's Medical Evaluation Board (MEB) examination. He complained of numbness and tingling in an October 2006 report of medical history, but the November 2006 MEB examination was negative for neurological abnormalities. Service records therefore document complaints of sensory symptoms and some medical evidence of radiculopathy. The post-service record also contains some evidence in support of the Veteran's claims; however, the clear weight of the evidence is against the finding of current radiculopathy of the upper and lower extremities. During February 2008 and May 2008 visits to the Des Moines VA Medical Center (VAMC), the Veteran's primary care physician observed some decreased sensation in the bilateral feet and legs. The Veteran has also reported instances of leg and arm numbness to his treating physicians. While these findings indicate the presence of a neurological deficit of the lower extremities, all other neurological examinations performed since the Veteran's separation from service have shown no clinical evidence of radiculopathy. VA examinations conducted in July 2007, January 2009, and November 2011 were completely negative for neurological abnormalities and a nerve conduction test conducted during the November 2011 examination showed no monofilament deficits of the upper or lower extremities. The Board notes that the VA examiners all considered the Veteran's reports of numbness and tingling in the extremities prior to rendering their findings, and the July 2007 VA examiner opined that the Veteran had experienced radiculopathy during service that had resolved with no residual effects. The Board finds that the opinions of the three VA examiners, to include the results of the November 2011 nerve conduction test, outweigh the isolated findings of the Veteran's primary care physician in 2008. As noted above, the Veteran has reported experiencing numbness and tingling in his upper and lower extremities and provided testimony regarding his symptoms during the April 2011 hearing before the Board. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds that the Veteran is competent to report radiating pain from his low back and cervical spine. However, the Board also finds that his lay statements are outweighed by the objective medical evidence of record. Three VA examiners provided medical opinions against the claims, all rendered following physical examination of the Veteran and review of the claims file. All three concluded that there was no clinical evidence of radiculopathy of the upper and lower extremities, and the Board finds their conclusions persuasive. Thus, the weight of the evidence is against a finding of any current disability due to service. Absent proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Accordingly, the Board must conclude that the preponderance of the evidence is against the claims for radiculopathy. Increased Rating Claims Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In applying regulations that rate disabilities based on range of motion, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, 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. 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, pertaining to functional impairment. PTSD Service connection for PTSD was granted in the October 2007 rating decision on appeal. An initial 10 percent evaluation was assigned effective January 23, 2007. In a January 2009 rating decision, an increased 30 percent evaluation was awarded, also effective January 23, 2007. Thus, the Veteran's disability has been rated as 30 percent disabling throughout the claims period. The Veteran contends that an increased rating is warranted as his PTSD is productive of symptoms that have negatively impacted his social and occupational functioning. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD is currently evaluated as 30 percent disabling under Diagnostic Code 9411, in accordance with the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the general rating formula, a 30 percent rating is warranted when the mental disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine actives; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As a preliminary matter, the Board notes that the Veteran was diagnosed with a nonservice-connected adjustment disorder during service and upon VA examination in November 2011. VA is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The November 2011 VA examiner specifically differentiated the symptomatology associated with the Veteran's two psychiatric disorders; he was found to demonstrate the full spectrum of PTSD symptoms with re-experiencing, sensitivity and avoidance to reminders, sleep disturbance, anger problems, hypervigilance, an episode of sleepwalking, and isolativeness. The nonservice-connected adjustment disorder was characterized by symptoms to include crying spells, eating problems, difficulty with memory and concentration, low energy and motivation, self-critical thoughts, and excessive worry. As the record contains medical evidence separating the symptoms of the Veteran's mental disabilities, the Board will only consider the PTSD-specific symptoms in its analysis below. For the period prior to January 9, 2009, the Board finds that the Veteran's PTSD most nearly approximated the current 30 percent evaluation. The specific symptoms associated with the Veteran's PTSD are considered by a 30 percent evaluation; he consistently complained of nightmares, intrusive thoughts, emotional numbing, irritability, anxiety, and a hyperstartle response while receiving treatment during service and after separation at the Des Moines VA Medical Center (VAMC). During the April 2008 DRO hearing at the RO, the Veteran testified that he experienced similar symptoms, to include irritability and defensiveness. There is also no indication of symptoms associated with a 50 percent evaluation, to include panic attacks, impaired judgment, impaired thinking, and memory and concentration difficulties due to PTSD. The Veteran's symptoms have also been characterized as mild to moderate by his health care providers. Upon VA examination in July 2007, the Veteran's PTSD symptoms were described as mild, with improvement following medication at the VAMC. The Global Assessment of Functioning (GAF) scores assigned his disability have also been indicative of mild to moderate impairment. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (adopted by VA at 38 C.F.R. §§ 4.125 and 4.126 (2009)), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." The majority of the Veteran's GAF scores during this period ranged from 55 to 80, consistent with moderate to slight symptoms and impairment. The Board notes that a GAF score of 50, attributed to serious impairment, was assigned following the Veteran's February 2006 initial PTSD evaluation at the Des Moines VAMC; however, this represents the only time a score lower than 55 was assigned during the applicable period. The July 2007 VA examiner also specifically found that the Veteran's PTSD symptoms improved after he was placed on medication by his VAMC provider, and the Board finds that the isolated GAF score in February 2006 is not truly representative of the severity of the Veteran's PTSD prior to January 9, 2009. The Veteran's occupational and social functioning has also not supported the assignment of a rating in excess of 30 percent prior to January 9, 2009. The Veteran was employed throughout this period as a county maintenance worker and reported during the July 2007 VA examination that he maintained a good relationship with his family. In February 2008, the Veteran told his VAMC psychiatrist that he experienced some stress at his job, but there is no indication that the Veteran's PTSD resulted in more than mild occupational impairment. Five months later, in July 2008, the Veteran also stated that his mood had significantly improved and he was less irritable. Therefore, the Veteran's occupational and social impairment due to PTSD has most nearly approximated mild during the period prior to January 9, 2009. Based on the mild to moderate symptoms identified by the Veteran's health care providers and the characterization of his social and occupational functioning as mild, the Board finds that the Veteran's PTSD most nearly approximates the criteria associated with the currently assigned 30 percent evaluation during the period prior to January 9, 2009. For the period beginning January 9, 2009, the Board finds that the Veteran's PTSD most nearly approximates an increased 50 percent evaluation. The January 2009 VA examiner concluded that the frequency and intensity of the Veteran's PTSD symptoms had increased in severity since the examination in July 2007 and had resulted in increased social and occupational impairment. At that time, the Veteran reported experiencing moderate anxiousness and increased struggles at work. The evidence also establishes that the Veteran's PTSD manifests difficulty in establishing and maintaining effective work and social relationships during this period. The Veteran's GAF scores during the period beginning January 9, 2009 have consistently indicated PTSD symptoms that are moderate in severity. The January 2009 VA examiner assigned a GAF score of 56 and the most recent VA examination in November 2011 noted a GAF score of 52. Both scores are associated with moderate symptoms and moderate difficulty in social and occupational functioning. The assigned GAF scores from his VAMC psychiatrist also range between 55 and 60 and are consistent with moderate symptoms and impairment. The Veteran has also demonstrated increased occupational and social impairment during this period that most nearly approximates moderate. During the January 2009 VA examination, the Veteran reported having increased problems at work interacting with other employees. He testified at the April 2011 hearing that he had a verbal altercation with another employer in January 2011 and was not social with any of his coworkers. Similar statements were made at the November 2011 VA examination, and he stated that he generally did not socialize a lot other than attending church and having one close friend. He also had some problems with his family during this period; while receiving treatment at the VAMC, the Veteran stated in April 2009 that he had temporarily moved out of his house due to disagreements with his wife and daughter, but the conflict was apparently resolved in July 2009 when the Veteran returned home. In January 2009, the Veteran stated that he only occasionally went out socially with his wife, and the November 2011 VA examiner found that the Veteran had difficulty establishing work and social relationships. The medical and lay evidence establishes that the Veteran's PTSD has demonstrated increased symptoms during the period beginning January 9, 2009 that most nearly approximate moderate and a 50 percent rating. The Board has considered whether a rating in excess of 50 percent is warranted, but finds that the Veteran's disability does not manifest symptoms or impairment associated with this evaluation. The criteria for a 70 percent rating for a psychiatric disability are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). In this case, the Veteran has not manifested any impairment to judgment or thinking, and there is no indication his speech, insight, concentration, or memory have been impaired due to PTSD. In addition, he has continued to work fulltime and has remained married throughout the entire claims period, and despite a few problems with his daughter and wife, has maintained good relationships with his family. Therefore, the Board finds that a 70 percent evaluation is not warranted for the Veteran's service-connected PTSD. In sum, the Veteran's PTSD warrants a 30 percent evaluation for the period prior to January 9, 2009 and an increased 50 percent evaluation thereafter. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against any additional increased ratings. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Thoracic and Lumbar Spine Disability Service connection for thoracic degenerative disc disease with lumbar spondyloarthrosis was granted in the October 2007 rating decision on appeal. An initial 10 percent evaluation was assigned effective January 23, 2007. In a September 2012 rating decision, an increased 20 percent evaluation was assigned effective November 16, 2011. The Veteran contends that increased ratings are warranted throughout the claims period as his back disability is productive of constant pain, muscle spasms, and neurological deficits. The Veteran's back disability is rated under Diagnostic Code 5239 for spondylolisthesis or segmental instability and the general rating formula for diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5237-5242. The Board also notes that the Veteran has been diagnosed with thoracic degenerative disc disease and the criteria pertaining to intervertebral disc syndrome are therefore for application. Intervertebral disc syndrome is evaluated under the general formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the general rating formula for rating diseases and injuries of the spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. For the period prior to November 16, 2011, the Veteran's back disability is rated as 10 percent disabling. The Veteran's disability demonstrated episodes of worsening and improvement throughout the applicable claims period, but when the disability is viewed as a whole, the Board finds that an initial rating in excess of 10 percent is not warranted. With respect to limitation of motion, the Veteran's thoracolumbar spine movement was most limited in March 2006 (while still on active duty) during a physical therapy session at Adel Physical Therapy. At that time, forward flexion was measured to 30 degrees with a combined range of motion of 112 degrees due to pain. These findings are consistent with an increased 20 percent evaluation; however, the Board finds they are not truly representative of the Veteran's impairment throughout the period. Three months after his separation from service, in April 2007, the Veteran was examined by his primary care provider at the VAMC, and his back pain was noted to have improved greatly with physical therapy. His back had excellent mobility and he was cleared to return back to his job operating heavy machinery. Similar findings were noted on the July 2007 VA examination when the Veteran's back manifested full range of pain-free motion with only mild to moderate functional limitations. Therefore, while the Veteran experienced severe loss of spinal motion when he began physical therapy during active service, at the time of his separation in January 2007 his symptoms had improved with little functional impairment. The other VA medical evidence dated throughout the period prior to November 16, 2011 also indicates that the Veteran's back disability most nearly approximated a 10 percent evaluation. He testified during the April 2008 hearing that he experienced pain, loss of motion, and muscle spasms, but these symptoms are contemplated by the current 10 percent evaluation. During the January 2009 VA examination, the Veteran's daily low back pain was again noted to improve with physical therapy exercises. He had a normal gait and no spinal contour deformities. Forward flexion of the spine was limited, but measured to 75 degrees with a combined range of motion to 255 degrees. With respect to the relevant functional factors, the Veteran reported that he missed one day of work per week due to low back pain, but the objective testing and range of motion values were reported with consideration of repetitive testing and the Veteran's complaints of pain. The Veteran also reported to his VA physician in November 2010 that his back pain had further improved following an April 2010 nephrectomy to treat renal carcinoma. These findings are consistent with the current 10 percent evaluation. The Veteran's records from private physical therapy indicate that he stopped regular treatment in 2006. In March 2011, the Veteran returned to physical therapy and stated that his back pain returned in November and December 2010. He began a new course of treatment and during a March 2011 therapy examination, forward flexion of the thoracolumbar spine was limited to 50 percent of normal (approximately 45 degrees). In May 2011, the physical therapist noted that the Veteran's pain had improved and available records indicate that he continued treatment through September 2011. Similarly, in April 2011 the Veteran testified that his back pain was not as severe as the other orthopedic pain he experienced from his shoulder and cervical spine. This evidence establishes that the Veteran experienced a temporary increase of back pain in 2010 that was improved by physical therapy. As discussed above, this is typical of the Veteran's back disability during the period prior to November 16, 2011, with episodes of increased symptoms that were ameliorated by treatment. The Board finds that the earlier in-service findings of restricted motion and later increased symptoms are not truly representative of the Veteran's limitations during the claims period. Thus, the service-connected back disability is appropriately rated as 10 percent disabling under the general rating criteria during the period prior to November 16, 2011. For the period beginning November 16, 2011, the Veteran's disability is rated as 20 percent disabling. Upon VA examination in November 2011, forward flexion of the thoracolumbar spine was limited to 30 degrees with a combined range of motion to 130 degrees with pain at the endpoint of testing. Flexion limited to 30 degrees is contemplated by the currently assigned 20 percent evaluation under the general rating criteria. There was no ankylosis, and while the examiner noted muscle spasms, there was no effect on the Veteran's gait or spinal contour. With respect to the relevant functional factors, the measurements noted above were reported by the VA examiner with consideration of the Veteran's complaints of pain. The Veteran also stated that he missed some work twice a week due to flare-ups of back pain, but the quantifiable objective evidence establishes that the manifestations of the service-connected back condition are contemplated by the currently assigned 20 percent evaluation. An increased rating is therefore not warranted at anytime during the claims period on the basis of limitation of motion of the thoracolumbar spine. Turning to whether an increased rating is warranted using the criteria pertaining to intervertebral disc syndrome. Under 38 C.F.R. § 4.71a, Diagnostic Code 5243, a 10 percent evaluation is assigned with incapacitating episodes having a total duration of at least once a week but less than two weeks during the past 12 months. A 20 percent evaluation is assigned in cases of intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. A 40 percent evaluation contemplates incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. In this case, the medical and lay evidence does not establish that the Veteran has been prescribed any periods of bedrest by a physician. Treatment records from the Veteran's VA physicians and the private physical therapist do not document any prescribed bedrest. In addition, the Veteran never reported requiring bedrest during the VA examinations in July 2007 or January 2009, and did not testify that he required bedrest in April 2008 and April 2011. Therefore, the record does not establish that the Veteran has experienced incapacitating episodes as defined by VA for a period of at least 4 to 6 weeks at anytime during the claims period. An increased rating under the formula for rating intervertebral disc syndrome is therefore not warranted. The Board has also considered whether separate ratings for neurological impairment associated with the service-connected back disability are warranted at anytime during the claims period. The rating criteria provides that associated objective neurological abnormalities are to be evaluated separately. As discussed in the first section of this decision, the Board has determined that the Veteran does not manifest radiculopathy of the lower extremities. Furthermore, although the Veteran testified in April 2011 that he experienced bowel problems due to his back disability, there is no medical evidence of neurological bowel or bladder abnormalities. In fact, the November 2011 VA examiner specifically found that the Veteran did not have any neurological impairment from his back condition. The Board finds that objective evidence is more probative on the question of whether the Veteran's disability is productive of neurological impairment than the Veteran's lay statements. The Veteran is competent to report symptoms he experiences, such as bowel disturbances, but finds that he lacks the necessary competency to relate these symptoms to a specific etiology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007). The Veteran's service-connected back disability therefore warrants a 10 percent initial evaluation for the period prior to November 16, 2011 and a 20 percent evaluation thereafter. The evidence does not establish that the disability has caused neurological impairment. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for an increased rating. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Cervical Spine Disability Service connection for degenerative disc disease of the cervical spine with C3-6 herniated discs (claimed as neck condition) was granted in the October 2007 rating decision on appeal. An initial 10 percent evaluation was assigned effective January 23, 2007. The Veteran contends that an initial rating in excess of 10 percent is warranted as his neck disability manifests pain, muscle spasms, and limited motion that affect his ability to function. The Veteran's cervical spine disability is rated under Diagnostic Code 5243 for intervertebral disc syndrome and the general rating formula for diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5237-5243. The Board also notes that the Veteran has been diagnosed with cervical degenerative disc disease and the specific criteria pertaining to intervertebral disc syndrome are therefore for application. Intervertebral disc syndrome is evaluated under the general formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The general rating formula provides a 10 percent disability rating for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Turning first to the period prior to March 23, 2011 and the general rating criteria, the Board finds that the criteria for an initial rating in excess of 10 percent are not met. The Veteran's cervical spine motion was most limited upon VA examinations in July 2007 and January 2009 when forward flexion was measured to 45 degrees. The total combined range of cervical motion was most limited during a private physical therapy session in March 2006, when it was measured to 299 degrees. These findings are consistent with the currently assigned 10 percent evaluation. The Board notes that all other examinations dated throughout the claims period demonstrate greater cervical range of motion. The Board has considered whether an increased evaluation is warranted with consideration of functional factors, but notes that the July 2007 VA examiner found that the Veteran's complaints of pain with motion actually decreased following repetitive testing. The VA examiner concluded that the Veteran experienced only mild to moderate impairment due to his service-connected cervical spine disability. Therefore, even with consideration of functional factors, an increased initial rating is not warranted for the period prior to March 23, 2011 based on limitation of motion. For the period beginning March 23, 2011, the Board finds that the cervical spine disability most nearly approximates an increased 20 percent evaluation. In March 2011, when the Veteran returned to private physical therapy, forward flexion of the cervical spine measured to 20 degrees. Similarly, upon VA examination in November 2011, the Veteran manifested forward flexion of the neck to 25 degrees. Both findings are consistent with a 20 percent rating. A rating in excess of 20 percent is not appropriate as forward flexion of the Veteran's cervical spine has clearly not most nearly approximated 15 degrees or less, nor is there evidence of ankylosis. The Board notes that the cervical range of motion reported by the November 2011 VA examiner included the Veteran's complaints of pain. The examiner also determined that the Veteran's cervical motion improved with repetitive testing. Even with consideration of functional factors, the Veteran has not manifested limited motion associated with a rating in excess of 20 percent and he has clearly retained some useful motion of his neck. Thus, a rating in excess of 20 percent is not warranted for the period prior to March 23, 2011. The Board has also considered whether increased ratings are warranted at anytime during the claims period under the criteria pertaining to intervertebral disc syndrome. Under 38 C.F.R. § 4.71a, Diagnostic Code 5243, a 10 percent evaluation is assigned with incapacitating episodes having a total duration of at least once a week but less than two weeks during the past 12 months. A 20 percent evaluation is assigned in cases of intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. A 40 percent evaluation contemplates incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. In this case, the medical and lay evidence does not establish that the Veteran has been prescribed any periods of bedrest by a physician. Clinical records from the Veteran's VA and private health care providers are negative for prescribed bedrest for neck pain. In addition, the Veteran has never reported requiring bedrest to treat flare-ups of symptoms of his cervical spine disability. Therefore, the record does not establish that the Veteran has experienced incapacitating episodes as defined by VA at anytime during the claims period. An increased rating under the formula for rating intervertebral disc syndrome is therefore not warranted. The Board has also considered whether separate ratings for neurological impairment associated with the service-connected cervical spine disability are warranted. The rating criteria provide that associated objective neurological abnormalities are to be evaluated separately. As discussed in the first section of this decision, the Board has determined that the Veteran does not manifest radiculopathy of the upper extremities. Therefore, separate rating for neurological impairment are not appropriate in this case. In addition, the doctrine of reasonable doubt is not applicable because the preponderance of the evidence is against the claim for an increased rating other than the 20 percent evaluation assigned from March 23, 2011. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Right Shoulder Disability Service connection for right shoulder tendonitis (claimed as a shoulder condition) was granted in the October 2007 rating decision on appeal. An initial noncompensable evaluation was assigned effective January 23, 2007. A January 2009 rating decision assigned an increased 10 percent evaluation from the date of service connection, January 23, 2007. The current 20 percent rating was awarded in a September 2012 rating decision effective November 16, 2011. The Veteran contends that increased ratings are warranted for his right shoulder disability as it manifests pain and limitation of motion especially above the shoulder level. For the period prior to November 16, 2011, the Veteran's right shoulder disability was rated as 10 percent disabling under Diagnostic Code 5024 for tenosynovitis. This diagnostic code provides for rating the disability as degenerative arthritis based on limitation of motion of the affected part. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2012). Diagnostic Code 5201 pertains to limitation of motion of the arm. When motion of the arm is limited at the shoulder level, it is rated 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 provides for a minimum rating of 20 percent. The 10 percent evaluation assigned in the January 2009 rating decision was awarded under Diagnostic Code 5003 for degenerative arthritis. Under this diagnostic code, when there is noncompensable limitation of motion of the specific joint involved, a 10 percent rating is assigned for each major joint or group of minor joints affected by limitation of motion. 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. During the period prior to November 16, 2011, the Board finds that a rating in excess of 10 percent is not warranted. The Veteran's right shoulder motion was most limited during this period while undergoing physical therapy with private and VA providers. At Adel Physical Therapy in November 2006, the Veteran's right shoulder flexed to 125 degrees. Abduction of the shoulder was most limited in March 2008 during a VA physical therapy session. At that time, abduction measured to 120 degrees. The Veteran is left hand dominant, and an increased 20 percent evaluation under Diagnostic Code 5201 requires limitation of motion of the arm at the shoulder level, i.e. flexion limited to 90 degrees or abduction limited to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Although the right shoulder manifested some painful motion during the period prior to November 16, 2011, it is clear that range of motion was not limited to 90 degrees. With respect to functional factors, the right shoulder manifested full strength upon VA examinations in July 2007 and January 2009, and during a VA physical therapy evaluation in March 2008. The VA examiners also reported range of motion measurements that took into account repetitive motion testing and the Veteran's reports of pain with flexion and abduction to 170 degrees or greater. The July 2007 VA examiner also determined that the right shoulder disability only resulted in minimal functional impact. The Veteran testified in April 2011 that he had trouble lifting his arm above his head and similar statements were made on the March 2009 substantive appeal. The Veteran is competent to report symptoms and manifestations of his disability, but the Board finds that the objective medical findings outweigh the Veteran's subjective lay statements. The medical evidence dated during the period prior to November 16, 2011 clearly shows that the Veteran was able to flex and abduct his shoulder above 90 degrees and resulted in only minimal functional impairment. A rating in excess of 10 percent is therefore not warranted. Turning to the period beginning November 16, 2011, the Veteran's right shoulder disability is rated as 20 percent disabling under Diagnostic Code 5201. Upon VA examination in November 2011, the right shoulder manifested flexion to 115 degrees and abduction to 90 degrees. These measurements reflect the Veteran's complaints of pain and were rendered following repetitive testing. Abduction of the right shoulder was therefore limited to the shoulder level and the current 20 percent rating is appropriate. A rating in excess of 20 percent is not warranted under Diagnostic Code 5201 as the Veteran is clearly able to move his right arm to more than 25 degrees from the side. The Board has also considered whether an increased rating is warranted during either claims period under the other criteria for rating the arm and the shoulder, but finds that such criteria are inapplicable to this case. The evidence of record is wholly negative for findings of shoulder ankylosis and the there is no indication that the Veteran experiences impairment of the humerus, clavicle or scapula. Therefore, Diagnostic Codes 5200, 5202, and 5203 are not for application in this case. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against an increased rating at anytime during the claims period. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Other Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disabilities. The Veteran's orthopedic disabilities are manifested by symptoms such as painful limited motion. His PTSD manifests mild to moderate social and occupational impairment. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disabilities and referral for consideration of extraschedular rating is not warranted. Entitlement to a TDIU is an element of all claims for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). A claim for TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). In this case, the record is negative for evidence that the Veteran is unemployable due to service-connected lumbar spine, cervical spine, right shoulder, and psychiatric disabilities. He is not in receipt of Social Security disability benefits, and has continued to work as a county maintenance worker throughout the claims period. The Veteran has not stated that he is unable to perform his duties due to his service-connected conditions and he has not alleged unemployability. Therefore, remand of a claim for TDIU is not necessary as there is no evidence of unemployability due to the service-connected spine, right shoulder, and psychiatric disabilities. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defined VA's duties to notify and assist a veteran in the substantiation of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). With respect to the claims for service connection, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in a February 2007 letter. The Veteran also received notice regarding the disability-rating and effective-date elements of the claims in the February 2007 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding the claims for increased ratings, this appeal originates from the assigned initial evaluations following an award of service connection. The claims for service connection for the disabilities on appeal are now substantiated and the filing of a notice of disagreement as to the October 2007 rating decision does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). See 38 C.F.R. § 3.159(b)(3) (2011). Rather, the Veteran's appeal as to the initial ratings assignments triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Under 38 U.S.C.A. § 7105(d), upon receipt of a notice of disagreement in response to a decision on a claim, the agency of original jurisdiction (AOJ) must take development or review action it deems proper under applicable regulations and issue a statement of the case (SOC) if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. However, section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. 38 C.F.R. § 3.159(b)(3). As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. The January 2009 SOC, under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic codes for rating the disabilities at issue, and included a description of the rating formulas for all possible schedular ratings under these diagnostic codes. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluations that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disabilities at issue. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained available records of treatment reported by the Veteran, including service treatment records, records of VA treatment, and private medical records. Additionally, the Veteran was provided proper VA examinations in response to his claims for service connection and increased ratings. With respect to the Veteran's private medical treatment, the claims file currently contains records from Adel Physical Therapy dating from January 2005 to March 2008 and from March 2011 to September 2011. There are no records for the period between March 2008 and March 2011. In response to the Board's September 2011 remand, VA made two additional requests for records from Adel Physical Therapy, specifically noting that records for the period from March 2007 to April 2011 were needed. In response, the facility provided additional records, but none were dated between March 2008 and March 2011. The Board notes that VA's requests to Adel Physical Therapy specifically noted that records during this period were necessary, and the records themselves indicate that the Veteran may not have received treatment between 2008 and 2011. During a March 2011physical therapy session, the Veteran reported that he "quit coming here 4 years ago" and decided to renew treatment after a recent worsening of his orthopedic pain in November and December 2010. Thus, the Board finds that VA has complied with the duty to assist requirements with respect to the procurement of all available records of private treatment, and additional efforts would not result in any evidence to support his claims. See 38 C.F.R. § 3.159(c)(1) (VA will make reasonable efforts to obtain relevant records not in the custody of a Federal department or agency, to include an initial request and at least one follow-up request). The Board also finds that VA has complied with the September 2011 remand orders of the Board. In response to the Board's remand, the Veteran was provided VA orthopedic, neurological, and psychiatric examinations in November 2011. He was also contacted in an October 2011 letter and asked to identify all private and VA health care providers who had treated the disabilities on appeal. As discussed above, VA has obtained all available records of private treatment reported by the Veteran, and the claims file does not indicate that additional records exist. The case was then readjudicated in a September 2012 supplemental statement of the case (SSOC). Therefore, VA has complied with the remand orders of the Board. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. ORDER Entitlement to service connection for radiculopathy of the bilateral upper extremities is denied. Entitlement to service connection for radiculopathy of the bilateral lower extremities is denied. Entitlement to an initial rating in excess of 30 percent for PTSD for the period prior to January 9, 2009 is denied. Entitlement to an increased rating of 50 percent, but not higher, for PTSD for the period prior to January 9, 2009 is granted. Entitlement to an initial rating in excess of 10 percent for thoracic degenerative disc disease with lumbar spondyloarthrosis for the period prior to November 16, 2011 is denied. Entitlement to a rating in excess of 20 percent for thoracic degenerative disc disease with lumbar spondyloarthrosis for the period beginning November 16, 2011 is denied. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine with C3-6 herniated discs for the period prior to March 23, 2011 is denied. Entitlement to an increased rating of 20 percent, but not higher, for degenerative disc disease of the cervical spine with C3-6 herniated discs for the period beginning March 23, 2011 is granted. Entitlement to an initial rating in excess of 10 percent for right shoulder tendonitis for the period prior to November 16, 2011 is denied. Entitlement to a rating in excess of 20 percent for right shoulder tendonitis for the period beginning November 16, 2011 is denied. REMAND In an August 2011 rating decision, the Veteran was awarded an increased 30 percent evaluation for headaches associated with degenerative disc disease of the cervical spine. In December 2012, the Veteran submitted a VA Form 9 expressing disagreement with the assignment of a 30 percent rating. Similarly, service connection for left shoulder tendonitis was granted in a January 2009 rating decision with an initial 10 percent evaluation assigned effective January 23, 2007. The Veteran submitted a VA Form 9 disagreeing with the initial 10 percent rating assigned the left shoulder disability in March 2009. He has not been provided a SOC in response to either notice of disagreement and a remand is required for the issuance of a SOC on these issues. See Manlicon v. West, 12 Vet. App. 238 (1999). Additionally, the Board notes that the December 2012 notice of disagreement included a request for a videoconference hearing before the Board. As discussed above, the Board has determined that the Veteran has already testified before the Board with respect to the claims for increased ratings and service connection addressed in the body of this decision, but he has not testified regarding the claims for an increased rating for headaches and left shoulder tendonitis. The request for a hearing is referred to the AOJ for appropriate action. Accordingly, the case is REMANDED for the following action: 1. Issue a SOC to the Veteran and his representative on the issues of entitlement to a rating in excess of 30 percent for headaches associated with degenerative disc disease of the cervical spine and entitlement to an initial rating in excess of 10 percent for left shoulder tendonitis. The Veteran should also be informed of the requirements to perfect an appeal with respect to these issues. 2. If the Veteran perfects an appeal with respect to either of these matters, schedule a videoconference hearing before a Veterans Law Judge at the RO. Then ensure that any indicated development is completed before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court (CONTINUED ON NEXT PAGE) 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). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs