Citation Nr: 1311291 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 09-05 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for plantar fascia fibromatosis. 3. Entitlement to an increased rating for lumbar strain/myositis, currently evaluated as 20 percent disabling. 4. Entitlement to an increased rating for left knee effusion, currently evaluated as 10 percent disabling. 5. Entitlement to an increased rating for right chondromalacia patella, currently evaluated as 10 percent disabling. 6. Entitlement to an increased rating for left shoulder degenerative joint disease with impingment, currently evaluated as 10 percent disabling. 7. Entitlement to an increased (compensable) rating for bilateral sensorineural hearing loss. 8. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran served on active duty form May 24, 1982 to September 23 1982, and from January 2006 to April 2007. He served in Iraq and Kuwait. He also had training in the Army Reserves. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from rating decisions of the VA Regional Office (RO) in San Juan, Puerto Rico that denied service connection for PTSD and plantar fascia fibromatosis, and increased ratings for lumbar myositis, left knee effusion, right chondromalacia patella, left shoulder degenerative joint disease, and bilateral sensorineural hearing loss. Appellant initially requested a Travel Board hearing. That request was subsequently withdrawn so that the matter may proceed. Review of the record reveals that a claim for a total rating based on individual unemployability has been raised. Pursuant to judicial guidance, the issue is listed on the title page and is considered in the Remand section of this document. Following review of the record, the issues of entitlement to service connection for an acquired psychiatric disorder, plantar fascia fibromatosis, an increased rating for the low back disorder, and TDIU are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Right knee disability is manifested by degenerative changes and periarticular pathology that includes, pain, noncompensable limitation of motion, grinding, crepitus, and some tenderness to palpation, etc.; there is no instability, ankylosis, or impairment of the fibula or tibia. 2. Left knee disability is manifested by periarticular pathology that includes degenerative changes, pain, noncompensable limitation of motion, grinding, crepitus, and some tenderness to palpation, etc.; there is no instability, ankylosis or impairment of the fibula or tibia. 3. Left shoulder degenerative joint disease with impingment is manifested by arthritic changes, forward flexion and abduction to at least 160 degrees, with complaints of pain, stiffness, and activity restrictions; there is no evidence of ankylosis, fibrous union, nonunion or loss of the humeral head and the Veteran is able to lift the left arm substantially beyond shoulder level. 4. Bilateral sensorineural hearing loss is manifested by no more than Level I hearing in the right ear and Level VI hearing in the left ear. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for right knee disability are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5014 (2012). 2. The criteria for an evaluation in excess of 10 percent for left knee disability are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5299-5260 (2012). 3. The criteria for an evaluation in excess of 10 percent for left shoulder degenerative joint disease are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5201-5003 (2012). 4. The criteria for a disability rating in excess of zero percent for bilateral sensorineural hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.85, Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The record reflects that the RO sent letters to the Veteran that advised him of the requirements of the VCAA, including the types of evidence and/or information necessary to substantiate his claims and the relative duties of the appellant and VA in developing the claims. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As to the duty to assist, the Veteran has indicated that he receives treatment only at VA, and VA has obtained his VA outpatient records. He has been provided VA medical examinations over the course of the appeal. He requested and was scheduled for RO and videoconference hearings but cancelled his appearances. The appellant has been accorded ample opportunity to present evidence and argument in support of the appeal. His statements in support of the claim have been carefully considered. The Board is satisfied that the originating agency properly processed the Veteran's claim after providing required notice, and that any procedural errors in the development and consideration of the claim by the originating agency were insignificant and non-prejudicial to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). As such, the claims of entitlement to increased ratings for lumbar strain/myositis, left knee effusion, right chondromalacia patella, left shoulder degenerative joint disease, and bilateral sensorineural hearing loss are ready to be considered on the merits. Pertinent Law and Regulations-Increased Ratings - General Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2012). The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life and is based, as far as practicable, on average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.10 (2012). With any form of arthritis, painful motion is an important factor of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59 (2012). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet.App. 55, 58 (1994). Where there is a change in the condition over the appeal period, staged ratings may be appropriate. Consideration herein has been given to whether staged ratings are appropriate as to the ratings discussed below. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.5 (2012). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet.App. 518, 519 (1996). Factual Background - Orthopedic Disabilities Among other things, by rating action dated in October 2007, service connection was granted for lumbar strain/myositis, mild left knee effusion with baker cyst and arthritis, right knee chondromalacia patella with joint effusion, and degenerative joint disease of the left shoulder with impingement. The Veteran filed a claim for increased ratings for service-connected orthopedic disabilities in July 2008. The Veteran was afforded A VA general medical examination in May 2007. He complained of back, left shoulder and knee pain. It was reported that he had adequate posture and gait. He was right hand dominant. Bilateral knee range of motion was from zero 140 degrees. Extension was full. There was no motion of the medial and collateral ligaments. The anterior and posterior cruciate ligaments were less than five millimeters. Left shoulder range of motion was from zero to 180 degrees. Pain was elicited in the last five degrees. Shoulder abduction was zero to 160 degrees with function loss of 20 degrees. Pain was elicited in the last five degrees. External rotation was from zero to 90 degrees. Internal rotation was from zero to 90 degrees. Magnetic resonance imaging (MRI) of the left shoulder disclosed mild acromioclavicular joint hypertrophic degenerative changes producing a mild impression on the proximal supraspinatus tendon. There was no MRI evidence to suggest rotator cuff tendon tear. MRI of the right knee revealed a small joint effusion and suspected early chondromalacia patella changes. There was a moderate sized Baker's cyst. MRI of the left knee was interpreted as showing a minimal amount of intra-articular fluid and a minute Baker's cyst but was otherwise unremarkable. Pertinent diagnoses were rendered of mild left knee effusion by MRI and Baker's cyst, chondromalacia patella with joint effusion of the right knee by MRI and degenerative joint disease of the left shoulder with impingment syndrome by MRI. The Veteran was afforded a VA joints examination in August 2008. He complained of pain, weakness, stiffness, swelling, heat and redness, instability or giving way, and locking. He stated that he had joint flare-ups two to four times monthly aggravated by cloudy or rainy days, which lasted several hours for which he took medication. He indicated that he had a one-point cane. He was asked repeatedly to flex/extend the left knee and left shoulder without resistance. Pain was elicited but there was no weakness or fatigue. There was no evidence of knee effusion or swelling. The Veteran limped from the left leg and gait was antalgic. Ankylosis was not present. There was no leg length discrepancy. Range of motion of the left knee was from 0-110 degrees with pain in the last 40 degrees. It was determined that there was functional loss of 30 degrees due to pain. Extension was zero degrees with pain in the last 30 degrees. There was no functional loss. There was a positive grind test in both knees and crepitance was noted. It was reported that there was no instability. The Lachman and McMurray tests were negative Left shoulder range of motion was from 0-160 degrees with pain in the last 30 degrees and functional loss of 20 degrees. Shoulder abduction was 0-180 degrees with pain in the last 30 degrees and functional loss of 20 degrees due to pain. Left shoulder internal rotation was 0-90 degrees with pain in the last 30 degrees and functional loss of zero degrees. The impingment test was negative. Prior X-ray and MRI studies were reviewed. Following examination, the diagnoses were left knee effusion, left shoulder impingement syndrome, and left knee degenerative joint disease. VA outpatient clinical records dated in April 2010 noted that right and left knee chondromalacia patella was asymptomatic. The Veteran continued to complain of chronic low back pain. It was noted that he had had facet joint injection with improvement but had later fallen with onset of worsening low back pain. It was reported that back pain was controlled with Tramadol and that he had an open appointment if he wished to consider a new injection. The examiner noted that range of motion was intact, muscle tone was adequate and that there were no deformities. There were no gross motor and sensory deficits. Social Security records dated in November 2010 reflect that the appellant was awarded disability benefits on account of musculoskeletal disorders, primarily the spine, and hearing loss. The Veteran was afforded VA joint and general medical examinations in March 2011. He described left shoulder pain of 5/10 intensity during cold weather and stated it was getting progressively worse. The appellant related that left knee pain was 9/10 in intensity that was worse during prolonged standing or sitting and with moderate ambulation. On examination of the left shoulder, it was noted that there was pain, but no deformity, giving way, instability, stiffness, weakness, incoordination, dislocation or subluxation, locking, effusion, inflammation or flare-ups. There was decreased speed of joint motion and tenderness with guarding of movement. Left shoulder flexion and abduction were 0-175 degrees. Left internal and external rotation was 90 degrees. There was evidence of pain with active motion and pain following repetitive motion. There were no additional limitations after three repetitions of range motion. On examination of the left knee, the Veteran reported pain, but no deformity, giving way, instability, stiffness, incoordination, dislocation or subluxation, locking, effusion, inflammation or flare-ups. There was weakness and decreased speed of joint motion, as well as subpatellar tenderness. He was able to stand for 15-30 minutes and walk 1/4 mile. Assistive devices included a brace and a crutch that he reported always using. There was evidence of grinding. Gait was antalgic. Left and right knee flexion was from 0-140 degrees. Right and left knee extension was zero degree. It was reported that there was objective evidence of pain with active motion on the left side but not on the right. There were no additional limitations after three repetitions of range motion. Prior X-rays and MRI studies were reviewed. Following examinations, impressions were rendered of left shoulder degenerative joint disease with associated impingement syndrome, left knee chondromalacia patella, lumbar strain with associated paravertebral myositis, lumbar disc paracentral protrusion at L5-S1 and lumbar spondylosis. The examiner opined that the impact on occupational functioning and the activities of daily living were moderate. When examined by VA in November 2011, the Veteran reported that since the last VA examination, right knee pain had gotten worse and was 8/10 in intensity. He stated that on walking, pain was so strong that it gave way at times. The appellant related that he had nine months of right knee flare-ups per year and that this impacted right knee functioning. On examination, it was reported that right flexion was 140 degrees or greater and that there was no objective evidence of painful motion. Extension was zero degrees with no objective evidence of painful motion. Left knee flexion was 140 degrees or greater with objective evidence that painful motion began at 110 degrees. Extension was zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions. Post test range of motion was to 140 degrees, bilaterally. It was reported that the Veteran had no functional loss of the right and left lower extremity. He had pain to palpation of the joint line or soft tissue of the right knee. Muscle strength was 5/5, bilaterally. Anterior, posterior and medial-lateral stability testing was 2+(normal). There was no evidence of recurrent patellar subluxation/dislocation. It was reported that he used assistive devices that included braces and a cane. It was reported that there was X-ray evidence of degenerative arthritis but no patellar subluxation. Following examination, the examiner stated that Veteran related that he retired from his position due to lumbar discogenic disease. It was opined that based solely on all the appellant's musculoskeletal condition and the current evaluation, the Veteran was able to obtain and secure gainful employment of a sedentary type. Diagnostic studies performed previously were reviewed. Following examination, the impressions were no definite meniscal tears or ligamentous injuries identified, mild osteoarthritic changes, and patellofemoral chondromalacia. 1. Increased rating for right knee chondromalacia patella/ left knee effusion. Pertinent law and regulations Service connection is in effect for right knee and left knee disabilities, evaluated as 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5014 for osteomalacia (Diagnostic Code 5014) and limitation of flexion (Diagnostic Code 5260), respectively. Osteomalacia is rated on limitation of motion of affected parts, as degenerative arthritis, except gout which is rated under Diagnostic Code 5002. 38 C.F.R. § 4.71. Other applicable rating criteria that apply to the knees are as follows. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling. Moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling. Severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The normal range of knee motion is from 0 to 140 degrees. See 38 C.F.R. § 4.71a, Plate II (2012). Limitation of motion of the knee is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261 (2012). When flexion of the knee is limited to 45 degrees, a 10 percent rating may be assigned. Flexion limited to 30 degrees warrants a 20 percent evaluation. A 30 percent rating may be assigned when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). When extension of the knee is limited to 10 degrees, a 10 percent evaluation may be assigned. When extension is limited to 15 degrees, a 20 percent evaluation may be assigned. When limited to 20 degrees, a 30 percent rating is warranted. If extension is limited to 30 degrees, a 40 percent evaluation is warranted. A 50 percent evaluation may be assigned when extension of the leg is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. §§ 4.71a, 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet.App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet.App 7 (1996). Legal Analysis Review of the evidence discloses that the Veteran's service-connected bilateral knee disability is manifested by complaints that pain, slight limitation of motion, stiffness, tenderness, grinding and crepitus, etc. The Board thus finds that such symptoms are emblematic of articular and periarticular pathology. Painful, unstable or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59 (2012). The presence of periarticular pathology comports with Diagnostic Code 5003 that provides for a 10 percent evaluation when limitation of motion is noncompensable but affected by painful motion. The Board finds a rating in excess of 10 percent is not warranted for either knee at any time based on limitation of motion. Over the course of the appeal period, the evidence reflects that flexion of both knees has primarily been determined to be as high as 140 degrees, but no less than 110 degrees. These ranges of movement are more than twice that required to warrant a compensable evaluation under Diagnostic Code 5260 based on limitation of flexion. Flexion of 110 degrees does not more nearly comport with the rating criteria for a higher evaluation, which requires that flexion be limited to 30 degrees. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5260. Neither the lay nor clinical evidence has shown at any time that flexion is functionally limited to 30 degrees due to any factor. As such, the Board finds no basis upon which to assign an evaluation greater than 10 percent for right or left knee based on limitation of flexion. An increased rating has not warranted at any time during the appeal period for the service-connected right and left knee disabilities based on limitation of extension under 38 C.F.R. § 4.71a, Diagnostic Code 5261. The record reflects that the appellant has been found to have full extension on examination at all times during the course of the appeal. Extension has consistently been zero which is normal. Extension of zero degrees does not warrant a compensable evaluation under Diagnostic Code 5261. Therefore, the criteria for a separate rating under Diagnostic Code 5261 are not met. The Board has further considered whether a separate and/or higher evaluation is warranted under 38 C.F.R. § Diagnostic Code 5257. However, there is no competent, objective evidence of the presence of subluxation or lateral instability. While the appellant is competent to report giving way or instability which he has done, the clinical findings on examination, to include Lachman and drawer testing, have been negative. The record reflects that although reporting use of a knee brace to VA examiners, no clinical findings of instability have been elicited on objective or subjective clinical consideration. In this regard, the Veteran is competent to report what he experiences through the senses (see Layno v. Brown, 6 Vet.App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet.App. 398, 405 (1995)). However, the Board assigns greater probative weight to the findings of the skilled clinical professionals and the clinical evidence that show no instability or subluxation, and less to the Veteran. The Board finds the probative value of the Veteran's subjective complaints is diminished by objective determinations indicating that the appellant's knees are stable. Accordingly, in weighing the evidence, a separate evaluation based on subluxation or lateral instability is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, a separate 20 percent evaluation is warranted where there are symptoms of frequent episodes of "locking," pain, and effusion into the joint. Id. In this instance, evidence of mild effusion was noted in May 2007. The Veteran has also reported locking. However, on VA examination in May 2008, it was related that there was no effusion and none has been noted since that time. There have been no clinical findings of locking. In view of such, the Board finds that such symptoms, if any, are no more than intermittent, are not frequent and do not comport with the diagnostic criteria of Diagnostic Code 5258. As such, neither the lay nor the medical evidence supports the assignment of a separate evaluation under Diagnostic Code 5258. Additionally, the Board has considered whether a higher or separate evaluation is warranted for the right and left knees under other applicable diagnostic codes pertaining to the knees. However, careful review of the evidence demonstrated that the Veteran does not have ankylosis (38 C.F.R. § 4.71a, Diagnostic Codes 5256 (2012)), or impairment of the tibia and fibula or genu recurvatum (Diagnostic Codes 5262 or 5263 (2012)) for which a higher rating might be considered. The Board has considered the appellant's report of knee pain and functional loss. See DeLuca v. Brown, 8 Vet.App. 202 (1995). However, neither the lay nor clinical evidence demonstrated painful motion that functionally limits knee motion beyond that contemplated by the current evaluations. See 38 C.F.R. § 4.59. The Board recognizes that the appellant experiences knee pain and reports flare-ups of pain. 38 C.F.R. §§ 4.40, 4.45. The record establishes the presence of intermittent pain and flare-ups triggered by prolonged walking, standing, etc. Furthermore, there have been reports of worsening pain, weakness, stiffness, swelling, giving way and locking, etc., on VA examination. However, the evidence demonstrates virtually full range of motion on VA examinations in 2007, and 2011, with functional loss of 30 degrees of flexion noted in August 2008. Although the appellant reports that he has used a cane, knee brace, and/or crutches, the record contains no lay or medical evidence of significant difficulty with ambulating. The Board accepts that the appellant has functional impairment with flare-ups of bilateral knee pain as indicated in VA clinical records. See DeLuca, supra. As noted above, however, neither the lay nor the medical evidence reflects the functional equivalent of flexion limited to 30 degrees or less. The 10 percent disability evaluations currently assigned contemplate limitation of flexion to 45 degrees. In order to warrant a higher evaluation, the disorder must approximate the functional equivalent of limitation of flexion to 30 degrees due to any factor which is not demonstrated in this case. See DeLuca, supra. In fact, the most probative evidence establishes that the Veteran has substantial remaining bilateral knee function as demonstrated by a range of motion of zero to 110 degrees at worst. Furthermore, on most recent VA examination in November 2011, the examiner stated that the appellant had no functional loss of the knees. As such, the Board finds that the preponderance of the evidence is against the claims for ratings in excess of 10 percent for each service-connected knee disorder, and the claims are denied. 38 U.S.C.A. § 5107(b); Gilbert v Derwinski, 1 Vet.App. 49 (1990). 2. Increased rating for left shoulder arthritis with impingement. Pertinent law and regulations The service connected left shoulder disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5201-5003 (2012). Hyphenated diagnostic codes are used when a rating requires use of an additional rating criteria to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.71a (2012). In this case, Diagnostic Code 5003 signifies an arthritis component of the disability. Diagnostic Code 5201 rates limitation of motion of the arm and provides that a 20 percent rating is warranted when motion is limited to shoulder level or to midway between the side and shoulder level for the minor arm; 20 percent when motion is limited midway between side and shoulder level for the minor arm; and 30 percent when motion is limited to 25 degrees from side for the minor arm. Id. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). For VA purposes, normal range of motion of the shoulder is forward extension and abduction from 0 to 180 degrees with 90 degrees being at shoulder level; internal rotation from 0 to 90 degrees; and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I (2012). Legal Analysis The Veteran has been assigned a disability evaluation of 10 percent for the left shoulder. A 10 percent evaluation is compatible with periarticular pathology productive of painful motion attributable to arthritis. In order to warrant a higher rating, the evidence would have to reflect the functional equivalent of limitation of motion to shoulder level of less. See 38 C.F.R. § 4.7, 4.71a, Diagnostic Code 5201. The record reflects that when examined by VA over the course of the appeal, the Veteran has referred to stiffness, progressive pain, lifting restrictions, and carrying out activities of daily living. The evidence reflects, however, that the appellant retains significant range of motion of the left shoulder and displays shoulder motion between 160-180 degrees. The ability to lift the arm to shoulder level is lifting it to 90 degrees. Therefore, left shoulder flexion far exceeds that required for a 20 percent rating in this regard which is the ability to lift the arm to no more than 90 degrees or to shoulder level. The evidence thus indicates that the appellant has had no more than articular and periarticular pathology during the appeal period. The presence of periarticular pathology, limited motion, and pain on use is contemplated by 38 C.F.R. § 4.59 that is consistent with Diagnostic Codes 5003-5201, and provides for a 10 percent evaluation when limitation of motion is noncompensable but affected by painful motion. As such, the Board finds that the symptoms associated with service-connected left shoulder with impingement have not more nearly comported with the criteria for a 20 percent disability evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5201 and that a 10 percent disability evaluation is appropriate. In determining the degree of functional impairment, the provisions of 38 C.F.R. §§ 4.40 and 4.45 are for consideration. The Board accepts that the appellant has some degree of functional impairment and pain as indicated above. When examined by VA over the course of the appeal period, it has been noted that there is evidence of left shoulder impingment and pain on motion. It has been found that also there is decreased speed of joint motion and tenderness with guarding of movement, but that the appellant does not have deformity, giving way, instability, stiffness, weakness, incoordination, dislocation or subluxation, locking, effusion, inflammation or flare-ups. Range of motion is somewhat reduced and he reports activity restrictions. However, neither the lay nor the clinical evidence reflects the functional equivalent of symptoms required for an evaluation in excess of 10 percent when all of the complaints and findings are considered. Left shoulder flexion and abduction do not impede the ability to lift the arm to shoulder level. The Board thus finds that the left shoulder symptoms displayed throughout the appeal period are contemplated by the 10 percent disability, and a rating in excess of 10 percent is not warranted. The Board must also consider whether any alternative diagnostic code serves as a basis for a higher rating for the service-connected left shoulder disability. However, the evidence discloses no ankylosis of the scapulohumeral joint, malunion or nonunion, or dislocation or subluxation of the clavicle or scapula by clinical report or lay assertion. Therefore, 38 C.F.R. § 4.71a, Diagnostic Codes 5201-5003 do not afford a basis for a higher evaluation for left shoulder disability. The preponderance of the evidence is against the claim of entitlement to a rating in excess of 10 percent for left shoulder disability and it is denied. 38 U.S.C.A. § 5107(b); Gilbert v Derwinski, 1 Vet.App. 49 (1990). 3. Increased rating for bilateral sensorineural hearing loss. Service connection for bilateral sensorineural hearing loss was granted by rating action dated in October 2007. A noncompensable disability evaluation was assigned, effective from April 16, 2007. The Veteran filed a claim for an increased rating in July 2008. Pertinent Law and Regulations Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 cycles per second, with 11 auditory acuity levels designated from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. § 4.85 (2012). In addition to the hearing loss criteria above, when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) are all 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa [C.F.R. § 4.85], whichever results in the higher numeral. 38 C.F.R. § 4.86(a) (2012). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b) (2012). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85 (2012). Factual Background The Veteran was afforded a VA audiology examination in August 2008. An audiogram was performed that disclosed the following pure tone thresholds in both ears: HERTZ 1000 2000 3000 4000 RIGHT 50 50 60 60 LEFT 80 70 70 60 Speech discrimination scores were 100 percent in each ear. Assessments of mild to severe sensorineural hearing loss were rendered. The examiner added that the results were not reliable and that the Veteran's responses appeared to be exaggerated, given the inconsistency between the speech and pure tone thresholds and his excellent speech discrimination. The Veteran was scheduled for audiology examination for VA compensation and pension purposes in October 2009. The examiner noted that after several attempts and re-instruction, it was not possible to obtain reliable voluntary responses for pure tone audiometry from the Veteran. It was noted that he would not respond even with his 'better ear' - the right - at any of the frequencies. The examiner stated that seven audiogram tests were reviewed and that all of them presented different results, including on the current date. It was recommended that an ABR [auditory brainstem response] test be performed to corroborate results and to establish the Veteran's hearing sensitivity. The Veteran reported for a VA audiology examination in April 2011. The examiner stated that the Veteran could not be evaluated after clinical and diagnostic tests were performed. In the diagnosis section, the examiner stated he was not interested in an audiology evaluation. It was noted that he came to the clinic very agitated and questioned why he was being scheduled so many times. It was reported that he left the clinic stating that he did not want to return, as he was not interested in any audiological evaluation anymore. Legal Analysis The Veteran asserts that he is entitled to a higher disability rating for bilateral hearing loss disability. The Board finds, however, that the evidentiary record does not support his contentions. In this regard, the evidence notes that the appellant provided unreliable responses on VA audiology evaluations in 2008, 2009 and 2011. In spite of such, the Board observes that although reported to be unreliable and exaggerated, the only audiology examination that contains any comprehensive and usable findings for rating purposes was conducted in August 2008. The audiometric values obtained in August 2008 are consistent with an average pure tone threshold of 55 decibels in the right ear and 70 decibels in the left ear. These clinical findings correlate to auditory acuity numeric designations of Level I hearing impairment in the right ear and Level II hearing in the left ear. See 38 C.F.R. § 4.85, Tables VII, which comport with no more than a zero percent disability rating. Additionally, for the right ear, the pure tone thresholds at each of the relevant audiometric frequencies in 2008 were not all 55 decibels or more, or 30 decibels or less at 1000 Hertz and 70 decibels or more at the 2000-Hertz frequencies. Therefore, the appellant does not meet the criteria for a higher disability evaluation under 38 C.F.R. § 4.86(a) or § 4.86(b) for exceptional hearing impairment in the right ear. When reviewing the results obtained for the left ear under 38 C.F.R. § 4.86 for exceptional hearing impairment, the evidence reflects that Veteran had puretone thresholds of 55 or more at each specified frequency. Given the threshold average of 70 decibels as reported above, he is entitled to a Roman numeral designation of Level VI hearing. See 38 C.F.R. § 4.85, Table VIA. However, when auditory acuity numeric designations of Level I hearing in the right ear and Level VI hearing in the left ear are further correlated under 38 C.F.R. § 4.85, Table VII, these comport with no more than a zero percent disability rating. Additionally, the pure tone thresholds at each of the relevant audiometric frequencies in 2008 were not 30 decibels or less at 1000 Hertz and 70 decibels or more at the 2000-Hertz frequencies for the left ear. Therefore, the appellant does not meet the criteria for a higher disability evaluation under 38 C.F.R. § 4.86(b) for exceptional hearing impairment in the left ear. The Board has carefully considered the Veteran's contentions attesting to more severe defective hearing. However, the evidentiary record, to include current lay and clinical evidence, does not support a basis to find that hearing loss disability approximates the criteria for a higher rating at this time. The Board points out that hearing impairment by VA standards is calibrated on controlled speech discrimination tests, together with the average hearing threshold levels, as measured by pure tone audiometry tests. The assignment of a disability rating for hearing loss is derived by a mechanical application of the rating schedule to the specific numeric designations assigned after audiology testing is completed and is not amenable to subjective interpretation. See Lendenmann v. Principi, 3 Vet. App. 345. Under the rating schedule, the severity of the Veteran's hearing loss as demonstrated on examination is no more than zero percent disabling. Additionally, the Board would also point out that as noted above, multiple attempts to obtain accurate hearing data have been unsuccessful. It appears that the Veteran has declined to report for additional VA audiology evaluation to remedy the problem. In order for VA to process claims, individuals applying for benefits have a responsibility to cooperate with the agency in the gathering of evidence necessary to establish continuing entitlement to benefits. See Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). There remains no known avenue for securing additional evidence in support of his claim in this regard. Therefore, the claim of entitlement to a compensable rating for bilateral hearing loss disability is denied on the evidence of record. Summary The appellant is competent to report that his disabilities are worse than currently rated. See Layno supra. However, whether the disabilities have worsened sufficiently to meet the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on both the appellant's complaints coupled with the medical evidence. Here, although the appellant believes he meets the criteria for higher disability ratings, his complaints and the medical findings do not meet the schedular requirements for the increased evaluations, as explained and discussed above. The Board thus concludes that the medical evidence elicited by the skilled clinical professionals is more probative of the degree of disability. The Board has also considered whether higher ratings for service-connected orthopedic disabilities and bilateral hearing loss disability are warranted on an extraschedular basis. The potential application of 38 C.F.R. § 3.321(b)(1) (2012) has been considered. However, the evidence does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." The Board finds that the ratings assigned for each service-connected disorder discussed above are precisely as contemplated by the rating criteria for the disabilities in question. See Thun v. Peake, 22 Vet. App. 111 (2008). Moreover, the Board finds that the evidence does not show that symptoms associated with service-connected orthopedic disorders and bilateral hearing loss have resulted in marked interference with employment by VA standards, nor does it appear that the Veteran has been hospitalized for a service-connected disability. Therefore, based on all the foregoing, the Board concludes that the Veteran has not demonstrated such a degree of disability to render impractical the application of the regular rating schedular standards. In the absence of such factors, the criteria for referral for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable in this instance. The preponderance of the evidence is against the claims and they are denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49, 54-56 (1990). ORDER An increased rating for left knee effusion is denied. An increased rating for right knee chondromalacia is denied. An increased rating for left shoulder degenerative joint disease is denied. An increased rating for bilateral sensorineural hearing loss is denied. REMAND The Veteran had service in Iraq during the Iraq War. He received citations that included the Global War on Terrorism Service Medal, the Iraq Campaign Medal and the Armed Forces Reserve Medal with M Device The Veteran asserts that he now has PTSD of service onset for which service connection should be granted. VA outpatient records dating from 2007 reflect that in July of that year, the Veteran underwent psychological evaluation for veteran outreach purposes and readjustment counseling. He reported that he had service in Operation Iraqi Freedom and that he actively engaged enemy troops. In June 2007,it was noted that he did not have a major depressive disorder. The depression and PTSD screens were positive. A PTSD screen in April 2009 was negative. A psychiatric progress note dated in February 2012 showed that the appellant was reevaluated and indicated that he had been doing better until the previous week when he felt somewhat sad and down due to the death of his grandmother and cousin on the same day. He said he was coping adequately with the situation and reported good compliance with Mirtazapine and no side effects. The Veteran denied any self-harm ideas or ideas to harm others. He denied perceptual disturbances. An assessment of depressive disorder, not otherwise specified, was added to his problem list. In a statement dated in September 2008, the appellant indicated that he desired to appeal service connection for PTSD and depression conditions. Review of the record discloses that the record has only been developed and adjudicated for PTSD. The United States Court of Appeals for Veterans Claims (Court) has held that a claim for benefits for one psychiatric disability also encompasses benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the original claim that was filed. See Clemons v. Shinseki, 22 Vet.App. 1 (2009). As indicated above, the record refers to another psychiatric diagnosis that must be addressed pursuant to Clemons. Therefore, the claim on appeal has been modified to encompass service connection any other acquired psychiatric disorder. The record reflects that the appellant has not had a psychiatric examination for VA compensation purposes. Additionally, the Veteran claims service connection for bilateral foot disability, claimed as plantar fasciitis fibromatosis. His extensive service treatment and reserves records do not reflect any complaints, symptoms or findings regarding the feet. A Functional Capacity Certificate dated in February 2007 indicated that he did not have any condition that prevented him from being on his feet continuously for four hours, carrying or lifting, walking 12 miles with field gear or in combat boots, walking six miles with field gear and a 40-pound rucksack or running or jogging. On VA general medical examination in May 2007, no reference to foot complaints or any symptomatic findings is recorded. The Board observes, however, that less than one year after the appellant's discharge from active duty, VA podiatry clinic records dated in March 2008 show that he sought consultation for a foot problem assessed as plantar fasciitis. VA clinic notes dated in May 2009 reflect a diagnosis of plantar fascial fibromatosis on the problem list. In a statement dated in September 2009, the Veteran related that this condition was directly related to the heavy weights he had to carry and the footwear he was issued. The record reflects that the appellant has also not had a VA compensation and pension examination in this regard. In these respects, the Board notes that the Veteran has psychiatric and foot diagnoses that he attributes to service but that he has never been afforded a VA examination as to these matters. This must be accomplished. The Court held in McLendon v. Nicholson, 20 Vet.App. 79, 83 (2006) that under the VCAA, VA is obligated to provide an examination where the record contains competent evidence that the claimant has a current disability, the record indicates that a disability or signs or symptoms of disability might be associated with active service, and the record does not contain sufficient information to make a decision on a claim. 38 U.S.C.A. § 5103(A) (West 2002). The threshold for getting an examination under the VCAA is low. See McLendon. The Veteran has been service connected for a lumbar strain/myositis. Recent pathology has also noted some disc degeneration. It is not clear whether this pathology is part and parcel of the service connected disorder, or whether there are separate identifiable symptoms due to service connected and non-service connected pathology. If separate pathology can be determined, that should be set out, and if such separate pathology cannot be ascertained, all pathology should be evaluated. Finally, the issue of TDIU that has been raised is intertwined with the issues being remanded, so that additional consideration of that issue is deferred pending the development requested herein. Accordingly, the case is REMANDED for the following actions: 1. Make a determination as to the exact nature and characterization of the Veteran's service connected low back disorder. Specifically the matter should be reviewed to ascertain whether the original grant of service connection included any disc pathology. The reasoning set forth should be set out. If additional development is needed to enter a decision, such development should be undertaken. 2. Schedule the Veteran for VA podiatry, spinal, and psychiatric examinations. The claims folder must be made available to the examiners and all tests and studies deemed necessary should be performed. The clinical findings must be reported in detail as well as specific diagnoses. Following review of the record, the examiners must provide opinions as to whether it is at least as likely as not any current psychiactric and/or foot disorder is related to active service. Detailed and complete rationale should accompany the opinions provided. As to the spine, the examiner should be asked to fully evaluate all pathology, to include any considered service connected or non-service connected. If possible to separate symptoms the medical rationale should be set out. If not possible, that too should be set out with applicable rationale. All functional impairment should be set out and all clinical findings should be reported in detail. 3. After taking any further development deemed appropriate, re-adjudicate the remaining issues on appeal. If a benefits sought are not granted, provide the appellant and his representative a supplemental statement of the case and afford an opportunity to respond before the case is returned to the Board for appellate disposition. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans Appeals Department of Veterans Affairs