Citation Nr: 1312007 Decision Date: 04/11/13 Archive Date: 04/19/13 DOCKET NO. 10-21 633 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial increased rating in excess of 20 percent for left shoulder (minor) injury residuals. 2. Entitlement to special monthly compensation (SMC) based on loss of use of the left hand. 3. Entitlement to a total disability rating for individual unemployability (TDIU). REPRESENTATION Appellant represented by: Wade R. Bosely, Attorney ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran had active duty service from March 1969 to March 1971. These issues come before the Board of Veterans' Appeals (Board) from a March 2008 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In that decision, the RO granted service connection for left shoulder injury residuals and assigned a 20 percent evaluation (effective February 1990). In March 2009, the RO also denied entitlement to a TDIU and continued the current rating. In a July 2012 statement, the Veteran's representative raised the issue of SMC under 38 U.S.C.A. § 1114(k) (West 2002); 38 C.F.R. § 3.350(a)(2) (2012). These issues are before the Board as part of the appeal of the initial rating. See Buie v. Shinseki, 24 Vet. App. 242 (2010) (Court adjudicated claim for SMC as part of initial rating issue); Rice v. Shinseki, 22 Vet. App. 447 (2008) (holding TDIU is an element of all initial ratings). The Veteran originally requested a Board hearing, but then withdrew the request in June 2012. The issues of entitlement to SMC based on loss of use of the left hand and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Since the effective date of service connection, the left shoulder injury residuals have been manifested by ankylosis of the scapulohumeral articulation without fibrous union or nonunion of the humerus and limitation of motion to 25 degrees from the side. CONCLUSIONS OF LAW The criteria for an initial rating of 40 percent for left shoulder injury residuals have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a (& Plate I), DCs 5003, 5200-5203 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA As provided for by the Veterans Claims Assistance Act of 2000 (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 and 3.326(a) (2012). This appeal arises from disagreement with the initial rating following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No further notice is needed under VCAA. VA has a duty under the VCAA to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Social Security Administration (SSA) records are in the file. Moreover, the statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Initial rating In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (2012). Also, for initials, the entire period since the effective date of service connection is considered for the possibility of staged ratings. Consideration will be given to the possibility of separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet App 119 (1999). Disability evaluations are determined by the application of a schedule of ratings which is based, as far as practicable, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (2012). 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. The Court has instructed that in applying these regulations 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, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive 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. 38 C.F.R. § 4.59. A rating in excess of 10 percent based on pain; however, requires a showing that the pain results in additional functional limitation. Mitchell v. Shinseki, 25 Vet App 32 (2011). The normal range of motion of shoulder for flexion and abduction is from 0 degrees at the side to 180 degrees over head. 38 C.F.R. § 4.71, Plate I (2012). Shoulder level is at 90 degrees, and exactly midway between the side and shoulder level is at approximately 45 degrees. Ankylosis of the scapulohumeral articulation is considered under DC 5200. A note states that ankylosis means the scapula and humerus move as one piece. Ankylosis is unfavorable where abduction is limited to 25°degrees from the side, and warrants a 40 percent rating for the minor arm. When ankylosis is intermediate between favorable and unfavorable a 30 percent rating is assigned. When it is favorable with abduction to 60 degrees and a veteran can reach his mouth and head a 20 percent rating is assigned. 38 C.F.R. § 4.71a, DC 5200. Under DC 5201, a 20 percent rating is assigned for limitation of the minor arm to shoulder level. If there is limitation of the shoulder midway between side and shoulder level a 20 percent rating is also assigned. If the limitation is 25 degrees from the side, a 30 percent rating is assigned. Id. In determining whether a veteran has limitation of motion to shoulder level, it is necessary to consider reports of forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003); see also 38 C.F.R. § 4.71, Plate I. Other impairment of the humerus is rated under DC 5202. A fibrous union results in a 40 percent rating. A nonunion or false flail joint of the humerus results in a 50 percent rating. And a loss of head of the humerus (flail shoulder) results in a 70 percent rating. 38 C.F.R. § 4.71, DC 5202. Clavicle or scapula impairment is contemplated under DC 5203, however, this would not provide for an increased rating since the Veteran is already in receipt of a 20 percent rating. See 38 C.F.R. § 4.71a. Separate ratings would not be warranted, because all of his shoulder impairment is contemplated under the ratings for limitation of motion and ankylosis of the scapulohumeral articulation. Traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, DCs 5003-5010 (Degenerative arthritis is covered under DC 5003). Note (1) states that the 20 and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. The Veteran has been in receipt of at least a 20 percent rating at all times since the effective date of service connection and his disability is rated on the basis of limitation of motion; hence, there is no basis for awarding a higher rating under DCs 5003-5010. Prior to April 22, 2009 Service treatment records show that the Veteran sustained a fracture of the left humerus in an auto accident. On examination for service separation in January 1971, there was marked atrophy of the left deltoid. The Veteran filed his original claim in January 1990. From December 1991 to January 1992, he was admitted at a VAMC for left shoulder pain and alcoholic blackouts. He fell twice, hurting his shoulder and claimed he was been unable to use his left hand. There was a past fracture of the humerus transfixed with a "staple" and three metallic screws fixing the head. The screws protruded beyond the head surrounded by radiolucency and destruction of the articular surface of the humerus. At that time, findings were highly suggestive of inflammatory changes such as osteomyelitis but negative for a recent fracture. He was to be followed at another VAMC. A January 1992 X-ray showed a status post open reduction, internal fixation (ORIF) of the left humerus. Osteomyelitis was apparently not confirmed, as the only pertinent discharge diagnosis was status post pinning left shoulder. In February 1992, the Veteran was readmitted to VA. He complained of shoulder pain and asked for pain medication. He said his left shoulder was "weak-unable to raise arm," however, the note indicates he was possibly under the influence of intoxicating substances. The assessment was left shoulder, post-traumatic syndrome. Another VAMC record showed that he said pain in the left shoulder was present since December 1991. The range of motion was reportedly decreased, but was not further described. The clinician commented: "Although he complained of disabling pain, he was able to move around." The shoulder screws were to be taken out after other orthopedic problems subsided. He still complained of shoulder pain at discharge, but was otherwise asymptomatic and moving around nicely. An attached physical examination and history showed pain and limited abduction of the left shoulder, but the extent of the limitation was not reported. In March, an orthopedic record showed the Veteran was in severe left shoulder pain. The note stated he should not work until the etiology of the pain was determined. An orthopedic note from the same month pain was getting worse and radiating. It was relieved by narcotics and rest. There was no weakness, numbness or tingling, but deltoid atrophy was noted. The range of motion was 85 degrees of forward flexion and 70 degrees of abduction; there was no limitation of motion to 25 degrees from the side. See 38 C.F.R. § 4.71(a), DC 5201. Another orthopedic record noted tomography showed that the fusion appeared intact. A note in the chart showed the Veteran had pain relief with a placebo injection and this did not correlate with what he was describing regarding pain. In April 1992, the Veteran stated he felt that his left arm would never be able to lift any amount of weight again and he would only be able to use his left hand to hold items like a fork and spoon. In July 1992, the Veteran entered hospital due to severe burns of hands and legs (he fell asleep on a heater while inebriated). Specifically, a VA record showed the Veteran was being treated for acute burn residuals of left forearm. He had severe limitation of motion of left shoulder. In November, a VA treatment record referred to his "crippled left arm and shoulder" but an X-ray still showed the ORIF with no fracture; changes in alignment in the hardware were to be ruled out. In December 1993, the Veteran went to a private doctor complaining of persistent left shoulder pain. The doctor noted the Veteran had been in multiple times asking for hardware removal. He smelled of alcohol. There were palpable screw heads but skin was non-tender over these. The pain was not in the area of the hardware. The X-ray showed a solid arthrodesis with no lucency around the screws. The assessment was no surgical indication with a solid glenohumeral fusion. In February 1994, an X-ray still showed the Veteran was status post ORIF with a "near anatomic result." In a September 1994 statement, the Veteran asserted he had lost almost total use of his arm. He had been to the VAMC orthopedic clinic, but he claimed he was a diabetic, so surgery was not an option. He said the hardware was starting to come through his skin. In November 1995, an X-ray showed the Veteran was status post ORIF of a left humeral fracture but there was a fusion of the left glenohumeral joint space. In May 1996, an X-ray and VA records showed removal of one screw through humeral head and scapula. Other hardware was unchanged. The next X-ray was in January 2000; it showed the fixated old trauma involving proximal left humerus; secondary degenerative changes in the glenohumeral and AC joints; and no evidence for acute fracture or dislocation. Some restriction of the left shoulder was noted in October 2001 in a VA primary care record. In an April 2003 X-ray, probable post-traumatic degenerative arthritis of the glenohumeral joint was noted in addition to the postoperative changes of ORIF of the old left humeral neck fracture. In May 2003, the Board held a hearing regarding clear and unmistakable error on a prior RO decision. The Veteran stated that he had total loss of use of his arm but he could move it at the hearing. (Transcript, p 17.) In August 2003 a VA orthopedic record showed the Veteran complained of chronic shoulder pain. The examination showed minimal glenohumeral joint motion and marked deltoid atrophy. An X-ray showed the glenohumeral joint was stable. The assessment was shoulder pain that was likely scapulothoracic in origin. No intervention was indicated. In May 2008, a VA emergency room (ER) record showed the Veteran fell out of his truck; an ER physician at another hospital did an X-ray and saw no fracture. He had further bruising and had increased pain; a second read of an X-ray saw a small acute fracture on top of a chronic bony abnormality. The hardware was in place. The Veteran came to VA for an orthopedic evaluation. In May 2008, a computed tomography (CT) scan showed a comminuted fracture deformity of the left humeral head and proximal shaft with metallic plate and pins. Cystic and sclerotic changes were noted with a non-displaced fracture of the lateral border of the scapula inferior to the glenoid cavity. In September 2008 X-ray noted the Veteran was unable to raise his arm and showed a status post fusion of the "left glenohumeral." The other showed widening lucent cortical defect of the humeral shaft concerning for delayed healing secondary to infection versus nonunion. A September CT scan showed portions of the humeral head appeared resolved. "There is evidence of comminuted fracture involving the proximal left humerus with evidence of nonunion." However, clinical correlation was advised. An October 2008 VA orthopedic record showed the Veteran was to have surgery, but was not cleared. In February 2009, the Veteran had a VA examination. It was determined that the Veteran's right hand was dominant by the way he writes. He claimed he "re-fractured" his left shoulder May 2008 when stepping off of his RV step; he had fracture with dislocation after a fall in May 2008 and wanted to do a surgical repair but couldn't due to his respiratory status. The Veteran did not have pain, heat, redness, or giving way. But he did have weakness, stiffness, swelling, instability, "locking", fatigability, or lack of endurance. He was being treated with medications that provided no response and he worried about becoming addicted to medication. He had flare-ups if he tried to do any activity with his left hand. The Veteran claimed the severity made him cry. The flare ups happened every time he tried to use the arm and lasted for hours. Regarding impairment on daily activities, he had to have help with all activities of daily living and he had problems concentrating due to the pain. He did not use ambulatory aids. He did not have recurrent subluxation, inflammatory arthritis, or prosthesis. There was no ankylosis of the shoulder joints. Initially, range of motion (ROM) of the left shoulder was as follows (pain was present throughout the entire range of motion). ROM/Normal ROM Forward flexion 51/180 Abduction 39/180 On the initial range of motion, he had pain, fatigue, weakness, and lack of endurance but no incoordination. There was no objective evidence of edema, effusion, instability, redness, or heat. He did have painful motion, weakness, tenderness abnormal movement and guarding of movement. Final range of motion was as follows (pain was present throughout). ROM/Normal ROM Forward flexion 45/180 Abduction 47/180 Again there was pain, fatigue, weakness, and lack of endurance but no incoordination. The extent of any additional limitation of motion due to these factors was not specified. X-rays were abnormal; it was possible one of the screws extended through the acromion into the humeral head. It was also unclear whether or not there was bone fusion across the glenohumeral joint. Both findings could greatly reduce the range of motion of the shoulder. Arthritis/degenerative changes were present as well as evidence of old healed fracture; these findings were described as moderate. The diagnosis was post-traumatic arthritis of the shoulder. The range of motion of the left shoulder was greatly limited his daily activities and he was unable to do his previous employment as a truck driver. Residuals included reduced range of motion, pain, fatigue and arthritis. On April 22, 2009, a VA orthopedic doctor related the Veteran's history of left arm pain. After a CT, he was treated with a cuff and collar and then a fracture brace. He had a plate and screws from an old fracture. He had pain from the fall and before the fall his discomfort from the fusion was little to none. He had been managing pain for other issues with narcotics. He had previously been diagnosed as having a "non-union" and was scheduled to have surgery in October 2008 but the surgery was cancelled secondary to chronic obstructive pulmonary disease exacerbation and pneumonia. On the current evaluation, the left shoulder had apparent muscle wasting and generalized tenderness to palpation. A two plus radial pulse palpable. An irregular finding was noted over the dorsal thenar web space which was secondary to a past skin graft, according to the Veteran. "Digits warm and well-perfused." Motor strength was intact over the anterior interosseus nerve and posterior interosseus nerve. Active and passive range of motion was to 30 degrees of elevation, and 15 degrees of abduction. There was no obvious bony instability. The X-ray showed no evidence of acute fracture and a solid arthrodesis with hardware in place. It was difficult to ascertain exact status of a bony union but there was "at least moderate bony healing apparent." There was no obvious motion noted at the fracture site. As a result the source of the pain was somewhat unclear because there was no obvious motion at his fracture site, making a non-union less likely. He was referred to the pain clinic. In April 2009, the VA orthopedic doctor note essentially stated the Veteran could not work because he had no useful function in his left arm and stated: "His impairment is 100% of the left upper extremity." A December 2009 VA primary care note showed the Veteran continued with chronic left arm pain with a nonunion fracture of the left humerus. In May 2010, he stated on his appeal form that it was painful to move his left arm. In February 2012, a VA examination report noted a closed fracture of left arm and ankylosis of the left shoulder joint (the report initially says right shoulder, but then corrected to the left shoulder). The Veteran complained of pain and marked range of motion. The Veteran had flare ups of the shoulder and arm. He slept in a recliner because his shoulder was painful. Range of motion was as follows (pain was present throughout). ROM/Normal ROM Forward flexion 20/180 Abduction 5/180 He was able to do repetitive testing. Range of motion was as follows (pain was present throughout). ROM/Normal ROM Forward flexion 10/180 Abduction 0/180 Additional functional loss included less movement than normal, weakened movement, excess fatiguability, incoordination and pain on movement. He had local tenderness, pain and guarding. Muscle strength testing showed palpable or visible muscle contraction but no joint movement (1/5). He had ankylosis of the shoulder joint and abduction was limited to 25 degrees from the side. Rotator cuff condition tests were positive. He had dislocation and subluxation of the glenohumeral joint with guarding of all movements. He had no acromioclavicular joint problems or any other impairment of the clavicle or scapula (no nonunion, malunion, dislocation or separation). The examiner stated that due to the shoulder condition there was functional impairment of an extremity such that no effective function remains other than that which would be equally well served by prosthesis; the examiner compared the left shoulder to the nonserivce-connected right shoulder (as explained further below, the SMC issue is being remanded). Imaging studies showed traumatic arthritis. The disability impacted the Veteran's ability to work. The examiner stated the left arm was significantly ankylosed. He was unable to reach behind himself, hold much of anything, cross his left arm, or reach his mouth with his left arm. The examiner referenced the 2009 note from his doctor stating he had no functional use of the left arm and concurred with this conclusion. In a May 2012 VA addendum opinion the examiner noted a March 2008 RO rating decision, which the examiner interpreted as showing abduction to 60 degrees. The examiner noted the Veteran re-injured his left shoulder after falling out of his truck in May 2008. The findings of the February 2009 VA examination were noted. The examiner stated the record showed little left shoulder pain prior to the 2008 fall and that it was reasonable to believe that without the fall, the disability would have remained static. So it was "at least as likely as not" that the left shoulder disability was the result of the intercurrent disability from May 2008. Finally, an August 2012 aid and attendance form completed by a VA physician noted the Veteran had a limited range of motion of the upper extremities due to shoulder problems. He was unable to dress himself-he needed assistance. He was able to feed himself a soft diet. A November 2012 VA record noted shoulder and other orthopedic pains; the Veteran was on medication. Analysis The most recent examination contains findings that would support a 40 percent rating. The examiner found the Veteran to have ankylosis of the scapulohumeral articulation with left arm motion to 25 degrees from his side. Mariano v. Principi, 17 Vet. App. at 314-16. Although the May 2012 addendum attempts to associate current findings with an intercurrent disability, the opinion is based on facts that are not supported by the record. The examiner stated that the Veteran had little shoulder pain prior to the intercurrent injury, but the record documents significant left shoulder pain dating back to the early 1990's. The examiner also misinterpreted the RO's rating decision as reporting the Veteran's actual range of motion; whereas the decision was merely stating the rating criteria relied upon by the RO in assigning the 20 percent rating. There is no other opinion as to whether any portion of the current disability can be attributed to the intercurrent injury rather than the current disability. The evidence is in at least equipoise. Resolving reasonable doubt in the Veteran's favor, the Board will consider all of the current shoulder disability as part of the service connected condition. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Accordingly, a 40 percent rating is warranted for the service connected left shoulder disability. 38 C.F.R. § 4.71a, Diagnostic Code 5200. This is the maximum rating under that diagnostic code. A remaining question is whether this rating should be staged. Earlier reports had shown greater ranges of motion that would not meet the criteria for a 40 percent rating under Diagnostic Code 5200. When the Veteran was reported to have 85 degrees of motion; however, it was not reported whether there was any additional limitation of motion due to functional factors. Cf. 38 C.F.R. §§ 4.40, 4.45. At the February 2009 examination the examiner noted that the left shoulder disability was manifested by flare-ups, pain, weakness, fatigue, and lack of endurance; but it was not reported whether and to what degree there was additional limitation of motion attributable to these functional factors. Given the absence of these necessary findings, it is not possible to rely on the reported ranges of motion to say that the Veteran did not meet the criteria for the 40 percent rating. The February 2009 examiner commented that there was no ankylosis of the shoulder, but an accompanying X-ray examination report included findings that there had been a fusion and that the humeral head and acromion were closely approximated. It appears that there was fusion of the humerus and clavicle throughout the period since the effective date of service connection. The evidence supports a finding that the criteria for a 40 percent rating have been met since the effective date of service connection. The record shows that the Veteran has been suspected on two occasions of having osteomyelitis. The suspicion; however, was never born out, inasmuch as subsequent treatment did not yield findings or diagnosis of osteomyelitis. The evidence is therefore, against a higher or separate initial rating on the basis of osteomyelitis. 38 C.F.R. § 4.71a, Diagnostic Code 5000 (2012). While the Veteran's representative asserts that a separate rating should be assigned for arthritis, the Veteran is currently rated under the diagnostic code pertaining to limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DC 5003, Note (1). This is precisely what is directed under DCs 5003, 5010. It is clear that the 10 and 20 percent ratings specified in DC 5003 are provided when a claimant does not meet the criteria for a compensable rating for limitation of motion under the appropriate code. The Veteran has met the criteria for a compensable rating under the appropriate diagnostic code for limitation of motion throughout the appeal period. The Board has reviewed all potentially applicable diagnostic codes in evaluating the Veteran's left shoulder residuals. As stated, it appears that for a period doctors suspected nonunion, but the April 22, 2009 orthopedic record stated that a nonunion was less likely and it was not found at the later February 2012 VA examination. The shoulder does not demonstrate fibrous union, nonunion or loss of head of the humerus to warrant higher ratings under the other pertinent diagnostic code. 38 C.F.R. § 4.71a, DCs 5202 (2012). The Veteran's representative also stated in July 2012 that the Veteran's left arm should be treated as if the arm was amputated and a 90 percent rating from April 22, 2009 is warranted under 38 C.F.R. § 4.71(a), DC 5120. This code covers amputation, disarticulation (the separation of a bone at its joint). Also noted is the statement in the February 2012 VA examination report that the left arm is "nonfunctional." The numerous diagnostic studies and treatment records contain no findings that would indicate there has been disarticulation. The record suggests that the joint is actually fused, rather than separated. Loss of use for purposes of SMC is addressed in the remand below. As a result, the amputation rating is not appropriate at this time. As discussed above, the Board has considered functional loss and pain on use as required by DeLuca v. Brown, 8 Vet. App. 202. However, these provisions are not for consideration where, as in this case, the veteran is in receipt of the highest rating based on limitation of motion. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). The Board has considered whether any further staged ratings are appropriate. Fenderson. In the present case, the Board finds that no staged ratings are warranted. Extraschedular For exceptional cases, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be awarded. 38 C.F.R. § 3.321 (b)(1) (2012). In Thun v. Peake, 22 Vet. App. 111 (2012), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. The schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology for the period on appeal. The Veteran's impairment is based ankylosis, and limited motion with associated functional factors. This symptomatology is specifically contemplated in the rating criteria. The assigned schedular evaluation is adequate and further consideration of extraschedular rating is not warranted. Thun, 22 Vet. App. at 115. Under these circumstances, a 40 percent evaluation for the left (minor) shoulder disability, but no more is awarded. ORDER An initial rating of 40 percent for left shoulder injury residuals is granted, effective from the date of service connection. REMAND SMC is payable in addition to the basic rate of compensation otherwise payable on the basis of degree of disability. See 38 U.S.C.A. § 1114 (West 2002 & West Supp. 2012); 38 C.F.R. § 3.350 (2012). SMC is payable at the (k) rate for, among other things, anatomical loss or loss of use of a hand as the result of service-connected disability. 38 U.S.C.A. § 1114(k). Loss of use of a hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2); 4.63 (2012). A VA physician has opined that the Veteran has loss of use of the left arm related to his shoulder disability, but further detail is needed to adjudicate the SMC issue. Hence an examination is required. The Veteran does not currently meet the percentage requirements for a TDIU. 38 C.F.R. § 4.16(a) (2012). VA policy is; however, to grant TDIU in all cases where a veteran's service connected disabilities preclude employment. Where there is evidence of unemployability and the veteran does not meet the percentage requirements, the claim should be submitted to the Director of Compensation and Pension Service for consideration under 38 C.F.R. § 4.16(b). The Board cannot award a TDIU in the first instance; instead it is required to remand the claim so that it can be submitted to the Director of Compensation for extraschedular consideration. See Bowling v. Principi, 15 Vet. App. 1, 10 (2001). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine whether there is loss of use of the left hand or arm, and whether this is due to the left shoulder disability. The claims folder and a copy of this remand must be made available to the examiner in conjunction with the examination. The examiner should state whether there is loss of use of the left hand due to the left shoulder disability. Loss of use exists where the Veteran would be better off with amputation at the site of election with prostheses in place. The examiner should reference: * June 1992 VA records showing treatment for burns of the left extremity; * February 2012 VA examination showing reduced grip strength; * April 22, 2009 VA record showing hand impairment due to past skin graft per the Veteran. * The April 22, 2009 opinion of a VA physician. The examiner should provide reasons for the opinion that includes consideration of the Veteran's reports of symptoms and limitations. 2. Refer the Veteran's claim for entitlement to a TDIU to the Director of Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 4.16(b). 3. If any benefit sought on appeal remains denied, issue a supplemental statement of the case; then return the case to the Board, if otherwise in order. 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 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). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs