Citation Nr: 1312380 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 08-03 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to a rating in excess of 10 percent for paralysis of the left long thoracic nerve. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. N. Moats, Counsel INTRODUCTION The Veteran has active service from October 1973 to December 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied the Veteran's claim of entitlement to a rating in excess of 10 percent for paralysis of the left long thoracic nerve. The RO in Wichita, Kansas, currently maintains jurisdiction of this case. Subsequent to a November 2009 remand directing the RO to schedule a Board hearing, the Veteran and his spouse testified before the undersigned Veterans Law Judge seated at the RO in Wichita in April 2010. A transcript of the hearing has been associated with the claims file. In October 2010, the Board remanded the case for further development. The case has now been returned to the Board for appellate review. In statements of record, the Veteran has consistently claimed symptoms of numbness and weakness of his left lower extremity. The Board recognizes that the issue of disability manifested by left foot numbness was denied in a September 2003 rating decision. Nevertheless, it is unclear whether the Veteran is raising a claim to reopen. He is advised that, if he wishes to file a claim, to so inform the RO. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. In this regard, while Virtual VA contains records of VA hospitalizations that are not in the paper file, such address admissions to treat substance dependence and psychiatric illnesses rather than the Veteran's paralysis of the left long thoracic nerve. FINDING OF FACT For the entire appeal period, the Veteran's service-connected paralysis of the left long thoracic nerve is manifested by subjective complaints of numbness and weakness, but does not more nearly approximate severe incomplete paralysis of the long thoracic nerve; and is not productive of the inability to raise arm above shoulder level, or winged scapula deformity. CONCLUSION OF LAW For the entire appeal period, the criteria for a rating in excess of 10 percent for paralysis of the left long thoracic nerve have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8519 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was sent a letter in December 2005 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter provided information as to what evidence was required to substantiate his increased rating claim and of the division of responsibilities between VA and a claimant in developing an appeal. The Board observes that the Veteran was not provided notice of the evidence and information necessary to establish an effective date in accordance with Dingess/Hartman, supra. However, the Board finds no prejudice in proceeding with a decision regarding the Veteran's increased rating claim. In this regard, as the Board concludes herein that the preponderance of the evidence is against the Veteran's claim, any question as to the appropriate effective date to be assigned is rendered moot. Therefore, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him 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 Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's post-service reports of VA treatment and VA examinations. A review of Virtual VA claims processing system does not reveal any additional records pertinent to the Veteran's claim. Moreover, the Veteran's statements and Board hearing testimony in support of the claims are of record. The Board has carefully reviewed such statements and testimony and concludes 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. Additionally, the Veteran was afforded VA examinations in May 2005, January 2006, February 2007, November 2010 and May 2011 with addendums in July 2011 and January 2012 to evaluate the severity of his service-connected paralysis of the long thoracic nerve. The Board finds that the VA examinations with addendums are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). The Board observes that, in connection with the May 2011 VA examination, the Veteran was scheduled for an EMG test, to which he failed to report. The Veteran has not provided any reason for this failure. When a Veteran fails without good cause to report for a necessary VA examination requested by VA in conjunction with a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655(b). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). In this regard, while VA has a duty to assist the Veteran in the development of his claim, the Veteran has a duty to cooperate with VA. See Wood v. Derwinski, 1 Vet. App. 190 (1991). However, as the Veteran has previously reported to VA examinations in connection with his claim for increase, the Board will evaluate his claim based on the evidence of record, although any evidence expected to result from the EMG testing cannot be considered. Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent May 2011 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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). Additionally, in April 2010, the Veteran was provided an opportunity to set forth his contentions during a hearing before a Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the decision review officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the April 2010 hearing, the undersigned Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the functional impact the Veteran's left arm disability has on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. In this regard, the Veteran testified that he had not received any additional treatment. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claim. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Finally, the Board finds that there was substantial compliance with the November 2009 and October 2010 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the November 2009 Board remanded directed that the Veteran be afforded his requested hearing before a Veterans Law Judge, which was accomplished in April 2010. Additionally, the Board in October 2010 directed the AOJ to schedule the Veteran for a VA examination. As noted above, the Veteran was afforded VA examinations in November 2010 and May 2011 with July 2011 and January 2012 addendums that are adequate for appellate review. Accordingly, the Board finds that there has been substantial compliance with the October 2010 Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). Analysis The Veteran is seeking an increased rating for his service-connected paralysis of the left thoracic nerve. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate ratings for distinct periods of time, based on the facts are for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is currently assigned a 10 percent rating under Diagnostic Code 8519 for paralysis of the long thoracic nerve. Under this code, a noncompensable (0 percent) rating is assigned for mild incomplete paralysis, a 10 percent rating is assigned for moderate incomplete paralysis, and a 20 percent rating is assigned for severe incomplete paralysis of the major or minor arm. A 20 percent rating is also assigned if there is complete paralysis, i.e., an inability to raise arm above shoulder level, winged scapula deformity, of the long thoracic nerve of the minor extremity, and a 30 percent rating is assigned for complete paralysis of the long thoracic nerve of the major extremity. A note indicates that these ratings are not to be combined with lost motion above shoulder level. 38 C.F.R. § 4.124a, Diagnostic Code 8519. A distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. In the instant case, the Veteran is right-handed; hence, his left arm is considered his minor upper extremity. The Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be just. See 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. See 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 4.2, 4.6. The rating schedule provides guidance for rating neurologic disabilities. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The Board has also considered a rating under Diagnostic Code 5201 for limitation of the arm. This code provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is also rated as 20 percent for the minor shoulder; and limitation of motion of the arm to 25 degrees from the side is rated as 30 percent for the minor shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The standard ranges of motion for shoulder abduction and forward elevation (flexion) are 180 degrees. 38 C.F.R. § 4.71, Plate I. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. By way of background, an April 1980 rating decision granted service connection for paralysis of the left long thoracic nerve and assigned an initial 10 percent rating, effective December 31, 1979. Over the years, the Veteran filed increased rating claims, which were subsequently denied. More recently, a September 2003 rating decision had denied a rating in excess of 10 percent for paralysis of the left long thoracic nerve. Thereafter, the Veteran entered a notice of disagreement in November 2003 and a statement of the case was issued in July 2004. However, the Veteran did not perfect his appeal by submitting a timely substantive appeal. Thereafter, in February 2005, the Veteran filed another claim for an increased rating for his paralysis of the left long thoracic nerve. Such was denied in a June 2005 rating decision. The Veteran did not enter a notice of disagreement with respect to such denial. Moreover, while additional VA treatment records and a January 2006 VA examination report were associated with the claims file within one year of the issuance of such decision, they do not reflect complaints or findings suggesting an increase in the severity of the Veteran's paralysis of the left long thoracic nerve. 38 C.F.R. § 3.156(b) (when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). Thereafter, VA received the Veteran's current claim for an increased rating for paralysis of the left long thoracic nerve in December 2005. The Veteran was afforded a VA examination in May 2005. The claims file was reviewed. The Veteran reported left-sided numbness that was an 8 out of 10 and weakness on a daily basis. During flares-up, his symptoms were a 10 out of 10. He indicated that he worked through the numbness. Flare-ups lasted approximately 20 minutes and improved with placing his left hand in hot water. He reported only 50 percent of feeling on his left side. He stated that he had sensory loss to heat and cold pressure. However, he was able to mow the grass and perform his activities of daily living. He had less strength in his hand, and relied more on his right hand when providing patient care. It was noted that he was right-handed. He reported decreased manual dexterity of the left hand. He denied redness, swelling, stiffness, heat and fatigue. He reported that his numbness affected the ulnar side of his hand with the 3rd and 4th fingers being more numb than the others. He expressly denied any adverse affects on his occupation and activities of daily living. On physical examination, the Veteran was able to perform the examination without complaints of weakness, fatigue, pain, instability, lack of endurance or guarding of movement. Muscle strength was slightly weaker in the left hand with hand grasp. He exhibited full range of motion of his left shoulder. There was no scapular winging. Neurological examination was within normal limits. Motion testing of dexterity of thumbs and fingers were all normal. Range of motion testing of the left wrist, left hand, fingers and thumb were also all normal. The examiner diagnosed peripheral neuropathy of the ulnar nerve, left hand, which was not related to the long thoracic nerve. The examiner also diagnosed peripheral neuropathy of the left foot, but determined that this disability was not related to the long thoracic nerve because the long thoracic nerve did not innervate the legs or feet. The examiner concluded that the Veteran had no evidence of paralysis of the long thoracic nerve as noted by no loss of motion, no scapular winging, and no relationship to ulnar nerve problem. The Veteran was afforded another VA examination in January 2006. At this time, the claims file was not available for review. In contrast to the May 2005 VA examination, at this time, the Veteran reported not working for several years. Again, it was noted that he was right hand dominant. The Veteran reported mild weakness, numbness, decreased sensation, and tingling, but no fatigue or functional loss. There was no flare up of pain, fatigue or functional loss. Numbness and tingling did not interfere with his activities of daily living. The specific nerves in the hand were ulnar and radial nerves. He also reported intermittent sore joint pain in the shoulder, but it did not impact his daily living or occupation. On physical examination, strength and hand grasp was 4 out of 5 on left upper extremity. Sensation to vibration and light touch was slightly diminished on the left. He had full range of motion of the shoulder. There was no decrease after repetitive use. The diagnosis was paralysis of the lower thoracic nerve due to injury, resulting in mild peripheral neuropathy with no evidence of brachial plexopathy for EMG testing, minimal left hand weakness and some decreased sensation to touch. It was observed that the Veteran refused to complete EMG testing. The condition was found to be stable at that time. A February 2006 EMG/Nerve Conduction Study documented that the Veteran's upper left extremity had full range of motion with normal strength. Sensory examination was normal except for a weak hand. The impression was mild peripheral neuropathy with no evidence of brachial plexopathy. It was noted that it was a limited test due to the Veteran's refusal of EMG. The examiner was unable to assess radiculopathy due to limited examination. The Veteran was afforded another VA examination in February 2007. The claims file was reviewed. At this time, the Veteran reported that his left hand was very weak with tingling sensation. On physical examination, deep tendon reflexes were bilaterally equal and adequate. Wrist pulses were bilaterally equal and adequate. Range of motion testing of the upper extremities was also bilaterally equal and adequate. Motor and sensory examinations of the upper extremities were bilaterally equal and within normal limits. The diagnosis was status post left long thoracic nerve partial paralysis. VA treatment records have been reviewed and show complaints of numbness or tingling in the Veteran's left upper extremity. The assessment was ulnar neuropathy. An October 2007 treatment record showed no gross focal deficits and he had intact sensation, but there were decreased reflexes in the upper extremity. However, strength and sensory examination in December 2007 was normal and sensory was again intact in March 2008. In statements of record, the Veteran reported that he had weakness and loss of sensation in his left hand. He also reported decreased strength. At the Board hearing, he testified that he could no longer work because he had done painting work all his life and he could no longer use the regular tools. However, he subsequently reported that he was working some answering phones. He reported that his sensation was gone and he experienced decreased strength and tingling. For example, he could not feel hot water temperature. His wife testified that he was very clumsy and dropped things a lot. He also reported an increase in severity since the last VA examination and asserted that the prior VA examination was not thorough. On remand, the Veteran was afforded a VA examination in November 2010. The claims file was reviewed. The Veteran reported that his symptoms had gradually worsened over the years. He reported left hand numbness. He also reported left shoulder tremors. He denied pain, but reported very little strength that seemed to be worsening. The examination did not provide any other findings except to note that EMG was pending. The Veteran was afforded another VA examination in May 2011. The claims file was reviewed. The Veteran essentially reported the same symptoms of numbness and decreased strength of the left hand. There were no flare-ups. He was able to function except for mild weakness. Motor examination showed 5 out of 5 strength, but hand grip on the left was -5/5 and left arm flexion/extension was -5/5, possibly some give away weakness. Shoulder abduction was pretty normal and there no any clear winging of the scapula. Sensory examination revealed decreased pinprick in the left mid upper arm to hands that became increasingly more prominent from upper mid arm to hands. Reflexes were 2+ biceps, 1+ brachioradialis and 1+ triceps. It was noted that he had an EMG of the lower extremities in April 2011 showed mild sensory neuropathy in the lower extremities. The examiner indicated that there was no significant weakness in the shoulder. The Veteran's abduction was normal and there was no clear winging of the scapular. The impression was status post injury, fall, head injury and injury to neck and shoulder in 1974 with a history of brachial plexus neurapraxic injury and long thoracic nerve injury with good recovery. The examiner recommended an MRI of the brain to rule out any brain injury and an EMG of the left upper extremity. A January 2011 addendum showed that findings on the MRI were more related to microvascular disease, which did not explain his symptoms. The Veteran did not report for EMG testing so no further opinion could be offered. In a January 2012 addendum, the examiner reiterated that on examination, there was no winging of the scapula or weakness of shoulder abduction with inability to raise arm above shoulder level. There was no clear long thoracic nerve paralysis that could be found on clinical examination that was of significance. The Veteran complained of left arm numbness and no cause could be found. Based on the evidence of record, the Board finds that a higher rating for the Veteran's paralysis of the left long thoracic nerve is not warranted. Although some decreased sensation and weakness has been observed, the objective evidence does not show severe symptomatology associated with the injury to the long thoracic nerve. In this regard, at the December 2005 and January 2006 VA examinations, the Veteran was able to perform his activities of daily living. The December 2005 examiner indicated that the Veteran's muscle strength was only "slightly" weaker. Moreover, at the January 2006 VA examination, sensation was also only "slightly" diminished. The examiner actually characterized the Veteran's peripheral neuropathy as mild. At the May 2011 examination, the Veteran again reported that he was able to function except for mild weakness. Importantly, there is no evidence of total loss of reflexes or muscle atrophy. Moreover, in the January 2012 addendum, the examiner indicated that no clear long thoracic nerve paralysis could be found that was of significance. These findings do not correspond to the "severe" incomplete paralysis necessary for a higher 20 percent rating under Diagnostic Code 8519. Significantly, there have also been no findings of winged scapula deformity or an inability to raise the arm above shoulder level. The examinations all clearly reported such findings. In sum, the 10 percent rating contemplates moderate symptomatology and is consistent with the Veteran's reports of constant numbness, decreased strength and weakness. Similarly, left shoulder range of motion findings have been consistently normal. Therefore, a higher or separate rating under Diagnostic Code 5201 is not warranted as range of motion of the arm is not limited to shoulder level even with consideration of the factors set forth in Deluca, supra. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his left arm disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected left long thoracic nerve; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), 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 the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected left long thoracic nerve with the established criteria found in the rating schedule. The Board finds that the Veteran's left long thoracic nerve symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran's 10 percent rating contemplates his incomplete paralysis as reported by numbness, weakness and decreased strength. There are no additional symptoms of his left long thoracic nerve that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran's reports concerning his employment have been inconsistent. For instance, at the December 2005 VA examination, he was still working and reported no adverse effects on his occupation. However, in January 2006, he reported that he not worked for several years, but there was still on impact on his occupation. In June 2006, the Veteran filed a claim for a TDIU indicating that he last worked 2005. In support of his claim, he filed an employer statement indicating that he had last been employed in January 2003 with a long term care facility, but was terminated due to excessive absences. The RO denied the Veteran's claim for TDIU in a March 2007 rating decision, which he did not appeal. Subsequently, a May 2008 VA treatment record showed that he had worked for more than 30 years in auto body repair, but then became certified as a CNA and worked in several long term care facilities before becoming medically retired in 2006. Nevertheless , at the various VA examinations, the Veteran reported that he was still able to perform his activities of daily living. Moreover, at the Board hearing, the Veteran indicated that he was employed answering telephones. As such, the evidence has not shown that the Veteran's service-connected left long thoracic nerve renders him unemployable. Moreover, during the course of the Veteran's increased rating claim, a claim for TDIU was considered and denied by the RO in a March 2007 rating decision. The Veteran has not appealed such decision. Such adjudication reflects the permissive bifurcation of the increased rating claim from the TDIU claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Holland v. Brown, 6 Vet. App. 443, 447 (1994) (holding that "it was not inappropriate" for the Board to refer a TDIU claim to the RO for further adjudication and still decide an increased-ratings claim). Moreover, while acknowledging the Rice decision, in Locklear v. Shinseki, 24 Vet. App. 311 (2011), the Court held that it is permissive for VA to address a claim for TDIU independently of other claims, including increased rating and service connection claims. Id. at 315. Given the foregoing, the Board concludes that the TDIU claim was separately adjudicated and not perfected for appellate review. Accordingly, the Board does not have jurisdiction over the claim and need not refer or remand the matter. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for his paralysis of the left long thoracic nerve for the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A rating in excess of 10 percent for paralysis of the left long thoracic nerve is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs