Citation Nr: 1314932 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 07-08 227 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for a left shoulder disability. 3. Entitlement to service connection for a right knee disability. 4. Entitlement to service connection for residuals of a left hand injury. 5. Entitlement to an increased initial rating for a lumbar spine disability, currently rated as 10 percent disabling. 6. Entitlement to an increased initial rating for hypertension, rated as 0 percent disabling prior to May 15, 2012, and as 10 percent disabling since May 15, 2012. ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from January 1985 to January 1988 and from January 2001 to July 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran was scheduled for a travel board hearing in July 2009. However, the Veteran failed to appear at this hearing. As the record does not contain any additional requests for an appeals hearing, the Board deems the Veteran's request for a hearing to be withdrawn. See 38 C.F.R. § 20.702 (2012). The Board remanded these claims for additional development in December 2009 and August 2011. A November 2012 rating decision increased the disability rating for a lumbar spine disability, from 0 percent to 10 percent, effective July 3, 2005. Additionally, a January 2013 rating decision increased the disability rating for hypertension, from 0 percent to 10 percent, effective May 15, 2012. However, as these grants do not represent total grants of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). 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 claims. A review of the documents in such file reveals that certain documents, including VA medical records dated from March 2012 to January 2013, are potentially relevant to the issues on appeal. Thus, the Board has considered these electronic records in its adjudication of the Veteran's case. Any future consideration of this appellant's case should also take into consideration the existence of this electronic record. The issues of entitlement to service connection for an acquired psychiatric disorder and for erectile dysfunction have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to service connection for a right shoulder disability and left shoulder disability and the issue of entitlement to an increased initial rating for hypertension 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. FINDINGS OF FACT 1. There is no competent and credible evidence establishing that the Veteran currently has a right knee disability. 2. Resolving all reasonable doubt in favor of the Veteran, the competent evidence shows that the Veteran's residuals of a left hand injury are due to his period of service. 3. The Veteran's lumbar spine disability has been manifested by pain, with full range of motion, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; there are no objective findings of a compensable neurological disability and there have been no incapacitating episodes in the past 12 months. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The requirements for establishing service connection for residuals of a left hand injury have been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303 (2012). 3. The criteria for an initial rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a September 2005 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. A September 2006 letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. Although the September 2006 notification was issued after the adjudication on appeal, the Veteran's case was subsequently readjudicated in the January 2007 statement of the case and the July 2007, October 2008, July 2011, and January 2013 supplemental statements of the case. The Veteran also had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis). Additionally, regarding the claim for an increased rating for a lumbar spine disability, the appeal arises from the initial award of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2012). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private medical records, VA examination reports, and the Veteran's statements. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included obtaining the Veteran's service treatment records for his first period of service and the May 2005 separation examination for his second period of service, verifying whether the Veteran had additional service in Iraq after 2005, scheduling the Veteran for current VA examinations for his increased rating claims, and contacting the Veteran at his new address and phone number to clarify whether he still wanted to appear at a Board hearing and whether he had any outstanding medical records. In response, the RO/AMC obtained the service treatment records from the Veteran's first period of service. The RO/AMC attempted to obtain the remainder of the Veteran's service treatment records but was unable to do so. Consequently, in July 2011 and January 2013, the RO/AMC made formal findings of the unavailability of the Veteran's service treatment records. The RO/AMC also determined that the Veteran did not have additional Iraq service subsequent to 2005, that the Veteran no longer wished to appear at a Board hearing, and that the Veteran had outstanding VA and private medical records. The RO/AMC obtained the Veteran's current VA medical records and sent an April 2012 request to the Veteran to fill out an Authorization and Consent Form for a private treatment provider that he had referenced. However, the Veteran failed to respond to the April 2012 request. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Finally, the RO/AMC scheduled the Veteran for a May 2012 VA examination for his lumbar spine disability. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In order to prevail on the issue of service connection, there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Barr v. Nicholson, 21 Vet. App. 303 (2007); Pond v. West, 12 Vet. App. 341, 346 (1999). As an initial matter, the Board notes that it has been shown that the Veteran's service treatment records for his second period of active service are mostly unavailable, as the RO made formal findings of unavailability of records in July 2011 and January 2013. The Board is mindful that, in a case such as this, VA has a heightened obligation to assist the Veteran in the development of his claim. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). 1. Right Knee Disability Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). Service treatment records for the Veteran's first period of service are negative for any complaints, treatment, or diagnoses of a right knee disability. The available service treatment records for the Veteran's second period of service are also negative for any complaints, treatment, or diagnoses of a right knee disability. The post-service evidence indicates that on VA examination in September 2005, the Veteran reported that his right knee pain was associated with radiation from his low back injury. He indicated that his right knee joint was currently not a problem for him. Examination of the right knee was normal. The examiner found that the Veteran had history of right knee pain that had resolved at that time. In a May 2012 VA medical report, the Veteran complained of right knee pain, but he received no diagnosis of any right knee disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a right knee disability falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of knee pain, any actual diagnosis of a right knee disability requires objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Moreover, whether symptoms the Veteran experienced in service or following service are in any way related to any current right knee disability requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent that the Veteran himself believes that he has current right knee disability that is due to service or his service-connected lumbar spine disability, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran's opinion as to the etiology of his claimed current right knee disability is not competent medical evidence, as such question requires medical expertise to determine. Id. In any event, the Board concludes that the medical evidence, which reveals no findings of a right knee disability, is of greater probative value than the lay contentions of the Veteran. In this case, while there is current medical evidence of record dating from September 2005 through January 2013, none of this evidence reflects findings of a right knee disability. While the Veteran complained of pain in the right knee, pain alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Accordingly, in the absence of objective evidence of a current right knee disability during the period of the claim, consideration of service connection for a right knee disability is not warranted on any basis. The Board has also considered the holding in McClain v. Nicholson, 21 Vet. App. 319 (2007). At no time during the period on appeal did the Veteran receive a right knee diagnosis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. In the absence of proof of present disabilities there can be no valid claims. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes); see also Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Residuals of a Left Hand Injury The Veteran contends that he injured his left hand while moving equipment during his period of service. Service treatment records for the Veteran's first period of service are negative for any complaints, treatment, or diagnoses of residuals of a left hand injury. In a November 2000 pre-screening medical examination prior to the Veteran's second period of service, the Veteran did not report any illnesses or injuries that had required hospitalization, surgical treatment, or other treatment. The Veteran's available service treatment records for his second period of service do not show any complaints, treatment, or diagnoses of residuals of a left hand injury. However, the Veteran underwent VA examination in September 2005, which was just 2 months after discharge from his second period of service. He reported that he had injured his left hand while moving equipment in a motor pool during service in Fort Hood. The examiner noted that the Veteran had suture repair of laceration of the distal 3rd, 4th, and 5th distal middle phalanges of the left hand. Examination of the left hand revealed irregular scars over the distal middle phalanges, 4th middle phalanges, and 5th middle phalanges from laceration. The Veteran was diagnosed with old scars of the left hand that were currently not a problem. The available service treatment records indicate that prior to the Veteran's second period of service from January 2001 to July 2005, he had not injured his left hand. However, the Board notes that the Veteran filed a claim for service connection for residuals of a left hand injury in August 2005, which was just one month after discharge from service. Additionally, the September 2005 VA examination, which was conducted only 2 months after his discharge from service, indicated that the Veteran had old scars on the left hand from a laceration injury. Given that the medical evidence of record indicates that the Veteran did not have a left hand laceration injury prior to his second period of service, but had old laceration scars of the left hand on VA examination 2 months after discharge from service, the Board resolves all reasonable doubt in favor of the Veteran and finds that he currently has left hand scars that are due to a left hand injury that was incurred during his period of service. In sum, the Board finds that the competent evidence of record shows that the Veteran's left hand scars were related to his service. Thus, the criteria for service connection for residuals of a left hand injury have been met. Therefore, reasonable doubt is resolved in favor of the Veteran, and the Board finds that service connection for residuals of a left hand injury is warranted. 38 U.S.C.A. 5107 (b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating 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. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The 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 innervation, or other pathology, or 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 which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). The Veteran contends that he is entitled to a higher disability rating for his lumbar spine disability. Such disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5237, as 10 percent disabling. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5010 pertains to arthritis due to trauma, which is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Diagnostic Code 5237 pertains to lumbosacral strain. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). The General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent evaluation requires evidence of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation requires evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). Any associated objective neurologic abnormalities should be evaluated separately, under an appropriate diagnostic code. Id. at Note 1. On VA examination in September 2005, the Veteran reported that he had low back pain that radiated to his right knee. He denied missing any work due to his lumbar spine disability. Examination of the lumbar spine revealed no evidence of swelling, effusion, muscle spasm, joint laxity, muscle atrophy, fibrous or bony residual of fracture, ankylosis, edema, ecchymosis, or erythema. The Veteran had tenderness of the bilateral paravertebral muscles. Straight leg raise was positive with radiation to the right lower extremity. Sensation of the lower extremities was intact distally, and strength of the lower extremities was normal. Reflexes were 2+ bilaterally. Range of motion of the lumbar spine was full, with no further limitation of pain with repeated efforts. An x-ray indicated degenerative changes at the lower lumbar spine at L4-5 and L5-S1 with mild narrowing of L5-S1 disc space, moderate narrowing of L5-S1 disc space, and minimal degenerative retrolisthesis at L5-S1. The diagnosis was degenerative changes at the lower lumbar spine at L4-5 and L5-S1 with mild narrowing of L5-S1 disc space and minimal degenerative retrolisthesis at L5-S1. At a May 2012 VA examination, the Veteran reported that due to his back disability, he could not run or stand for prolonged periods of time. He complained that his pain level was currently an 8/10. He stated that his pain level usually averaged 9/10 without flare-ups. The examiner noted that there was no visible evidence of a pain level of 8/10. The Veteran took no medication for his back disability and had not had any surgery, hospitalizations, or physical therapy. He stated that he worked overseas in Iraq as a civilian in the fuel business. Examination revealed localized tenderness or pain to palpation of the back. There was no guarding or muscle spasm of the back. Range of motion testing of the lumbar spine was full. There was no objective evidence of painful motion. Upon repetitive testing, there was pain on movement and disturbance of locomotion, but there was no additional limitation of motion. The Veteran had no muscle atrophy, and muscle strength of the lower extremities was normal. Deep tendon reflexes of the lower extremities were normal bilaterally. Sensation to light touch was intact in the bilateral lower extremities. The Veteran had positive straight leg raise bilaterally. However, the examiner found no evidence of radicular pain or any other signs or symptoms due to radiculopathy. There was also no evidence of any other neurologic abnormalities or findings related to the lumbar spine disability. The Veteran did not have intervertebral disc syndrome and did not report any incapacitating episodes over the past 12 months. He used no assistive devices as a normal mode of locomotion, and his lumbar spine disability did not have functional impairment so extreme that no effective function remained other than that which would be equally well-served by amputation with prosthesis. An x-ray showed degenerative changes in the lower lumbar spine at L4-5. The Veteran was diagnosed with lumbosacral strain. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the Veteran's lumbar spine disability is appropriately evaluated as 10 percent disabling for the period under consideration. The objective findings of record do not reflect evidence of forward flexion of the thoracolumbar spine to 60 degrees or less; combined range of motion of the thoracolumbar spine to 120 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). During the period under consideration, the Veteran had full range of motion. The May 2012 VA examiner noted that although there was pain on movement and disturbance of locomotion after three repetitions, the range of motion was not additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. Thus, even considering the Veteran's subjective complaints of pain, the medical evidence of record does not support any additional limitation of motion in response to repetitive motion that would support an evaluation in excess of the 10 percent assigned. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). The Veteran has not alleged that when his back pain occurred, he had to take time off work and be limited to bed rest. Indeed, at his May 2012 VA examination, the Veteran was not found to have intervertebral disc syndrome, and he also did not report any incapacitating episodes of spine disease during the past 12 months. An "incapacitating episode" for purposes of Diagnostic Code 5243 is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Accordingly, evaluation of the Veteran's disability pursuant to Diagnostic Code 5243 based on incapacitating episodes is not warranted. See 38 C.F.R. § 4.71a. With regard to Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Board acknowledges that the Veteran reported that he had back pain that radiated down his right knee at his September 2005 VA examination. Additionally, the Veteran was found to have positive straight leg raise at both his September 2005 and May 2012 VA examinations. However, the Veteran had no other objective neurological findings or symptoms at his VA examinations other than the positive straight leg raise. Specifically, sensation was intact in the lower extremities at both VA examinations. Moreover, the May 2012 VA examiner found no objective evidence of radicular pain or any other signs or symptoms due to radiculopathy, or evidence of any other neurologic abnormalities or findings related to the lumbar spine disability. The Veteran was also not found to have intervertebral disc syndrome. As the medical evidence fails to show any objective neurological symptomatology other than positive straight leg raise, the Board finds that the Veteran would not meet the criteria for a compensable rating under 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012), and therefore, a separate compensable rating for the neurological manifestations of the Veteran's lumbar spine disability is not warranted at this time. 38 C.F.R. §§ 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1), 4.124a, Diagnostic Code 8520 (2012). The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his lumbar spine disability. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation at any time during all relevant periods on appeal. See 38 C.F.R. §§ 4.71a, Diagnostic Code 5237 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's lumbar spine disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. His 10 percent rating contemplates his subjective complaints of pain and minimal functional impairment. Although the Veteran reported back pain that was an 8/10 in severity and that radiated into the right knee, the only objective manifestation of his back disability was tenderness. He had full range of motion of the lumbar spine without pain on motion or additional limitation following repetitive use. There were no compensable neurological manifestations or any other objective manifestations. Indeed, the Veteran had not had any incapacitating episodes of his spine disability. The Veteran's subjective complaints of pain were therefore included in the 10 percent rating. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for residuals of a left hand injury is granted. Entitlement to an initial rating in excess of 10 percent for a lumbar spine disability is denied. REMAND Although the Board sincerely regrets the additional delay, after a review of the record, the Board observes that further development is required prior to adjudicating the Veteran's claims for service connection for a right shoulder disability and left shoulder disability and the claim for increased initial rating for hypertension. Regarding the Veteran's bilateral shoulder disability, he contends that he injured his shoulders during service when he fell off a gas truck. He reported that he had problems with his shoulders on active duty because he had to stand in formation with his hands behind his back. He also stated that he had to stop playing in the center field position in softball due to the sharp right shoulder pain he experienced when he threw the softball. Service personnel records reveal that the Veteran's military occupational specialty was in motor transport. Service treatment records are negative for any complaints, diagnoses, or treatment for any shoulder disabilities. On VA examination in September 2005, the Veteran was diagnosed with history of bilateral shoulder pain which had resolved. VA medical records show that the Veteran was treated in the emergency room for back and shoulder pain in March 2012 and May 2012. In a May 2012 treatment record, the Veteran was diagnosed with arthritis and questionable frozen shoulders, and his May 2012 discharge diagnoses included arthritis. In January 2013, a VA examiner reviewed the Veteran's claims file but did not perform an examination. The examiner found that the Veteran's claimed bilateral shoulder condition was less likely as not incurred in or caused by his period of service. He explained that because the Veteran had not undergone a VA examination for his shoulders and there was only a brief mention of shoulder pain in May 2012, there was no evidence to establish a diagnosis or etiology for any current claimed shoulder condition. The examiner found that the Veteran would need an examination to determine the etiology of any current shoulder condition. He noted that the Veteran had complained of his shoulders in service, but explained that without a current examination, it could not be determined what the Veteran's current shoulder condition was without resorting to mere speculation. Given the evidence outlined above, especially the January 2013 VA examiner's recommendation that the Veteran needed a current examination in order to determine the etiology of his shoulder disabilities, the Veteran should now be afforded a VA joints examination with a medical opinion clarifying whether he has a current bilateral shoulder disability that arose during service or is otherwise related to any incident of service, including a fall off of a gas truck. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the claim for increased initial rating for hypertension, the Veteran was last afforded a VA examination for his hypertension in May 2012. The Board acknowledges that this examination is not unduly remote and that the Veteran's blood pressure reading at the examination was 142/98. However, the evidence indicates that prior to the VA examination, the Veteran had to be treated in the VA emergency room for hypertension in March 2012, and that his blood pressure reading had been 190/133. Additionally, subsequent to the May 2012 VA examination, VA treatment records reveal that the Veteran had a blood pressure reading of 163/115 later in May 2012 when he was again treated in the emergency room for back and shoulder pain. The Veteran also had a blood pressure reading of 174/122 in January 2013 when he was treated for hypertension with headaches. The evidence suggests that since the May 2012 VA examination, the Veteran's blood pressure has increased, and that the Veteran had also experienced a very high blood pressure reading in March 2012 prior to his VA examination. However, it is unclear to the Board whether these blood pressure readings are indicative of permanently increased diastolic pressure or whether the Veteran had temporarily higher blood pressure readings associated with treatment for his other disabilities (i.e. back and shoulder pain, headaches). Because there may have been changes in the Veteran's condition, the Board finds that a new hypertension examination is needed to fully and fairly evaluate the Veteran's claim for increased initial rating. Allday v. Brown, 7 Vet. App. 517 (1995) (where the record does not adequately reveal current state of disability, fulfillment of duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since previous examination); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA joints examination to obtain a medical opinion as to whether his current right shoulder disability and left shoulder disability are possibly related to his periods of service. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any bilateral shoulder disability arose during service or is otherwise related to any incident of service, to include a fall off of a gas truck. The examiner should provide a rationale for the conclusions reached. 2. Schedule the Veteran for a hypertension examination to determine the current severity of his hypertension. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected hypertension. The examiner should determine the Veteran's current diastolic pressure and systolic pressure. The examiner should also determine whether the Veteran's blood pressure readings since March 2012 are indicative of permanently increased diastolic pressure or whether the Veteran had temporarily higher blood pressure readings associated with treatment for his other disabilities (i.e. back and shoulder pain, headaches). The examiner should make a finding regarding whether the Veteran's diastolic pressure since March 2012 is considered to be predominantly 110 or more, predominantly 120 or more, or predominantly 130 or more. A rationale for any opinion expressed should be provided. 3. After the development requested above as well as any additional development deemed necessary has been completed, the record should again be reviewed. If the benefits sought on appeal remain denied, then the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. 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). ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs