Citation Nr: 1316499 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 07-08 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE 1. Entitlement to an increased rating in excess of 20 percent for service-connected left brachial plexus neuropathy prior to September 17, 2012 and in excess of 30 percent thereafter. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran served on active duty from October 1979 to March 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In April 2009, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A copy of the transcript is of record. In July 2009, July 2011 and August 2012, the Board remanded this claim for additional development. In July 2009, the Board remanded the claim to obtain a VA examination and to obtain outstanding VA treatment records. Pursuant to that remand, the Veteran was afforded a VA examination in October 2009, and VA treatment records were obtained. In July 2011, the Board remanded this claim to obtain outstanding VA treatment records and Social Security records and to afford the Veteran a VA examination. Pursuant to the July 2011 remand, outstanding Social Security records and VA treatment records were obtained. The Veteran was afforded a VA examination in August 2011. In an August 2012 remand, the Board determined that the VA examination provided in August 2011 did not comply with the remand instructions, as the VA examiner did not provide the information requested in the remand. The Board remanded this claim in order to obtain a VA examination in compliance with the July 2011 remand instructions and to obtain all outstanding records pertaining to left brachial plexus neuropathy. A review of the claims file indicates that the outstanding VA treatment records were obtained and associated with the claims file. The Veteran was afforded a VA examination in compliance with the remand directives. The Board finds that the development ordered in the July 2009, July 2011 and August 2012 remands has been completed, and no additional development is necessary to comply with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT For the entire time period on appeal, left brachial plexus neuropathy has been manifested by no more than moderate incomplete paralysis of the upper radicular group. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, but no more, for left brachial plexus neuropathy have been met for the entire time period prior to September 17, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8510 (2012). 2. From September 17, 2012, the criteria for a rating in excess of 30 percent for left brachial plexus neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8510 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ, in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for an increased rating, 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 VCAA duty to notify was satisfied by way of a letter sent to the Veteran in November 2006. The November 2006 letter informed the Veteran of what evidence was required to substantiate his claim and of the Veteran's and VA's respective duties for obtaining evidence. The letter was submitted to the Veteran prior to the December 2006 rating decision on appeal. To the extent there exists any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1), such error was nonprejudicial, in that it did not affect the essential fairness of the adjudicatory process. Based on a review of the entire file, it is clear that the appellant and his representative have a full understanding and actual knowledge of the elements required to prevail on the claim. Moreover, neither the appellant nor his representative has raised allegations of prejudice resulting from any error on the part of VA. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); see also Goodwin v. Peake, 22 Vet. App. 128 (2008). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the record indicates that the RO obtained all information relevant to the Veteran's claim. The Veteran underwent adequate VA medical examinations for his claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's statements. The Veteran was afforded a VA examination in September 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as the examinations considered all of the pertinent evidence of record, to include service treatment records, VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provide a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) 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 RO has obtained relevant records, and has provided an adequate examination to the Veteran. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran 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). II. Analysis of Claim A. Disability Ratings - Law and Regulations Disability evaluations (ratings) are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Left brachial plexus neuropathy is rated according to the criteria for diseases of the peripheral nerves, upper radicular group. The criteria are set forth in Diagnostic Code 8510. Diagnostic Code 8510 pertains to paralysis of the upper radicular group (fifth and sixth cervicals). In this case, the evidence indicates that the Veteran is right-handed; therefore, the Board will consider the criteria pertaining to the minor extremity. A 20 percent rating is assignable for mild incomplete paralysis of both the minor extremity. A 30 percent rating is assignable for moderate paralysis of the minor extremity. A 40 percent rating is assignable for severe incomplete paralysis of the minor extremity. A 60 percent rating is assignable for complete paralysis of the upper radicular group of the minor extremity with all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected. 38 C.F.R. § 4.124a, Diagnostic Code 8510 (2012). The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range-of-motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. B. Rating period prior to September 17, 2012 Service connection for left brachial plexus neuropathy has been in effect since August 1982. A 20 percent rating was assigned from October 1995. A claim for an increased rating was received in October 2006. The Veteran had a VA examination in November 2006. The Veteran reported that he was on a training exercise during service and was in the midst of completing a 25-mile run with his rucksack in place. He reported that when he returned to the barracks, his left arm was, in his words, numb and useless. The Veteran reported some pain at the time but reported it was mostly numbness and inability to use the arm. The Veteran reported that it continued to be mild to moderately painful constantly, and he was subsequently released from the military because of the problem. The Veteran reported that his symptoms had worsened and that he had an increasing feeling of numbness in his left arm. Upon physical examination, there was no gross asymmetry in the shoulder girdles left to right. The VA examiner indicated that there was no obvious atrophy or wasting of the shoulder girdle musculature. On active range of motion, the left shoulder had forward flexion to 170 degrees, which was slightly less than the right shoulder and abduction to 120 degrees, which was substantially less than the right shoulder. He had external rotation on the left to 80 degrees and internal rotation to 40 degrees. On direct palpation of the shoulder girdle, the Veteran had point tenderness in the distribution of his trapezius muscle in the posterior shoulder girdle between his medial scapular border and his spinous processes. The VA examiner noted he was quite tender to palpation there. The VA examiner noted that there were no obvious muscular spasms or any nodules. The Veteran had no tenderness to palpation over the bony prominences of the shoulder, including his AC joint and acromion. On supraspinatus testing, he had 5/5 supraspinatus strength and normal strength relative to his contralateral uninvolved side. He had 5/5 strength in external rotation and internal rotation. On strength testing of his left upper extremity, he had 5/5 in his deltoid and 5/5 biceps and triceps. The VA examiner noted that, overall, the Veteran was unable to give a good effort consistently through all the exams by his report secondary to pain inhibition. He was unable to demonstrate repetitive motions adequately for a good assessment by his report because of the increased pain with the exam and reports in his normal activities that any repetitive activity with his arm, shoulder, elbow or wrist aggravates his pain but does not cause any new neurologic-type symptoms. The VA examiner noted that his passive range of motion was equal to his active range of motion, and he was unable to relax and comply with complete passive range of motion secondary to pain in his shoulder girdle. His deep tendon reflexes were 2+ and symmetric. The VA examiner's impression was that the Veteran had subjectively worsened symptoms from his previously documented problems of left shoulder pain. The VA examiner diagnosed left shoulder muscular strain, chronic, with mild radicular symptoms. The VA examiner noted that the findings on physical examination were somewhat unremarkable given his history other than that the Veteran had increased pain. VA outpatient treatment records dated in March 2007 show that the Veteran was seen in the walk-in clinic with complaints of throbbing left shoulder pain he described as "muscle spasms" and a sharp pain that radiated down his arm. The Veteran rated it at worst 7/10. He stated that it was continuous, but that it varied throughout the day, usually worse with activity and use of the arm. The Veteran noted a worsening weakness of the arm as well. A physician recommended a full EMG. In the substantive appeal dated in August 2007, the Veteran reported that he was receiving treatment at the VA hospital and had appointments for occupational therapy and for EMG and MRI of his left shoulder. The Veteran reported that he was using a TENS unit. VA occupational therapy notes dated from January 2008 to June 2008 reflect that the Veteran reported left shoulder pain and a pinched nerve. An occupational therapy note dated in June 2008 reflects that the Veteran was discharged and was strongly encouraged to continue a home program. The Veteran had a VA joints examination in April 2008. The Veteran reported left shoulder pain, weakness, and stiffness which had been going on for approximately two years. His complaints included shoulder pain and decreased motion as well as weakness. The Veteran reported that the pain was about 7/10 in severity and that he had radiation down the arm all the way to the hand, specifically to the radial 3 digits. The Veteran reported that he had significant weakness, especially with overhead activities, and significant stiffness. He denied any swelling. He denied heat or redness. He denied instability, giving way or history of dislocation. The Veteran reported some fatigability with elevation of the arm or overhead activities. The Veteran also reported a lack of endurance with any repetitive overhead activities. The VA examiner noted that the Veteran had undergone occupational therapy one to two times a week for the past year. The Veteran reported that his usual pain was a 7/10 in severity, and flare-ups would go to 8 or 9/10. The flare-ups occurred every other night. Precipitating factors for flare-ups included repetitive or overhead motion or elevating or raising the arm. The Veteran reported that he was formerly employed as a logger, but he quit his job as a logger because he was unable to do the job with his arm. Upon physical examination, the Veteran had active range of motion of the left shoulder from 0 to 80 degrees. He had extension from 0 to 30 degrees. The Veteran had internal rotation from 0 to 20 degrees and 0 to 20 degrees external rotation. The Veteran had 0 to 80 degrees of abduction and 0 to 30 degrees adduction. There was no change in range of motion with repetition. The VA examiner noted that the Veteran had pain beginning at 50 degrees of forward flexion and ending when the arm was returned below 50 degrees of forward flexion. He had pain beginning at 10 degrees extension. The Veteran had pain at 0 degrees of internal rotation and 5 degrees external rotation. He had pain beginning at 40 degrees of abduction and 10 degrees adduction. The VA examiner indicated that the joint was not ankylosed, but there was significant pain with any motion. The VA examiner noted that the Veteran had a severe guarding response with any attempt at passive or active range of motion of the left shoulder. The VA examiner noted that there was minimal weakness with the rotator cuff exhibiting 4+/5 strength throughout. There was no lack of endurance. There was no additional limitation following repetitive use and no evidence of effusion, redness or heat about the shoulder. The VA examiner stated that, on final evaluation of limitation of joint function, there was significant limited impairment of joint function. The VA examiner stated that it appeared that the Veteran lost approximately 100 degrees of forward flexion and 20 degrees of extension due to pain. The VA examiner indicated that the Veteran lost 70 degrees of internal rotation due to pain and stiffness, 70 degrees of external rotation due to pain and stiffness, 100 degrees of abduction due to pain and stiffness and 20 degrees of adduction due to pain and stiffness. The VA examiner opined that the Veteran has left adhesive capsulitis. The VA examiner opined that the left shoulder problem is at least as likely as not caused by his service-connected left upper extremity brachial neuropathy. In April 2008, the Veteran had a VA examination for neurological disorders. The Veteran reported difficulty with pain on moving the left arm, starting in the shoulder region and radiating down the left arm. The VA examiner noted that the Veteran stated that he had "weakness" of the left arm, but it was clear that his complaint of pain prevented him from using the arm normally. The VA examiner stated that he was not sure if the arm was truly weak or whether the arm gave way to discomfort. Upon examination, the VA examiner indicated that he could not accurately assess strength in the left upper extremity, as the Veteran complained that any movement of the left arm caused intense pain. The VA examiner noted, however, that the Veteran had some spontaneous movements of the arm that were of much greater amplitude than the passive movements that the examiner attempted. The VA examiner indicated that the Veteran did not have atrophy or fasciculations in the left shoulder or arm. He had normal biceps and triceps reflexes. He had two normal EMGs of the left upper extremity in the last two years. The VA examiner noted that the Veteran had bilateral carpal tunnel syndrome by nerve conduction velocities. He had bilateral carpal tunnel syndrome and callouses on both hands consistent with ongoing use of both hands. The VA examiner indicated that rucksack injuries are generally upper brachial plexus injuries, with shoulder weakness and possibly biceps and brachioradialis weakness. The VA examiner noted that there was occasionally an injury to the long thoracic with winging of the scapula, or to the suprascapular nerve with weakness of abduction of the arm at the shoulder and/or external rotation of the arm at the shoulder. The VA examiner indicated that most heal within a few weeks to months, as they are generally thought to be demyelanating lesions from local compression. The VA examiner stated that, had there been a persistent axonal injury or frank tearing of a nerve, there would be evidence of lower motor neuron injury on exam or by EMG. The VA examiner noted that the clinical examination and the EMG were normal. At a hearing before the Board in April 2009, the Veteran testified that the symptoms of brachial plexus neuropathy included shoulder pain, pain down the arm and spasms. The Veteran stated that his pain is moderate. The Veteran testified that his shoulder was weak and that he can hardly extend it. He testified that he had throbbing and spasm in his shoulder. In October 2009, the Veteran had a VA examination. The Veteran reported pain throughout the back of the shoulder and into the back of the arm and elbow and all the way down to the hand. The Veteran reported pain and weakness in the left arm and spasms in the back of the arm. The Veteran reported that he had numbness all the way down the arm to all of the fingers and on both sides of the left arm. The Veteran reported that numbness and pain were constant. The Veteran reported taking hydrocodone two to three times a day and tramadol occasionally, as well as cyclobenzaprine and occasionally Percocet. The Veteran reported tingling and parasthesias in all his fingers but particularly across the supraclavicular area on the left shoulder and down the back of the arm and into the elbow. The Veteran also described pain in the lateral aspect of the left neck. On physical examination, the Veteran had abduction of the left shoulder from 0 to 90 degrees. The Veteran could actively abduct the shoulder but did not appear to be making any effort to be cooperative with the motion of voluntary active motion. Shoulder external rotation was 0 to 90 degrees, and with repetition, there was no loss of motion or decreased motion and no complaint of pain. The Veteran would externally rotate the left shoulder only 0 to 45 degrees and complained of pain throughout, constantly twisting and turning as he did so. The VA examiner observed that shoulder internal rotation is normally 90 degrees. The VA examiner noted that the Veteran would internally rotate the right shoulder 0 to 90 degrees with no complaint of pain and with no loss of motion with repetitions. The Veteran would allow only 45 degrees of internal rotation of the left shoulder, either actively or passively. The VA examiner noted that, based on the review of the claims file and on the diagnosis given by the evaluation board, the original diagnosis appeared to be some type of brachial plexus neuropathy with paralysis of the left arm. The VA examiner indicated that he was unable to identify any specific nerve involvement objectively on examination. In a statement dated in December 2009, the Veteran reported that he had to go to the emergency room because of severe pain and that he received a shot that did not help his pain. A VA orthopedic clinic note dated in February 2010 reflects that the Veteran complained of left shoulder pain. He reported that he underwent physical therapy, but it did not seem to help. He reported that occupational therapy told him he had a frozen shoulder. On physical examination of the shoulder, there was no edema, echymyosis, scars, deformity or asymmetry. The Veteran had abduction to 90 degrees, forward flexion to 90 degrees, extension to 10 degrees and external rotation to 80 degrees. Assessment was left shoulder impingement. In a brief dated in June 2011, the Veteran's representative alleged that the Veteran's left arm is weaker and less mobile than the right. The Veteran had a VA examination in August 2011. The Veteran reported pain predominantly in the left shoulder anterolaterally that radiated all the way down to the dorsum of his left hand. The Veteran reported that the pain was constant, and he rated it as a 7 on a 1 to 10 scale. The Veteran reported taking hydrocodone daily. The Veteran reported pain, stiffness, weakness, giving way and locking in the left shoulder. The Veteran reported that he did have a period of flare-ups where the pain was worse, which he rated as an 8 on a scale of 1 to 10. The Veteran reported additional weakness, fatigue and incoordination. The VA examiner noted that the Veteran had a soft brace on the shoulder. The Veteran had no history of inflammatory arthritis. The Veteran reported that the left shoulder prevented him from working, and he had not worked since 2008. On physical examination, the biceps reflexes were 1+ bilaterally. Triceps reflexes were 1+ bilaterally, and brachioradialis reflexes were 1+ bilaterally. Radial nerve, ulnar nerve, and median nerve showed normal motor exam and normal sensory exam in the right upper extremity. The Veteran complained of numbness throughout the left arm and shoulder down to the fingertips, with the exception of the medial side of the left forearm. The VA examiner indicated that he was unable to adequately examine the left shoulder itself due to the Veteran constant resisting any attempt at range of motion or to examine the Veteran for muscle strength in that the Veteran very strongly resisted moving the shoulder and when asked to do resistance himself would not lift the arm up. The VA examiner noted that the left arm showed normal muscle strength and muscle development from the elbow down. The Veteran had forward flexion of the left shoulder from 0 to 70 degrees and complained of pain throughout. With repetitions, there was no further loss of motion or increased pain. The Veteran had abduction of the left shoulder from 0 to 70 degrees with a complaint of pain throughout, and with repetitions, there was no further loss of motion or increased pain. The Veteran had external rotation of the shoulder from 0 to 45 degrees with pain throughout. With repetition, there was no further loss of motion or increased pain. The Veteran had internal rotation of the left shoulder from 0 to 45 degrees with pain throughout. With repetition, there was no further loss of motion or increased pain. The VA examiner diagnosed chronic impingement of the left shoulder and adhesive capsulitis. The VA examiner stated with regard to the issue of current residuals of the brachial plexus neuropathy, that he was unable to determine any objective evidence of residual brachial plexus neuropathy. In September 2011, EMG studies of the left shoulder were performed. An addendum dated in September 2011 noted impressions of left cervical polyradiculopathy in predominantly the C6-C7-C8 territory and left grade 2 carpal tunnel syndrome. After a review of all of the evidence, lay and medical, the Board concludes that the criteria for a 30 percent rating were met for the entire period prior to September 17, 2012. During the time period, the Veteran reported symptoms of left shoulder pain and weakness and pain and numbness in the left arm. Upon VA examination in November 2006, the Veteran reported that his left arm was mild to moderately painful. The examiner noted tenderness in the shoulder and that the Veteran's symptoms had worsened from his previously documents problems of the left shoulder. The March 2007 VA treatment record noted worsening weakness of the arm. The April 2008 VA joints examination noted that the Veteran reported significant weakness, especially with overhead activities. Pain on motion was noted as well as significant limited impairment of joint function. In April 2009, the Veteran testified that his pain was moderate and that the shoulder was weak. The October 2009 VA examination noted complaints of pain and weakness in the left arm. On VA examination in August 2011, the Veteran continued to complain of left shoulder pain, stiffness and weakness. The Veteran also complain of numbness throughout the left arm and shoulder. The Board concludes that these findings more nearly approximate moderate incomplete paralysis of the upper radicular group of the minor extremity, for which a 30 percent rating is warranted. The Board finds that the criteria for a rating in excess of 30 percent were not met during the time period prior to September 17, 2012. Under Diagnostic Code 8510, in order to warrant a rating in excess of 30 percent, the evidence must show severe incomplete paralysis of the upper radicular group. In this case, during the time period prior to September 17, 2012, there were no findings of severe incomplete paralysis. As noted above, the evidence shows complaints of weakness and pain in the left shoulder which were described as mild to moderate. While there is evidence of pain on motion, the evidence demonstrates that the Veteran was able to move the shoulder. The November 2006 VA examiner assessed mild radicular symptoms. The April 2008 VA examiner noted a normal clinical examination and normal EMG. The October 2009 VA examiner indicated that he was unable to identify any specific nerve involvement on examination. The August 2011 VA examiner indicated that he was unable to determine any objective evidence of residual brachial plexus neuropathy. The weight of the lay and medical evidence does not demonstrate that the manifestations of the Veteran's left brachial plexus neuropathy more nearly approximates severe incomplete paralysis of the upper radicular group during this period and a rating in excess of 30 percent is not warranted. The Board has considered whether a higher rating is warranted under the criteria pertaining to disabilities of the shoulder and arm. Under those criteria, a rating in excess of 30 percent is assignable where there is unfavorable ankylosis of the scapulohumeral articulation of the minor extremity, with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5200. Upon VA examination in April 2008, the Veteran had abduction of the left shoulder to 80 degrees. The April 2008 VA examiner indicated that the joint was not ankylosed but had significant pain and limited motion actively and passively. An August 2011 VA examination reflects that the Veteran had abduction of the left shoulder to 70 degrees with pain throughout. Based upon these findings, the Board concludes that the criteria for a rating in excess of 30 percent under Diagnostic Code 5200 are not met. The Board has considered functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. In this case, the VA examination reports and treatment records reflect that the Veteran has painful motion and fatigability of the left shoulder and left arm. The evidence does not show that pain and fatigability results in functional limitation which more nearly approximates unfavorable ankylosis of the scapulohumeral articulation, with abduction limited to 25 degrees from the side. The November 2006 VA examination report noted that the Veteran indicated that because of increased pain he was not able to demonstrate repetitive motions for a good assessment but he also reported that any repetitive activity with the arm and shoulder did not cause any new neurologic-type symptoms. The April 2008 and October 2009 examination reports indicated no additional limitation following repetitive use. The August 2011 VA examination report indicated no additional loss of motion or increased pain with repetition. Accordingly, a rating in excess of 30 percent is not assignable based upon functional limitation. For these reasons, the Board concludes that a 30 percent rating, but no higher, is warranted for left brachial plexus neuropathy for the period prior to September 17, 2012. C. Rating period from September 17, 2012 The Veteran had a VA examination in September 2012. The Veteran reported increased pain and stiffness of the left shoulder. He reported that flare-ups affected the function of the shoulder and arm. Upon physical examination, the Veteran had flexion of the left shoulder to 90 degrees, with painful motion starting at 70 degrees. The Veteran had abduction of the left shoulder to 90 degrees, with painful motion starting at 70 degrees. The VA examiner noted that there was functional loss of the shoulder with repetitive use. The functional loss included less movement than normal and pain on movement. The VA examiner indicated there was no ankylosis and no history of recurrent dislocation of the shoulder. Strength testing of the left shoulder showed left shoulder abduction 4/5 and left forward flexion 4/5. The VA examiner noted that the Veteran did not have any other AC joint condition or other impairment of the clavicle or scapula. With regard to functional impact, the VA examiner noted mild to moderate rotator cuff syndrome and mild limitation of motion and mild functional impairment. The VA examiner noted that the Veteran had a diagnosis of left brachial plexus neuropathy. The VA examiner described the following symptoms attributable to the Veteran's peripheral nerve conditions: constant moderate pain of the left upper extremity and moderate numbness of the left upper extremity. The VA examiner noted that the radial nerve, median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, long thoracic nerve, upper radicular group, middle radicular group and lower radicular group were normal. The evidence from this time period reflects that the Veteran's left brachial plexus neuropathy is manifested by constant moderate pain of the left upper extremity, moderate numbness of the left upper extremity, and pain and limitation of motion of the left shoulder. The VA examination noted normal findings with regard to the left upper radicular group. Accordingly, as the evidence does not show severe incomplete paralysis of the upper radicular group, the criteria for a higher rating under Diagnostic Code 8510 are not met. The Board has considered whether a higher rating is warranted based upon the criteria pertaining to the shoulder and the arm. Under those criteria, a rating in excess of 30 percent is assignable where there is unfavorable ankylosis of the scapulohumeral articulation of the minor extremity, with abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5200. In this case, as the evidence of record indicates that ankylosis of the left shoulder is not present, a higher rating is not assignable on that basis. The Board has considered whether a disability rating in excess of 30 percent is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. The evidence for this time period reflects that the functional impact of the Veteran's disability included mild to moderate rotator cuff syndrome and mild limitation of motion and mild functional impairment. Thus, the evidence does not show that a rating in excess of 30 percent is warranted based upon pain and fatigability, as it is not demonstrated that pain and fatigability results in functional limitation which more nearly approximates unfavorable ankylosis of the scapulohumeral articulation, with abduction limited to 25 degrees from the side. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 30 percent for left brachial plexus neuropathy for the period from September 17, 2012. As there is a preponderance of the evidence against the appeal for a rating in excess of 30 percent for left brachial plexus neuropathy, the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. III. Extraschedular considerations The Board has considered whether referral for an extraschedular evaluation is warranted for the Veteran's left brachial plexus neuropathy. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's left brachial plexus neuropathy has manifested in pain and numbness of the left shoulder and left arm and limitation of motion of the left shoulder. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically provides ratings for incomplete paralysis of the upper radicular group (Diagnostic Code 8510, 38 C.F.R. § 4.124a ), and contemplate ratings based on limitation of motion due to orthopedic factors such as pain and weakness (38 C.F.R. §§ 4.40 , 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of left brachial plexus neuropathy to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is therefore adequate. In the absence of exceptional factors associated with left brachial plexus neuropathy, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Prior to September 17, 2012, a 30 percent rating is granted for left brachial plexus neuropathy, subject to regulations governing the payment of monetary benefits. From September 17, 2012, a rating in excess of 30 percent for left brachial plexus neuropathy is denied. REMAND The Court has held that a request for a 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). A VA examination reports dated in April 2008 reflects that the Veteran reported that he stopped working in 2006 because he was unable to do his job with his left arm. A VA examination report dated in August 2011 reflects that the Veteran reported that he had not worked since 2008, in part due to his left shoulder. Upon VA examination in September 2012, a VA examiner opined that pain and limitation of motion associated with the Veteran's peripheral nerve condition impacts his ability to work. In light of this evidence, the issue of TDIU is reasonably raised by the record and must be adjudicated. The Board finds that a remand is warranted so that the Veteran may be provided with an examination to determine his unemployability, with adjudication thereafter of entitlement to a TDIU. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran VCAA notice regarding the issue of entitlement to a TDIU. 2. Schedule the Veteran for a VA examination. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examination report should indicate that the claims file was reviewed. After a thorough examination, the examiner should provide an opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. The examiner should provide a detailed rationale for the opinion. 3. After completion of the above and any additional development deemed necessary, entitlement to a TDIU should be adjudicated in light of all the evidence of record, to include on an extraschedular basis. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs