Citation Nr: 1317591 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 10-17 690 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for a headache disorder, claimed as secondary to service-connected hypertension. 2. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected hypertension. 3. Entitlement to service connection for sleep apnea. 4. Entitlement to service connection for depression. 5. Entitlement to an evaluation in excess of 20 percent for lumbosacral strain. 6. Entitlement to an increase in the 10 percent evaluation currently assigned for right shoulder entrapment syndrome. 7. Entitlement to an initial compensable evaluation for hypertension. 8. Entitlement to an increased (compensable) evaluation for photophobia of the right eye. 9. Entitlement to special monthly compensation (SMC) for loss of a creative organ. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from June 1981 to June 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2008 and October 2009 decisions by the RO. In November 2008, the RO granted service connection for hypertension and assigned a noncompensable evaluation, granted an increased rating to 20 percent for lumbosacral strain, and denied service connection for sleep apnea and increased ratings for the right shoulder and right eye disabilities. In October 2009, the RO denied service connection for erectile dysfunction (ED), headaches and depression and entitlement to SMC for loss of a creative organ. An RO hearing was held in January 2011, and a hearing before the undersigned at the RO was held in July 2012. The issues of service connection for erectile dysfunction, sleep apnea, depression, an increased rating for lumbosacral strain, and entitlement to SMC 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. The evidence concerning the Veteran's headache disorder is in relative equipoise and, therefore, is resolved in the Veteran's favor. 2. The Veteran's right shoulder disability is objectively manifested principally by pain and stiffness without instability, dislocation, nonunion or more than moderate limitation of motion, (motion to above shoulder level was possible), and no demonstrable functional impairment due to pain, incoordination, fatigability, or on repetitive use and no credible flare-ups. 3. The Veteran has a history of diastolic blood pressure predominantly 100 or more and requires continuous medication for control; since service connection was established, his hypertension has been manifested by diastolic pressure less than 100, and a systolic pressure less than 200. 4. Other than a sensitivity to light, there is no objective medical evidence of any impairment of visual acuity or field loss, pain, rest requirements, episodic incapacity or continuous active pathology associated with the Veteran's service-connected right eye photo phobia. CONCLUSIONS OF LAW 1. Service connection for a headache disorder is warranted. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, (2012). 2. The schedular criteria for an evaluation in excess of 10 percent for right shoulder entrapment syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Part 4, including Diagnostic Code 5203 (2012). 3. The criteria for an increased evaluation to 10 percent, and no higher, for hypertension are met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.104, Part 4, including Diagnostic Code 7101 (2012). 4. The criteria for a compensable evaluation for photophobia of the right eye are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.84a, Part 4, including Diagnostic Code 6009 (in effect prior to December 10, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claims, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Such notice must indicate that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id; 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in May 2008 and July 2009. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Furthermore, no argument has been advanced that there exists any error in the accomplishment of the duty to notify. With respect to the duty to assist in this case, the Board finds that, with respect to the issues addressed in this decision, all necessary development has been accomplished, and that appellate review may proceed without prejudice to the Veteran. The Veteran's service treatment records (STRs) and VA and private medical records have been obtained and associated with the claims file and are sufficient to decide the claim. The Veteran was also examined by VA during the pendency of this appeal and testified at an RO hearing in January 2011, and before the undersigned at the RO in July 2012. The Board also reviewed the Veteran's Virtual VA records. The Board finds that the VA examinations were comprehensive and adequate upon which to base a decision on the merits of the issues addressed in this decision. The VA examiners personally interviewed and examined the Veteran, elicited a medical history and provided the clinical information necessary to adjudicate the issues addressed in this decision. Further, neither the Veteran nor his representative have made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues on appeal, and have not argued that any error or deficiency in the accomplishment of the duty to assist has prejudiced him in the adjudication of his appeal. As noted above, the Veteran testified a hearing before the undersigned in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the hearing, the acting VLJ fully identified the issues on appeal and asked specific questions directed at identifying the location of any potentially outstanding medical evidence. Additionally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the undersigned has complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Accordingly, the Board finds that the duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service connection also may be granted for a disability that is proximately due to or the result of a service-connected condition. When service connection is established for a secondary condition, the secondary condition is considered as part of the original condition. 38 C.F.R. § 3.310(a) (2012). Also, when aggravation of a disease or injury for which service connection has not been granted is proximately due to, or the result of, a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Where a Veteran served for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and an organic disease of the of the nervous system becomes manifest to a degree of 10 percent within one year of 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). An alternative method of establishing the second and third Shedden/Caluza elements for a chronic disability listed under 38 C.F.R. § 3.309(a), is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir 2013); see also, Barr v. Nicholson, 21 Vet. App. 303 (2007); Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition listed under 38 C.F.R. § 3.309(a) was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). Headache Disorder The Veteran contends that service connection should be established for a headache disorder, because he was treated for headaches in service and was told that they were probably related to his hypertension. The STRs showed that the Veteran was treated for headaches on several occasions during service. An STR dated in May 1982, indicated that the Veteran's headaches began after he was started on a hypertension medication (handwritten medication illegible). STRs in February and March 1984 showed the Veteran was treated for headaches and light headedness that had been present for several days. The diagnosis in February was possible essential hypertension, and in March was rule out hypertension. At this point, the Board notes that the STRs showed that the Veteran was treated for elevated blood pressure readings on numerous occasions and was started and taken off hypertensive medications during service, but that he was not given a definitive diagnosis of hypertension until after his discharge from service. An STR in August 1988 indicated that the Veteran had known hypertension that was untreated because of headache side effects of medications. At the time of his service separation examination in January 1996, the Veteran denied any headaches. The report also noted that he was not taking any medications for hypertension. When examined by VA in August 2009, the Veteran reported that he had headaches three times a week, with pain in his neck and tightness like a band around his head and settling in his eyes. The report noted that the Veteran was taking two medications for hypertension, a muscle relaxer and medication for his mood. The diagnosis was muscle contracture, tension headaches. The examiner indicated that all of the Veteran's prescribed medications carried a possible side effect for headaches and, therefore, he could not render an opinion as to whether the Veteran's current headaches were related to his hypertensive medications, without resorting to speculation. The evidence required to warrant a grant of disability benefits does not have to be conclusive. The question is whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In adjudicating his claim, the Board must evaluate the Veteran's credibility. See Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005) (noting that the veteran and other persons can attest to factual matters of which they had first-hand knowledge, e.g., experiencing pain in service and witnessing events). In this case, the STRs showed that the Veteran complained of headaches when treated for elevated blood pressure readings consistent with hypertension on several occasions in service, and that on at least one occasion, his headaches were reported to have been associated with a hypertensive medication that he had been prescribed at that time. The Board notes that while the Veteran denied any headaches at the time of his service separation examination in January 1996, the report indicated that he was not taking any medications for his history of hypertension at that time. Although the VA examiner in August 2009, stated that he could not render an opinion as to whether the Veteran's headaches were related to his hypertensive medications without resorting to speculation, he noted that one side effect of the hypertensive medications was headaches. Given the noted history of headaches associated with the hypertensive medication he was taking in service, the Veteran's testimony that he has had chronic, recurring headaches since his discharge from service, and the VA medical opinion that such medications can cause headaches, the Board will resolve reasonable doubt in favor of the Veteran. Accordingly, service connection for a headache disorder is granted. Increased Ratings - In General In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1 (2012). 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 these elements. 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 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 which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. In evaluating musculoskeletal disabilities, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability and to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Right Shoulder Disability Historically, the Veteran's claim for an increased rating for his service-connected right shoulder disability was received in April 2008. Thereafter, the Veteran was examined by VA in August 2008, to determine the extent and severity of his shoulder disability. On examination, flexion was from zero to 160 degrees; adduction from zero to 150 degrees; internal rotation from zero to 40 degrees, and external rotation was from zero to 60 degrees, with pain reported through all ranges of motion. The Veteran complained of daily flare-ups that lasted a "few minutes." There was no additional limitation of motion due to pain, fatigue, weakness, lack of endurance or incoordination on repetitive motion. There was no heat, redness, edema, effusion or instability. There was some tenderness and reported weakness in the right shoulder, though the examiner noted that the Veteran was unable to give full effort due to pain. There was some guarding, but no abnormal movements in the shoulder. An x-ray study revealed AC joint and glenohumeral osteoarthritis. A VA physical therapy note, dated in September 2009 showed forward flexion of the right shoulder to 95 degrees, abduction to 105 degrees, extension to 40 degrees, external rotation to 75 degrees and internal rotation to 20 degrees. Strength in the shoulder was 3-/5. When examined by VA in February 2011, the Veteran complained of chronic pain and difficulty performing overhead activities with his right shoulder. On examination, there was some tenderness in the right shoulder but no deformity, giving way, instability, stiffness, weakness, incoordination, locking, effusion, flare-ups, dislocation or subluxation. Forward flexion and abduction was to 170 degrees, and external and internal rotation was to 90 degrees. There was pain on motion, but no additional limitation on repetitive movements. X-ray studies revealed minimum degenerative joint disease in the AC joint with possible impingement on the supraspinatus muscle or tendon and some calcific bursitis. In this case, the Veteran's right (major) shoulder disability is rated 10 percent disabling under Diagnostic Code (DC) 5203, for clavicle or scapula impairment, which provides for a 20 percent evaluation for dislocation or nonunion with loose movement, and a 10 percent evaluation for nonunion without loose movement or malunion. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Other potentially applicable code provisions include DC 5200 for ankylosis of the scapulohumeral articulation (where the scapula and humerus move as one piece). Under DC 5200, a 50 percent evaluation is assigned for unfavorable ankylosis of the minor joint with abduction limited to 25 degrees from the side; 40 percent for intermediate between favorable and unfavorable; and 30 percent for favorable ankylosis with abduction to 60 degrees, can reach mouth and head. Diagnostic Code 5202 provides for assignment of a 20 percent rating when there is malunion of the humerus with moderate deformity of the major or minor arm, and a 30 percent rating when there is malunion of the humerus with marked deformity of the major arm. Diagnostic Code 5202 also provides for assignment of a 20 percent rating when there is recurrent dislocation of the humerus at the scapulohumeral joint (of the major or minor arm) with infrequent episodes, and guarding of movement only at shoulder level; and a 30 percent rating when there is recurrent dislocation of the humerus at the scapulohumeral joint of the major arm with frequent episodes, and guarding of all arm movements. Diagnostic Code 5202 also provides for assignment of a 50 percent rating when there is fibrous union of the humerus of the major arm, a 60 percent rating when there is nonunion of the humerus (false flail joint) of the major arm, and an 80 percent rating when there is loss of head of the humerus (flail shoulder) of the major arm. DC 5201 provides for a 40 percent evaluation for the major joint when there is limitation of motion of the arm to 25 degrees or less from the side, a 30 percent rating when limitation of motion is midway between side and shoulder level, or with motion at shoulder level, and a 20 percent rating with limitation of motion to shoulder level. In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider reports of forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Forward flexion is the range of motion from the side of the body out in front, and abduction is the range of motion from the side of the body out to the side. Id. Normal range of shoulder motion is forward extension (flexion) from zero to 180 degrees; shoulder abduction is from zero to 180 degrees; internal rotation is from zero to 90 degrees; and external rotation from zero to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2012). Applying the appropriate Diagnostic Codes to the facts of this case, the objective assessment of the Veteran's impairment from his right shoulder disability does not suggest that he had sufficient symptoms so as to a warrant an evaluation in excess of 10 percent at any time during the pendency of this appeal. While clinical findings from the two VA examinations and physical therapy notes showed some limitation of motion of the right shoulder, the Veteran was able to raise his arm to no less than 95 degrees and significantly, no less than 150 degrees on multiple VA examinations, all of which were above shoulder level. In addition, there was no evidence of impairment of the humerus, such as malunion, fibrous union, nonunion or loss of head of the humerus (flail shoulder). Thus, there is no basis for an evaluation in excess of 10 percent under DC 5203, or under any other potentially applicable rating provision. The Board must also consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). In this regard, while the Veteran had increased pain on repetitive movement, there was no additional limitation of motion or impairment of the right shoulder when examined by VA during the pendency of this appeal. There was no objective evidence of any instability and no history of any dislocations of the shoulder. Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32 (Aug. 23, 2011) (holding that pain alone does not constitute functional loss, but is just one fact to be considered when evaluating functional impairment. The Court agreed that pain alone as a basis for a higher rating would produce such "absurd results" as for example where a claimant who experiences very slight pain throughout the range of motion of the knee would receive a 50% disability rating under DC 5261 and a 30% disability rating under DC 5260, whereas a claimant who experiences actual limitation of flexion to 30 degrees and limitation of extension to 20 degrees would only receive disability ratings of 20% and 30% respectively.). In addition, the Veteran did not complain of flare-ups at the Board hearing and denied flare-ups at the February 2011 VA examination but complained of flare-ups at the January 2011 DRO hearing and flare-ups that lasted a "few minutes" at the August 2008 VA examination. This inconsistency renders a showing of flare-ups unreliable and therefore not credible and certainly cannot form the basis for a higher rating. A higher rating cannot be based on medical speculation and certainly not lay speculation. Neither the Veteran nor the Board can speculate and arbitrarily pick a disability rating; there must be a basis in fact for the assigned rating. In regard to symptoms other than flare-ups, the Veteran is competent to report on symptoms and credible in his belief that he is entitled to a higher rating. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the shoulder impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The evidence of record does not show any additional functional impairment in the right shoulder commensurate with the criteria for an evaluation in excess of the 10 percent rating currently assigned. Applying all of the appropriate Diagnostic Codes to the facts of this case, an objective assessment of the Veteran's present impairment of the right shoulder does not suggest that he has sufficient symptoms so as to warrant an evaluation in excess of 10 percent at any time during the pendency of this appeal. See Fenderson v. West, 12 Vet. App. 119 (1999); see also, Hart v. Mansfield, 21 Vet. App. 505 (2007). Hypertension Historically, service connection was granted for hypertension by rating action in November 2008, based on VA examiner's opinion that the Veteran's elevated blood pressure readings in service were the initial manifestations of hypertension, which was first diagnosed less than two years after discharge from service. The RO assigned a noncompensable evaluation under DC 7101, on the basis that the Veteran was not shown to have a diastolic pressure predominantly 100 or a systolic pressure of predominantly 160 or more, or a history of diastolic pressure predominantly of 100 or more who requires continuous medication for control. Under DC 7101, a 10 percent rating is assigned when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation requires a diastolic pressure predominantly 110 or more; or systolic pressure of predominantly 200 or more. A 40 percent rating is assigned when diastolic pressure is predominantly 120 or more, and a 60 percent rating is assigned when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. In this case, post service medical records showed that the Veteran was treated for hypertension by a private physician beginning as early as December 1998. A report in December 1998, indicated that the Veteran's hypertension was out of control and that he was restarted on hypertensive medication at that time. A treatment note in February 1999, indicated that the medication he was started on (Cardizem), was not effective and was changed to hydrochlorothiazide. Private treatment notes from February until late May 1999 showed diastolic readings were predominantly 100. The medical reports since 1998, showed that the Veteran has been maintained on medication continuously, with some degree of control, except for instances when the Veteran either forgot or choose not to take his medication, and was strongly advised to continue taking them regularly. When examined by VA in October 2008, the Veteran reported that he had been monitoring his blood pressure, and that in recent weeks his systolic pressure ranged from 150 to 165, and his diastolic pressure ranged from 88 to 100. The report noted that the Veteran was taking two medications for his hypertension with no adverse side effects. The report noted that the Veteran was able to exercise for 11 minutes with no signs of ischemia on a recent stress test. Blood pressure readings were 156/86, 165/100 and 150/88. His heart size was normal, and there were no rubs, murmurs, or gallops. The diagnosis was essential hypertension, not optimally controlled. The Veteran's complaints and the clinical and diagnostic findings on VA examination in February 2011 were not significantly different from the 2008 VA examination, and showed the Veteran's blood pressures were 146/82, 136/86, and 137/83. After reviewing all the medical reports of record, the Board finds the preponderance of the evidence favors the assignment of a 10 percent evaluation for the Veteran's poorly controlled hypertension. The evidence showed that the Veteran had a diastolic pressure of predominantly 100 for nearly four months in 1999, when he was initially started on hypertensive medications. Although the medical reports indicated that the Veteran's hypertension was, at times, poorly controlled with medication, it is not clear what part the Veteran's failure to take his medications on a regular basis have played in that process. In any event, the medical reports of record clearly show that the Veteran's hypertension requires continuous medication. As such, the Board finds that the objective evidence supports the assignment of a 10 percent evaluation for his hypertension, since service connection was granted. However, the medical reports do not show a diastolic pressure of 110 or more, or systolic pressure of predominantly 200 or more at anytime during the pendency of this appeal. Accordingly, an evaluation in excess of 10 percent is not warranted. Right Eye Photo Phobia Initially, it should be noted that the criteria for the evaluation of disabilities of the eyes were amended effective December 10, 2008. However, the amended criteria govern cases only when the claim is filed on or after that date. 73 Fed. Reg. 66543 (November 10, 2008). Here, the Veteran's claim for an increased rating for his right eye disability was received in April 2008. Therefore, the rating criteria revised effective December 20, 2008, are not applicable. The Rating Schedule provides that unhealed eye injuries in chronic form are rated from 10 percent to 100 percent based on impairment of visual acuity or field loss, pain, rest requirements or episodic incapacity combining an additional 10 percent rating during continuous active pathology. 38 C.F.R. § 4.84a, DC 6009. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a, Table V. Historically, service connection was established and a noncompensable evaluation assigned for photo phobia of the right eye by the RO in July 1996, based on the STRs which showed treatment for itching, redness and tearing in the right eye on several occasions during service. Other than occasional conjunctivitis and daytime sensitivity to light, no pertinent abnormalities were noted and the Veteran's uncorrected visual acuity ranged from 20/15 to 20/20, bilaterally throughout his military service. During the pendency of this appeal, the Veteran was examined by VA at least five times, twice on an outpatient basis and three VA examinations. The Veteran's complaints and the clinical findings were not substantively different on all of the examinations. When seen for a diabetic eye evaluation in May 2008, the Veteran complained of tearing in both eyes and itching and light sensitivity in the right eye. The Veteran's uncorrected vision was 20/20-, bilaterally and there was no objective evidence of floaters/flashes, pain or discomfort. The assessment included type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy in the right eye and refractive error, bilaterally. The Veteran's visual acuity on a VA optometrist outpatient note in July 2008 was unchanged. When examined by VA in July 2008, the Veteran reported that his eyes burn and that it felt like grit under the eye lid. He also reported that his right eye tears when he is in the wind or in direct light, and that his eye feels better when he wears his reading glasses for near work. On examination, the Veteran's uncorrected vision was 20/20- in the right eye. Extraoccular movements were full, there was no evidence of visual field deficit, and the cornea, lens and anterior chambers were clear. The diagnoses included early diabetic retinopathy in the right eye, dry eye syndrome, bilaterally, and ectropion lower lids exacerbating the dry eye syndrome. When examined by VA in February 2011, the examiner indicated that the claims file was reviewed and included a description of the Veteran's complaints, medical history and the clinical findings on examination. Uncorrected (far and near) vision in the right eye was 20/20-2 and 20/30, respectively; the near vision was corrected to 20/20. There was no evidence of visual field deficit or diplopia. Motility was full, applanation was 16 mmHg and the lids and iris were normal, bilaterally. Conjunctiva was quiet, the cornea arcus, the anterior chamber deep and quiet, and the lens clear. The diagnoses included mild background diabetic retinopathy, bilaterally, not affecting vision with no history, treatment or limitations. History of dry eye syndrome, bilaterally; treated effectively with occasional artificial tears, posterior vitreous detachment without retinal pathology, bilaterally likely causing floaters, and corneal arcus, bilaterally - not affecting vision. In the present case, while the Veteran believes that his service-connected right eye photo phobia should be assigned a compensable rating, the objective evidence of record does not show any significant impairment of visual acuity, and no field of vision loss, pain, rest requirements, episodic incapacity or continuous active pathology on account of the photophobia. The Veteran's need for reading glasses is due to refractive error, and his mild nonproliferative diabetic retinopathy is due to his nonservice-connected diabetes mellitus. Other than needing sunglasses in bright lights and occasional dry eye bilaterally, the medical evidence does not show any evidence of active pathology or any pertinent abnormalities associated with his photo phobia of the right eye. The Veteran is competent to report on symptoms and credible in his belief that he is entitled to a higher rating. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the eye impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. Accordingly, there is no basis for the assignment of a compensable evaluation, and the claim is denied. Collateral Matters Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2012); Thun, 22 Vet. App. at 116. The rating criteria in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected disabilities, but the evidence reflects that those manifestations are not present in this case. The Veteran primarily complains of shoulder pain on movement and burning, dryness, and light sensitivity of the eye. These are not exceptional or unusual features of the disabilities and are symptoms contemplated in the rating criteria and related regulations. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board finds that a claim for a TDIU was not expressly raised by the Veteran or reasonably raised by the record. The Veteran has been employed full-time for the same employer for 10 years and reported missing only a few days of work due to the service-connected disabilities. Moreover, the Veteran does not allege nor does the evidence suggest that he is unemployable due to his service-connected disabilities. Based on the evidence of record, the Board finds that further consideration of a TDIU is not warranted. ORDER Service connection for a headache disorder is granted. An increased evaluation for right shoulder impingement syndrome is denied. An increased evaluation to 10 percent, and no higher, for hypertension is granted, subject to VA laws and regulations pertaining to the payment of monetary benefits. An increased evaluation for photophobia of the right eye is denied. REMAND Concerning the claims of service connection for a erectile dysfunction (ED), sleep apnea, depression and an increased rating for the low back disability, the Board finds that additional development is necessary prior to appellate review. Specifically, while the VA examiner in August 2009, indicated that the claims file was reviewed, there are some factual inconsistencies reported on in the examination report. Specifically, the examiner reported that the Veteran was diagnosed with ED in 2004. However, private medical reports of record showed that he had ED problems and was first given a prescription for Viagra in early 2000, around the same time that he was first diagnosed with diabetes mellitus. Concerning the claims for sleep apnea and depression, the Board notes that while the Veteran was examined by VA during the pendency of this appeal, the examiners did not offer a medical opinion as to the etiology or date of onset of the claimed disabilities. Where a medical examination does not contain sufficient detail to decide the claim on appeal, the Board must return the report as inadequate for evaluation purposes. Hayes v. Brown, 9 Vet. App. 67, 73 (1996); see also, Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (noting that once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). In this case, the Board finds that the August 2009 VA examinations were inadequate, and that further development is necessary. VA is required to attempt to obtain a clear and unambiguous medical opinion based on the available evidence of record. If, after review of all the pertinent evidence of record, the examiner is unable to render an opinion, he or she must include a discussion of all relevant facts and provide an explanation as to why an opinion would be speculative. Also, at the Board hearing, the Veteran reported that he received mental health treatment on two occasions in service and received medication to treat his depression. The December 1995 separation Report of Medical History shows the Veteran reported a positive history of "depression or excessive worry" and "nervous trouble of any sort." The Board recognizes that mental health records are often maintained separately from service treatment records. Accordingly, a specific request for these records should be made. Lastly, the SMC claim is inextricably intertwined with the ED claim. At the hearing before the undersigned in July 2012, the Veteran testified that he had an EMG/NCV study at Temple VA about a year earlier that showed he had foot drop associated with his low back disability. However, a review of the claims file and Virtual VA records system failed to include the reported EMG study. In as much as the Veteran was not shown to have foot drop or any other objective neurological manifestations when last examined by VA in February 2011, the reported diagnostic study is pertinent to his claim and must be obtained prior to appellate review. In light of the Veteran's testimony, a new examination should be scheduled to evaluate the current severity of his service-connected lumbosacral strain. Caffery v. Brown, 6 Vet. App. 377 (1995); see also VAOPGCPREC 11-95 (1995). In this regard, the Board notes that service connection is established for lumbosacral strain. While the STRs showed treatment for back strain in service, there were no complaints or any neurological abnormalities noted, and no diagnostic evidence of any degenerative changes in the lumbar spine in service. Similarly, no neurological abnormalities were shown when examined by VA in February 1996. However, a private medical report dated in January 2008, showed that the Veteran now has evidence of degenerative disc disease at the L5-S1 disc level, with radiating pain into his lower extremities. A letter from a private physician, dated in May 2009, indicated that an MRI showed widespread degenerative disc disease with a bulging disc on the left side, which the physician indicated was the probable cause of the Veteran's symptoms. Part of VA's duty to assist under the Veterans Claims Assistance Act of 2000 (VCAA) is to provide the Veteran with an examination if, as in this case, there is competent evidence of a current disability, and the evidence indicates that the current disability may be related to an event in service or to a service-connected disability. 38 C.F.R. § 3.159(c)(4) (2012). In light of the discussion, it is the decision of the Board that further development is necessary prior to appellate review. Accordingly, the claim is REMANDED for the following action: 1. The AMC should take appropriate steps to contact the Veteran and obtain the names and addresses of all medical care providers who treated him for his sleep apnea and any psychiatric problems since his discharge from service, and for any low back problems since 2010. After the Veteran has signed the appropriate releases, all available outstanding, pertinent records should be obtained and physically or electronically associated with the claims folder, including any VA treatment records since January 2010 - the most recent VA treatment report of record. Of particular interest is an EMG/NCV test reportedly conducted at Temple VAMC in 2011. 2. From appropriate sources, request the Veteran's in-service mental health records, if any. 3. After any additional records have been obtained, the Veteran should be scheduled for appropriate VA genitourinary, respiratory and psychiatric examinations to determine the nature and etiology of his ED, sleep apnea and psychiatric problems. The claims folder and a copy of this remand should be made available to the examiners for review, and a notation to the effect that this record review took place should be included in the reports. The examiners should respond to the following: Genitourinary: Is it at least as likely as not that the Veteran's ED is proximately due to, the result of, or aggravated by his service-connected hypertension, including any medications taken for that disability? Respiratory: Is it at least as likely as not that the Veteran's sleep apnea was first manifested in service or is otherwise related to service? The examiner must consider the Veteran's contention that he was advised by his roommates that he would snore and stop breathing during service and that he continued to experience such symptoms after service. Psychiatric: Is it at least as likely as not that any psychiatric disorder was first manifested in service or is otherwise related to service? The examiner is to consider all the evidence of record including the December 1995 separation Report of Medical History that shows the Veteran reported a positive history of "depression or excessive worry" and "nervous trouble of any sort." A fully articulated medical rationale for any opinion expressed should be set forth in the examination reports. The examiners should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If the examiners are unable to render an opinion without resorting to speculation, this should be noted and explained. In so doing, the examiners should identify the evidence required in order to render a non-speculative opinion, or indicate the inability to provide the opinion is based on the limits of medical knowledge. If the examiners are unable to render an opinion because of a lack of specified evidence, the AMC should attempt to obtain that evidence and return the claims file to the examiner for completion of the opinion. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravation" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. 4. The Veteran should also be afforded VA orthopedic and neurological examinations to determine the current severity of his lumbosacral strain and the etiology of his lower extremity symptoms. All indicated tests and studies are to be performed. The claims folder must be made available to the examiners for review, and a notation to the effect that this record review took place should be included in the report. The examiners should provide a response to each of the following questions/instructions. The orthopedic examiner should respond to the following: a) Note any limitations of motion in the thoracolumbar spine and the degree at which pain, if any, is experienced. b) Indicate whether the thoracolumbar spine exhibits weakened movement, excess fatigability, or incoordination. If feasible, these determinations should be expressed in terms of additional range of motion loss or favorable or unfavorable ankylosis due to any excess fatigability, weakened movement or incoordination. c) Lastly, the examiner should express an opinion on whether pain of the thoracolumbar spine could significantly limit functional ability during flare-ups or when the spine is used repeatedly over a period of time. These determinations should also, if feasible, be portrayed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. The neurological examiner should identify any neurological complaints or findings attributable to the service-connected lumbosacral strain. If the Veteran has neurological symptoms associated with his lumbosacral strain, the examiner should provide a written discussion of the degree of any residual weakness or sensory disturbance, and how it impacts on motor function of the lumbar spine. The examiner should also: a) The examiner should note whether any intervertebral disc syndrome that may be present in the thoracolumbar spine results in incapacitating episodes, and indicate the total duration of any episodes. 5. Following completion of the foregoing, the AMC must review the claims file and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC should determine whether the examiner has responded to all questions posed. If not, the reports must be returned for corrective action. See 38 C.F.R. § 4.2 (2012). 6. After the requested development has been completed, the AMC should readjudicate the claims. This should include consideration of whether any current ED is proximately due to, the result of, or aggravated by the service-connected hypertension, including the medications taken for said disability. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. 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). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs