Citation Nr: 1318310 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 06-22 842 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to a rating in excess of 20 percent for a right shoulder disability. 2. Entitlement to a rating in excess of 10 percent for hypertension. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1983 to November 1990. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision by the St. Louis, Missouri Department of Veterans Affairs (VA) Regional Office (RO) which granted an increased 10 percent rating for the Veteran's service-connected hypertension, effective April 2, 2004, and continued a noncompensable rating for a right shoulder disability. The Veteran's claims file is now in the jurisdiction of the Chicago, Illinois RO. The Veteran testified before the undersigned Veterans Law Judge in a May 2009 Travel Board hearing. A transcript of the hearing is associated with the claims file. In an August 2010 rating decision, the Veteran was granted an increased 10 percent rating for the right shoulder disability, effective November 14, 2009. In September 2011, the Board issued a decision that granted an increased 20 percent rating for the Veteran's right shoulder disability, effective April 2, 2004, and denied an increased rating for hypertension. He appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2012, the Court vacated the Board decision denying a rating in excess of 20 percent for a right shoulder disability and a rating in excess of 10 percent for hypertension and remanded the issues to the Board for further action consistent with a Joint Motion for Partial Remand (Joint Motion) by the parties. In December 2012, the Board remanded the matters for further development. The Board notes that the issue of entitlement to service connection for headaches was remanded by the Board in September 2011. Because this claim remains in remand status, it is not currently ready for appellate review. FINDINGS OF FACT 1. The Veteran is right-hand dominant. 2. Prior to October 6, 2010, the Veteran's right shoulder disability was manifested by arthritis with painful motion and evidence of impairment of the clavicle and scapula manifested by recurrent dislocation. Ankylosis of the scapulohumeral articulation, compensable limitation of motion, malunion of the humerus with marked deformity, loss of the head of the humerus, nonunion of the humerus, fibrous union of the humerus, or recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements, is not shown. 3. Effective October 6, 2010, resolving all reasonable doubt in the Veteran's favor, the Veteran's right shoulder disability approximates limitation of motion of the arm to midway between the side and shoulder level and impairment of the clavicle and scapula manifested by recurrent dislocation. Ankylosis of the scapulohumeral articulation, limitation of motion to 25 degrees from the side, malunion of the humerus with marked deformity, loss of the head of the humerus, nonunion of the humerus, fibrous union of the humerus, or recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements, is not shown. 4. The Veteran's overall disability picture does not show that his hypertension has been manifested by diastolic blood pressure predominantly 110 or more or systolic blood pressure predominantly 200 or more. CONCLUSIONS OF LAW 1. The criteria for the assignment of a rating in excess of 20 percent for impairment of the Veteran's right shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes (DC) 5200, 5202, 5203 (2012). 2. Prior to October 6, 2010, the criteria for the assignment of a separate rating of 10 percent for arthritis of the Veteran's right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5003-5201 (2012). 3. Effective October 6, 2010, the criteria for an increased rating to 30 percent rating, but no higher, for limitation of motion of Veteran's right shoulder disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a, DCs 5003-5201 (2012). 4. The criteria for a rating in excess of 10 percent for the Veteran's hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.104, DC 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. In a claim for increase, the VCAA requirement is notice of 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 notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of his claims. May 2004 (regarding the hypertension claim only), March 2006, and January 2009 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The March 2006 letter also informed him of the degree of disability and effective date criteria. It is not alleged that notice in this case was less than adequate. See Shinseki v. Sanders, 556 U.S. 396 (2009) (discussing the rule of prejudicial error). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances of the case. The Veteran's service treatment records are associated with the claims file, as are postservice private and VA treatment records, particularly VA treatment records for the period from August 2009. The Veteran has also been afforded appropriate and adequate VA examinations. The examinations assessed the current severity of his service-connected right shoulder disability and hypertension, noting all findings necessary for a proper adjudication of the matters. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The Veteran was also afforded a hearing before a VLJ at which he presented oral argument in support of his increased rating 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 VLJ who chairs a hearing fulfill two duties to comply with the above 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. During the May 2009 Board hearing, the VLJ did not note the bases of the prior determination or the elements that were lacking to substantiate the claims. The VLJ asked specific questions, however, directed at identifying whether the Veteran had symptoms meeting the criteria for an increased rating. The VLJ indicated the types of evidence that would help substantiate the Veteran's claims and specifically sought to identify any pertinent evidence not currently associated with the claims file. In addition, the Veteran volunteered his pertinent treatment history and symptoms since service. Accordingly, he is not shown to be prejudiced on this basis. Finally, neither he nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, 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 the claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Accordingly, the Board finds that the duty to notify and the duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (i.e., VA's electronic data storage system), 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) (VA must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). 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 (Rating 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. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996); Dalton v. Nicholson, 21 Vet. App. 23, 28 (2007). Right Shoulder Disability As noted above, the Board in a September 2011 decision granted an increased 20 percent rating for the Veteran's right shoulder disability, effective April 2, 2004 (date of claim), under 38 C.F.R. § 4.71a, Code 5203. The grant was effectuated by an October 2011 rating decision. Arthritis due to trauma is rated as degenerative arthritis, based on limitation of motion of the joint involved. See 38 C.F.R. § 4.71a, Codes 5010, 5003. When there is x-ray evidence of degenerative arthritis in a specific major joint or group of minor joints, a 10 percent rating may be assigned for limitation of motion of such joint(s) that does not meet the criteria for a compensable rating for limitation of motion of that joint under the specific diagnostic code for the joint. Shoulder disabilities are evaluated under Codes 5200 to 5203. [Because the Veteran is right-arm dominant, the right shoulder disability is evaluated as a major joint. 38 C.F.R. § 4.69.] Under Code 5200, ankylosis of the scapulohumeral joint warrants a 30 percent evaluation for favorable ankylosis with abduction to 60 degrees and the ability to reach the mouth and head. 38 C.F.R. § 4.71a. Under Code 5201 (for limitation of shoulder motion), the minimum schedular rating (20 percent) is warranted where there is limitation of motion of an arm at the shoulder level. Limitation of major arm motion to midway between the side and shoulder level warrants a 30 percent rating. Id. Under Code 5202, malunion of the major humerus with moderate deformity or recurrent dislocation at the scapulohumeral joint with infrequent episodes and guarding of movement warrants a 20 percent rating. Malunion of the humerus with marked deformity, or; recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements warrants a 30 percent rating. Id. Under Code 5203, a 10 percent rating is warranted for malunion of the clavicle or scapula, or for nonunion of the clavicle or scapula without loose movement. A 20 percent (maximum) rating is warranted if there is nonunion of the clavicle or scapula with loose movement, or if there is dislocation of the clavicle or scapula. Impairment of the clavicle or scapula may also be rated based on the impairment of function of the contiguous joint. Id. Normal range of motion of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Historically, the Veteran's service treatment records show that he fell and dislocated his right shoulder. X-rays revealed a third-degree separation of the right acromioclavicular (AC) joint. Although surgery was considered, the Veteran ultimately decided on a more conservative course of rest and immobilization, followed by physical therapy. A November 1991 rating decision granted service connection for a right shoulder disability, effective November 2, 1990 (day after separation from active service). The instant claim for an increased rating was received in 2004. On June 2004 VA examination, the Veteran reported he has periodic right shoulder separation, last separating one year ago. He also reported he has right shoulder pain (rated 5 on a scale to 10) for which he takes aspirin. On physical examination, the Veteran demonstrated an ability to lift 30 to 40 pounds with his right upper extremity, with no signs of crepitus or muscle injury. The muscles around the shoulder appeared well-developed with 5/5 muscle strength. On range of motion testing, forward flexion was from 0 to 180 degrees, abduction from 0 to 180 degrees, and internal and external rotation from 0 to 90 degrees. Range of motion during passive, active and on repetitive testing was the same. There was no limitation due to weakness, fatigability, incoordination or flare-ups. The Veteran denied any incapacitating episodes or any effect on his usual occupation or daily activities. The examiner provided a diagnosis of right shoulder strain. On January 2005 VA examination, the Veteran reported he has separation of the right shoulder when he does some activities, last occurring in July 2004. He also related he has right shoulder pain, rated a 4 (on a scale to 10), two times per week, relieved by aspirin. He indicated he works as a truck driver without any problem regarding his shoulder, and that his daily activities are not restricted because of his right shoulder. On physical examination, the right shoulder was not swollen, tender, or warm. On range of motion testing, forward flexion was from 0 to 180 degrees, abduction from 0 to 180 degrees, and internal and external rotation from 0 to 90 degrees. There was no additional limitation due to pain, weakness, fatigability or incoordination on repetitive range of motion testing, and there were no flare-ups. The examiner provided a diagnosis of intermittent right shoulder separation. In his April 2005 notice of disagreement, the Veteran related that he is unable to lift anything of weight or help anyone with any type of physical support. He further indicated he was limited in his responsibilities at work because of right shoulder pain. He also stated he has constant aggravation of his right shoulder. Postservice VA treatment records include August and October 2007 reports noting the Veteran's complaint of minimal right shoulder pain. On physical examination, there was full range of motion with crepitus. In a November 2008 report, he complained of decreased strength, reduced range of motion, persistent pain, bone protrusion, and a "popping" sound. In December 2008 correspondence, the Veteran reported he has chronic right shoulder pain and reduced strength. At the May 2009 Travel Board hearing, the Veteran testified that a bone sticks up off of his right shoulder and that it is very painful. He also testified he has a diminished grip, decreased strength, is unable to sleep on his right shoulder, and has constant pain. He also indicated that it affects his job as a truck driver. He further stated that his right shoulder disability is manifested by stiffness, soreness, and limited range of motion (with popping). VA treatment records include a March 2009 report noting the Veteran's complaint of chronic right shoulder pain (rated a 7 on a scale to 10). In June 2009, he reported no limitation to range of motion in his shoulder, but occasional nighttime soreness. On November 2009 VA examination, the Veteran complained of right shoulder pain, especially with overhead-type activities. He also complained of difficulty lying on his right shoulder. He indicated he was able to complete his duties at work. On physical examination, there was a prominent distal clavicle and AC joint on the right shoulder. There was no evidence of muscle atrophy. There was tenderness to palpation over the AC joint. Range of motion testing revealed pain on flexion and abduction at 120 degrees, and internal and external rotation without painful limitation of motion. There was no change in range of motion during passive, active, or after repetitive motion testing. There was no loss of joint function with use due to pain, weakness, fatigability, incoordination or flare-ups. It was noted that there were no incapacitating episodes and his right shoulder disability had no effect on his usual occupation or daily activities. There was positive impingement testing of the right rotator cuff musculature, but the rotator cuff appeared grossly intact. There was no evidence of gross instability. X-rays revealed a previous grade 3 AC joint separation, calcification along the distal clavicle region, and calcification along the AC ligament near the coracoid extending to the midshaft of the clavicle. The examiner provided an impression of posttraumatic grade 3 AC joint separation with rotator cuff impingement and rotator cuff tendinitis. The examiner further noted that the Veteran was developing degenerative changes in the AC joint secondary to his AC joint separation which are becoming symptomatic with certain over-head activities. VA treatment records include an August 2010 report noting the Veteran's complaint of right shoulder pain. It was noted he may have degenerative disease in his shoulder. August 2010 radiology of the right shoulder was essentially negative. There was an old injury with slight separation of the AC joint and ossifications in the interior aspect of the lateral and of the right clavicle. An October 6, 2010 report noted his complaint of moderate right shoulder pain and difficulty abducting his shoulder. On physical examination, there was a decrease in abduction of the right shoulder. There was no difficulty with flexion. On January 2013 VA examination, the Veteran reported a worsening of pain and increased limitation of motion since the original injury during active service. He denied incapacitating episodes, but reported he has moderate to moderately severe pain with motion. He also indicated he can no longer lift his right arm above shoulder level. He denied any redness, swelling, heat, or drainage from his right shoulder. It was noted that the Veteran has flare-ups of severe pain in the right shoulder once weekly with usage usually associated with previous repetitious activity. On physical examination, range of motion testing revealed forward flexion to 145 degrees (with pain beginning at 125 degrees), abduction to 80 degrees (with pain beginning at 70 degrees). Following repetitive range of motion testing, flexion was to 125 degrees, and abduction was to 75 degrees. It was noted that repetitive use caused less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, and deformity. There was localized tenderness/pain on palpation of the right shoulder. There was no guarding of the right shoulder. Muscle strength was 4/5 (active movement against some resistance) on shoulder abduction, and 5/5 on shoulder flexion. The examiner specifically noted there was no evidence of ankylosis. It was noted that there was no history of recurrent dislocation of the glenohumeral joint. It was noted that there was dislocation of the AC joint, and tenderness on palpation of the AC joint. The examiner provided a diagnosis of osteoarthritis right shoulder secondary to traumatic acromioclavicular separation grade 3 in military, as well as residuals of AC separation with rotator cuff tendinitis resulting in limitation of range of motion and pain with range of motion. The examiner stated that limitation of motion is such that his right arm on abduction can only go from his side to part-way to the level of the shoulder (i.e., less than 90 degrees). As noted above, the Veteran is rated 20 percent for his service-connected right shoulder disability under Code 5203 for frequent shoulder dislocations of the clavicle or scapula. Prior to October 6, 2010, there is evidence of degenerative arthritis established by x-ray findings (see November 2009 VA examination report) of the right shoulder with noncompensable limitation of motion. Under Code 5003, such warrants a separate 10 percent rating throughout the appeal period. As the Board is granting a separate 10 percent rating under Code 5003, the Board finds that it has complied with the instructions of the March 2012 Joint Motion. To the extent the Veteran seeks a further increased rating, the Board notes that the Veteran is receiving the maximum, 20 percent, rating under Code 5203. Accordingly, Code 5203 is of no benefit to the Veteran. Furthermore, as the evidence of record shows no evidence of ankylosis, and there is no allegation of such, DC 5200 is of no benefit to the Veteran. In addition, there is no evidence of malunion of the humerus with marked deformity, or recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements. Hence, Code 5202 is also not applicable. To warrant a separate rating under Code 5201, there must be limitation of motion to the shoulder level (90 degrees). For the period prior to October 6, 2010, the Veteran has had right shoulder motion well above shoulder level, to include to 180 degrees in June 2004, January 2005, and October 2007, and to 120 degrees in November 2009. While the Veteran has some additional limitations due to pain/on use, these do not rise to the level of equivalency to limitation of motion to the shoulder level. Notably, on November 2009 VA examination, while there was evidence of limitation of motion on flexion and abduction, there was no change in range of motion during passive, active, or after repetitive motion testing, and there was no loss of joint function with use due to pain, weakness, fatigability, incoordination or flare-ups, so as to approximate limitation of motion to the shoulder level. Hence, the Board finds that prior to October 6, 2010, entitlement to a separate rating under Code 5201 for limitation of motion (with consideration of DeLuca) is not warranted. For the period since October 6, 2010, as noted above, an October 6, 2010 VA treatment report noted the Veteran's complaint of moderate right shoulder pain and difficulty abducting his shoulder. On physical examination, there was a decrease in abduction of the right shoulder (the extent of the limitation not documented). Furthermore, on January 2013 VA examination, abduction was limited to 80 degrees, with pain beginning at 70 degrees. Repetitive range of motion testing revealed abduction limited to 75 degrees. Significantly, the examiner noted that repetitive use caused less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, and pain on movement. The Board finds that the level of functional impairment caused by the Veteran's right shoulder disability, to include pain, limitation of motion, and weakened movement, most closely approximates motion limited to midway between the side (0 degrees) and shoulder level (90 degrees). See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, the criteria for a separate 30 percent disability rating under Code 5201 have been approximated for the period since October 6, 2010. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). A further increased separate rating is not warranted as there is no evidence of limitation of motion to 25 degrees from the side, ankylosis of scapulohumeral articulation, loss of the head of the humerus, nonunion of the humerus, or fibrous union of the humerus. Therefore, at this time, Diagnostic Codes 5200, 5202, and 5203 are not properly applicable. [To the extent the Board grants a separate 30 percent rating under Code 5201 for limitation of motion for the period since October 6, 2010, the Board notes that such does not disturb the 20 percent rating under Code 5203 for impairment of the clavicle and scapula manifested by recurrent dislocation.] Hypertension Hypertension is rated under Code 7101. A 10 percent evaluation is to be assigned if diastolic pressures are predominantly 100 or more, or; systolic pressures are predominantly 160 or more, or; as a minimum evaluation with a history of diastolic pressures predominantly 100 or more and continuous medication required for control. A 20 percent rating requires diastolic pressures predominantly 110 or more, or; systolic pressures predominantly 200 or more. The next higher (40 percent) rating requires diastolic pressures predominantly 120 or more. 38 C.F.R. § 4.104. (Notes following include that hypertensive heart disease is to be separately rated from hypertension.) Historically, an April 2005 rating decision granted an increased 10 percent rating for the Veteran's service-connected hypertension, effective April 2, 2004 (date of claim). Private treatment records show that in April 2003, a blood pressure reading was 140/90. In May 2003, a blood pressure reading was 130/90. VA treatment records show that in May 2003, blood pressure readings were 146/73 and 131/90. In June 2003, a blood pressure reading was 124/65. In September 2003, a blood pressure reading was 143/77. In February 2004, a blood pressure reading was 136/76. In April 2004, blood pressure readings were 162/86 and 130/90. On June 2004 VA examination, it was noted the Veteran had no hypertensive heart disease or arteriosclerotic complications of hypertension. It was also noted that his medications include Atenolol, Lisinopril, and Diltiazem for high blood pressure. Blood pressure readings were 150/80, 150/80 and 150/80. The diagnoses included hypertension and no heart disease. VA treatment records show that in June 2004, a blood pressure reading was 156/83. In July 2004, a blood pressing reading was 116/59. In December 2004, a blood pressure reading was 135/75. Private treatment records show that in July 2004, a blood pressure reading was 140/90. In August 2004, blood pressure readings were 130/90 and 140/80. In September 2004, a blood pressure reading was 128/86. On January 2005 VA examination, it was noted that the Veteran's medication for hypertension included Lisinopril, Diltiazem, Potassium Chloride and Metolazone. Blood pressure readings were 135/75, 135/75 and 135/75. It was noted that there was no evidence of hypertensive heart disease and no cardiovascular complications of hypertension. The diagnosis was hypertension, moderate severity. VA treatment records show that in January 2005, a blood pressure reading was 114/78. In March 2005, a blood pressure reading was 124/68. In April 2005, blood pressure readings were 161/82 and 136/84. In June 2005, blood pressure readings were 145/91 and 151/96. In July 2005, a blood pressure reading was 151/96. In August 2005, a blood pressure reading was 146/98. In September 2005, a blood pressure reading was 158/84. In January 2006, blood pressure readings were 164/107 and 167/97. In March 2006, a blood pressure reading was 138/88. Private treatment records show that in March 2005, a blood pressure reading was 122/70. In May 2005, a blood pressure reading was 130/90. In August 2005, a blood pressure reading was 150/100. In November 2005, a blood pressure reading was 150/88. In May 2006, a blood pressure reading was 120/74. In June 2006, blood pressure readings were 122/82 and 124/82. On VA examination in May 2006, blood pressure readings were 140/95 on two readings, and 140/90 on a third. The impression was hypertension-poorly controlled requiring multiple medications. In his July 2006 VA Form 9, the Veteran reported that his blood pressure readings were sometimes 200/110. VA treatment records show that in September 2006, blood pressure readings were 128/80 and 122/80. In November 2006, a blood pressure reading was 122/78. In February 2007, a blood pressure reading was 119/67. In March 2007, blood pressure readings were 108/68 and 124/86. In May 2007, a blood pressure reading was 138/89. In June 2007, a blood pressure reading was 150/110; it was noted he had been drinking coffee. In July 2007, blood pressure readings were 134/90 and 130/78. In August 2007, a blood pressure reading was 136/79. In October 2007, a blood pressure reading was 138/81. In June 2008, a blood pressure reading was 135/74. In December 2008, blood pressure readings were 136/92 and 123/74. In March 2009, blood pressure readings were 141/77 and 143/72. In June 2009, blood pressure readings were 123/74 and 141/85. In August 2009, blood pressure readings were 135/82 and 137/78. In October 2009, a blood pressure reading was 146/87. Private treatment records show that in August 2006, a blood pressure reading was 130/82. In November 2006, a blood pressure reading was 130/88. In February 2007, a blood pressure reading was 130/78. In December 2008, a blood pressure reading was 120/82. In February 2009, a blood pressure reading was 136/82. In May 2009, a blood pressure reading was 140/84. In June 2009, a blood pressure reading was 140/90. In October 2009, a blood pressure reading was 120/80. On November 2009 VA examination, blood pressure readings were 160/100, 160/100 and 155/95. On February 2010 VA examination, blood pressure readings were 130/80, 130/80 and 125/80. VA treatment records show that in February 2010, a blood pressure reading was 153/74. In March 2010, a blood pressure reading was 146/92. In April 2010, a blood pressure reading was 166/112. In May 2010, blood pressure readings were 142/88 and 140/92. In July 2010, a blood pressure reading was 152/84. In August 2010, blood pressure readings were 134/78 and 131/77. In September 2010, a blood pressure reading was 141/82. In October 2010, blood pressure readings were 141/82 and 160/80. In March 2011, blood pressure readings were 132/77 and 146/82. In April 2011, blood pressure readings were 160/97 and 127/76. In May 2011, a blood pressure reading was 119/75. In June 2011, a blood pressure reading was 141/86. In July 2011, blood pressure readings were 128/82, 132/82 and 134/82. In August 2011, a blood pressure reading was 128/64. In September 2011, a blood pressure reading was 146/80. In October 2011, a blood pressure reading was 140/90. In November 2011, a blood pressure reading was 122/70. In December 2011, blood pressure readings were 144/87 and 129/59. In January 2012, blood pressure readings were 122/72 and 124/66. In February 2012, a blood pressure reading was 161/104. In March 2012, blood pressure readings were 150/70, 172/108, 154/104 and 146/78. In April 2012, a blood pressure reading was 158/100. In May 2012, blood pressure readings were 157/85 and 118/63. In June 2012, blood pressure readings were 153/83, 158/95 and 150/75. In July 2012, blood pressure readings were 142/82 and 148/78. In October 2012, blood pressure readings were 134/83, 116/58 and 118/108. In November 2012, a blood pressure reading was 166/93. On January 2013 VA examination, it was noted that the Veteran's hypertension medications included Metoprolol, Nifedipine, and Lisinopril. On physical examination, blood pressure readings were 140/84, 146/90 and 142/88. The examiner found that the Veteran's hypertension had no impact on his ability to work. The examiner also noted the Veteran was on a multiple drug regimen and found he has moderately severe hypertension. With good compliance with his medication, which the Veteran attested to, he has had reasonable control of his hypertension, albeit not optimal. The Veteran's blood pressure readings recorded throughout the rating period consistently provide evidence against his claim, as the overall disability picture shows diastolic and systolic pressures that do not meet the schedular criteria for the next higher, 20 percent, rating. The record does not show that at any time during the rating period the Veteran's systolic pressures were predominantly 200 or more; there was not a single systolic pressure of 200 or more. In fact, the highest systolic pressure recorded is 172 in March 2012. In addition, the Board notes that there were only two instances throughout the rating period during which diastolic pressures were 110 or more. Specifically, a diastolic pressure of 110 was found in June 2007. However, it was noted that he had been drinking coffee, and such indicates the elevated diastolic pressure was due to the coffee, and not due to his hypertension. Such is supported by the fact that in May 2007, his diastolic pressure was 89, and in July 2007, his diastolic pressure was no greater than 90. The other instance in which a diastolic pressure of 110 was found was in April 2010, which found a diastolic pressure of 112. The Board finds that the April 2010 diastolic pressure of 112 reflects an acute episode of elevated diastolic pressure as subsequent May 2010 blood pressure readings were 142/88 and 140/92. Hence, the evidence of record during the rating period does not show diastolic pressures predominantly 110 or more so as to warrant an increased (20 percent) rating under 38 C.F.R. § 4.104, Code 7101. To the extent the Veteran attempts to substantiate his claim for an increased rating in his July 2006 VA Form 9 wherein he reported that his blood pressure readings were sometimes 200/110, the Board finds such accounts not credible. While the Veteran is certainly competent to remember blood pressure readings which he may obtain while at his home or elsewhere (see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007)), the Board finds his recollection of blood pressure readings that would warrant an increased 20 percent rating to be unsupported by the medical evidence of record and made in connection with a claim for compensation, not credible. See Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). The objective medical evidence is of more probative and persuasive value. While the Board is certainly sympathetic to the Veteran's claim, the blood pressure readings throughout the appeal period do not warrant an increased 20 percent rating for his hypertension, even with consideration of medicine to control his hypertension. The Board therefore finds that the Veteran's hypertension is consistent with a 10 percent rating throughout the appeal period. See Jones v. Shinseki, 26 Vet. App. 56, 61-63 (2012) (holding that the Board may deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria). As the Veteran's hypertension specifically entails rating the disability based on the effect of the disability by medication, the Board finds that denying a rating in excess of 10 percent is not in error. Extraschedular Consideration The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is, thus, found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Here, the Board finds that the schedular ratings for the Veteran's right shoulder disability and his hypertension fully address his underlying symptoms. Referral to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for consideration of an extraschedular evaluation is not warranted. The competent evidence of record does not show that these service-connected disabilities, alone or together, cause impairment beyond that contemplated by the schedular rating criteria. As set forth above, the Veteran's disability picture prior to October 6, 2010 was productive of arthritis confirmed by x-ray findings and impairment of the clavicle or scapula resulting in recurrent dislocations. As contemplated by the rating schedule, separate ratings of 10 percent and 20 percent are now in effect for the Veteran's right shoulder impairment during that time period. Thereafter, the record demonstrates that the Veteran's right shoulder disorder increased in severity so as to cause decreased limitation of motion. Accordingly, a rating of 30 percent for limitation of motion has now been assigned. Again, the rating codes compensate the Veteran for his impairment. The January 2013 VA examiner's finding that the Veteran's right shoulder disability would prevent him from doing activities that require him to raise his arm above the level of his shoulder (e.g., paint a ceiling, hang drywall) are acknowledged. However, on November 2009 VA examination, it was noted that the Veteran works as a truck driver but does not have to load or unload or do any heavy lifting. Hence, while the right shoulder disability clearly causes some impairment/interference with employment, it is not equivalent to marked interference with employment. Rather, it is the type of occupational impairment that is contemplated by the rating schedule. Therefore, referral for consideration of an extraschedular rating is not warranted. Finally, the Court held that entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, the Board notes that the evidence of record shows that the Veteran has worked as a truck driver throughout the appeal period. As the record shows he is employed, the Board finds that the matter of a total rating based on individual unemployability is not raised by the record. ORDER A rating in excess of 20 percent for clavicle or scapula impairment of the Veteran's right shoulder disability is denied. Subject to the law and regulations governing the payment of monetary benefits, prior to October 6, 2010, a separate rating of 10 percent for arthritis of the Veteran's right shoulder disability, but no higher, is granted. CONTINUED ON THE NEXT PAGE Subject to the law and regulations governing the payment of monetary benefits, effective October 6, 2010, a separate rating of 30 percent, and no higher, for limitation of motion of the Veteran's right shoulder disability, is granted. A rating in excess of 10 percent for hypertension is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs