Citation Nr: 1318690 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 04-16 300A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to a disability rating in excess of 10 percent for right foot hallux valgus with tender calluses and bunion. 4. Entitlement to a disability rating in excess of 10 percent for tender calluses on the sole of the left foot. (The issues of entitlement to a rating in excess of 10 percent for varicose veins of the right lower extremity; a rating in excess of 10 percent for varicose veins of the left lower extremity; a rating in excess of 10 percent for irritable bowel syndrome (IBS); a total disability rating based on individual unemployability due to service-connected disabilities (TDIU); and compensation under 38 U.S.C.A. § 1151 for muscle cramps involving the back, neck, legs, arms, hands, feet, and sides, are the subject of a separate decision of the Board of Veterans' Appeals (Board).) WITNESSES AT HEARING ON APPEAL Veteran, A.H., and H.C. ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from November 1990 to May 1991 and from June 1991 to September 1992 with additional reserve service. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied the benefits sought on appeal The Veteran was afforded a Board hearing in April 2006 by a Veterans Law Judge who is no longer employed by the Board. A copy of the transcript has been associated with the record. The Board notes that the Veteran submitted a signed statement, received in October 2009, in which she waived her right to an additional hearing by a current member of the Board on the issues that are the subject of this Board decision. In a February 2007 decision, the Board denied, in part, the Veteran's claims for entitlement to a rating in excess of 10 percent for right foot hallux valgus, a rating in excess of 10 percent for calluses of the left foot, and concluded that new and material evidence had not been received to reopen the Veteran's claim for entitlement to service connection for PTSD, in February 2007. Following an appeal to the United States Court of Appeals for Veterans Claims (Court), the Court, in June 2009, reversed the Board's decision with regard to whether new and material evidence had been submitted to reopen the claim of entitlement to service connection for PTSD, and vacated and remanded the remaining claims to the Board for further development. In March 2010 and March 2012, the Board remanded the Veteran's claims for additional development. That development has been completed, and the case now returns to the Board for further appellate review. FINDINGS OF FACT 1. The Veteran has a delusional disorder which is not attributable to service; she does not have PTSD or a personality disorder. 2. The Veteran's current left shoulder disability, characterized as left shoulder degenerative joint disease and bursitis, is attributable to service. 3. The Veteran's bilateral foot disabilities contemplate inter-related hallux valgus, flatfeet, metatarsalgia, bunions, and arthritis; these disabilities result in marked pronation, extreme tenderness of the plantar surfaces of the feet, and are not improved by orthopedic shoes or appliances; the Veteran does not have loss of use of either foot. CONCLUSIONS OF LAW 1. A psychiatric disability including PTSD was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304. 3.306 (2012). 2. A left shoulder disability, characterized as left shoulder degenerative joint disease and bursitis, was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304. 3.306 (2012). 3. The criteria for a 50 percent combined rating for bilateral foot disabilities are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.20, 4.59, 4.71a, Part 4, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 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. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VCAA letters were sent in February 2004 (right foot), April 2004 (psychiatric impairment), May 2004 (psychiatric impairment), February 2005 (feet and psychiatric impairment), February 2007 (left shoulder), and August 2010 (left shoulder, feet, psychiatric impairment. The letters, especially in combination, indicated the type of evidence and information needed to substantiate the claims and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified the Veteran that a "downstream" disability rating and an effective date for the award of benefits would be assigned if service connection was granted, in compliance with Dingess. Regarding the increased rating claims, the notice requirements under 38 U.S.C.A. § 5103 underwent significant changes during the pendency of the Veteran's appeal. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) recently held that, for increased rating claims, notice provided to the Veteran under 38 U.S.C.A. § 5103 need not be "veteran specific," and that VA is not required to notify the Veteran that he may submit evidence of the effect of his worsening disability on his daily life, nor is VA required to notify the Veteran of diagnostic codes that his disability may be rated under. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which she presented oral argument in support of her claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the 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 the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ did not specifically note the bases of the prior determinations 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 schedular criteria for a higher rating and for service connection. The Veteran also volunteered her treatment history and her symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she 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 her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her 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). Regarding the duty to assist, VA also satisfied this obligation in terms of obtaining all potentially relevant evidence concerning these claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records (STRs), VA medical treatment records, Social Security Administration records, and identified private medical records were obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that any additional evidence, relevant to these claims, is available and not part of the claims file. The Veteran also was provided VA compensation examinations, including for medical nexus opinions concerning the etiology of the claimed disorders and their potential relationship with military service, as well as the current medical status of her feet, as the Board directed when remanding these claims. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The examinations of record are adequate to address all pertinent concerns, as the claims file was reviewed for the relevant medical and other history, the Veteran examined, the findings reported in sufficient detail, and there was discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports are thorough and supported by the record. The records taken as a whole satisfy 38 C.F.R. § 3.326. Furthermore, in obtaining the additional medical evidence, the Board is satisfied there was compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) (indicating the Veteran is entitled, as a matter of law, to compliance with a remand directive and that the Board, itself, commits error in failing to ensure this compliance). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (discussing situations when it is acceptable to have "substantial", though not "exact", compliance with a remand directive). Thus, in summary, the Board finds that it is difficult to discern what additional guidance VA could have provided the Veteran regarding what further evidence she should submit to substantiate her claims. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) 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); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In addition, arthritis and psychoses will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board notes that 38 C.F.R. § 3.303(b) provides that with chronic diseases shows as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of cases, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. The term "chronic disease", whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and the Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with §4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). The following provisions apply to claims for service connection of PTSD diagnosed during service or based on the specified type of claimed stressor: (1) If the evidence establishes a diagnosis of posttraumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. (2) If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. (3) If a stressor claimed by the Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. (4) If the evidence establishes that the Veteran was a prisoner-of-war under the provisions of §3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. (5) If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a posttraumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. A personality disorder is not considered a disease or an injury for VA compensation purposes and, therefore, except as provided in 38 C.F.R. § 3.310(a), disability resulting from it cannot be service-connected as a matter of express VA regulation. However, this exception noted (§ 3.310(a)) pertains to the granting of service connection instead on a secondary basis, and disability resulting from a mental disorder that is superimposed upon a personality disorder may be service-connected. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. See, too, Quirin v. Shinseki, 22 Vet. App. 390 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996); and VAOPGCPREC 82-90 (July 18, 1990). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, 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 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 Court similarly 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). The determination as to whether the requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Psychiatric Disorder Including PTSD The service treatment records do not reveal any psychiatric abnormality. Post-service, more than one year after discharge, in December 1993, the Veteran underwent a psychiatric profile which yielded findings likely representing chronic dysthymia. There was no mention of the Veteran's service during the testing. In March 2004, the Veteran was afforded a VA examination. The claims file was not reviewed. The Veteran reported that she made errors in her job during service because she had not been properly instructed and felt that her superior was plotting against her to get in trouble. Also, she felt that she was not treated the same as others, based on her race. She reported a bomb threat involving some apartments on one occasions and that there was supposed to be sniper fire in the area. The diagnosis was dysthymia, but PTSD could not be ruled out completely. The examiner recommended that the Veteran be further evaluated for a more definite diagnosis. A June 1994 VA outpatient record indicated that the Veteran had a non-psychotic mental disorder, not otherwise specified, and a personality disorder, not otherwise specified. Another record noted that she had dysthymia. A subsequent August 1996 outpatient record indicated that the Veteran had a major depressive disorder. In May 1999, the Veteran was afforded a VA examination in which the Veteran reported that she had been depressed since she had returned from Saudi Arabia. The diagnosis was personality disorder, not otherwise specified. In October 2003, the Veteran was evaluated as having a paranoid personality disorder. A January 2004 outpatient record reflected that the Veteran was evaluated for psychiatric problems. The assessment was that the Veteran had a delusional disorder, persecutory type, and anxiety disorder, not otherwise specified. In August 2004 correspondence, the Veteran reported that she endured stressors during service. She stated that there was a bomb scare in her building and they had to evacuate. The second incident occurred when their commander tried to "lose" a group of them (service members) in a war situation. The third incident was when two other service members told her superiors of mistakes that she had made. The next incident was when an oil well burned and the gas alarm went off. She indicated that she could not get her gas mask out quickly enough so she was scared and was hyperventilating. A January 2005 private psychiatric evaluation revealed that the Veteran had a paranoid personality disorder. It was noted that the paranoia related to the personality disorder began while the Veteran was stationed in the Persian Gulf. At an April 2006 hearing, the Veteran testified that she believed that the malaria pills that she took during service resulted in PTSD. She also stated that being separated from her children caused PTSD. July 2008 psychiatric testing revealed that the Veteran was an acceptable candidate for vocational rehabilitation. Also, in July 2008, the Veteran was afforded a VA examination for other issues, but it was noted that she had somatic complaints associated with an unnamed psychiatric disorder. In September 2010, the Veteran was afforded a VA examination. She reported being stressed during service and angry since her return from service. The examiner determined that the Veteran did not have PTSD, but rather had a delusional disorder, persecutory type. The various past diagnoses were discussed. The examiner felt that the personality disorder was likely present prior to service and the current symptoms are the same sequelae of symptoms that began in 1985 or before. However, in June 2012, a medical addendum opinion was obtained from the examiner who conducted the September 2010 examination to resolve the nature of her psychiatric impairment, per the Board's most recent remand decision. The examiner reviewed the record, then clarified that the Veteran actually had a delusional disorder, not a personality disorder. The Veteran had reported that her military service helped her relate better to authorities. The examiner stated that there was no evidence to suggest that the Veteran's experiences in service caused or aggravated her medical health condition. The Veteran served as a nurse practitioner during service. Thus, she is competent to provide a medical opinion. She has asserted, as noted, that she has PTSD or other psychiatric impairment, which is etiologically related to inservice stressors. However, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the Board finds that recent VA medical opinion, which was provided by a physician, is more probative than the Veteran's personal opinion, as well as the prior medical opinions. The VA physician had the benefit of a review of the entire record. She also examined the Veteran and reviewed past psychiatric testing. The prior examination reports do not reflect a complete current review of the record, particularly since there has been a change in diagnosis. The only examiner to address this matter was the most recent one. Further, there is no evidence that the Veteran is trained in psychiatry or psychology such that she can self-diagnose her own psychiatric impairment, particularly given her presented symptoms. In any event, the Board finds that the VA examiner's opinion, as provided in 2012, is more probative than the other medical opinions given the opportunity for a thorough and objective review of the record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Turning to the VA examiner's opinion, the Veteran does not have PTSD or a personality disorder, but rather currently manifests a delusional disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). Since the Veteran does not have PTSD or a personality disorder, service connection for either disorder cannot be made. The most probative evidence of record, the recent VA opinion which is the only opinion based on a longitudinal review of the entire record, establishes that the Veteran has a delusional disorder, but also states that it is not etiologically related to service. The record shows a pattern of psychiatric symptoms which were reported post-service, but not during service. Since the most probative evidence of record reflects that the current diagnosis did not have a service onset or any relationship to service, service connection for a psychiatric disorder, diagnosed as a delusional disorder, is not warranted. Left Shoulder Disorder The service treatment records show that on January 29, 1991, the Veteran reported that she had been in a fight the night before. She related that she had pain in her left shoulder. The examiner noted that there was full range of motion. The diagnosis was dislocation of the left shoulder with reduction. There was no further left shoulder treatment or diagnosis. Post-service, in June 1995, the Veteran was afforded a VA examination. She reported that she dislocated her left shoulder while involved in a fight in Saudi Arabia. It reduced spontaneously and she was given a sling. She related that she had dislocations at bedtime when she would sleep with her arms over her head. The diagnosis was residuals of a left shoulder injury. In April 2004, the Veteran reported left shoulder pain, but April 2004 x-rays revealed a normal shoulder. In October 2004, the Veteran reported that she had tendonitis of the shoulder. She stated that her left shoulder initially dislocated while she was in Saudi Arabia. Range of motion was normal, but strength was decreased and pain was present. In September 2005, the Veteran was afforded a VA examination. The diagnosis was bursitis of the left shoulder with degenerative arthritis. A June 2008 VA examination revealed that the Veteran had normal range of motion of the left shoulder with no pain. The diagnosis was tendonitis of the left shoulder. A September 2008 examination noted the same diagnosis. In July 2012, the Veteran was afforded a VA examination. The examiner determined that there was no functional loss of the left upper extremity. There was tenderness and pain reported, but no loss of function. However, there was minimal degenerative joint disease of the acromioclavicular (AC) joint on the left side. The examiner opined that it was less likely than not secondary to or related to the one inservice left shoulder incident which resolved quickly. He indicated that there were no complaints with regard to the left shoulder until 2005; thus there was no nexus of a connection to service and no evidence existed to connected military service to the current left shoulder condition. In reviewing the evidence, the Veteran dislocated her left shoulder during service. In 1995, she reported that her left shoulder occasionally dislocated. She was competent to report that she had dislocations. There is a gap in complaints and treatment until 2004. She currently has a left shoulder disability in the area of the dislocation, at the AC joint. In reviewing the examiner's opinion, it is flawed. The examiner stated that the initial injury resolved and that there were no further complaints until 2005. However, the evidence shows complaints in at least 1995 and in 2004, when bursitis was diagnosed. Given the error in the opinion, the probative value is diminished. The Board alternatively affords more probative value to the Veteran's statements that she has had dislocations since service since she competently and credibly reported this history, in the years after service, in conjunction with treatment, and at the present time. Also, currently arthritis is present in the AC joint. See, e.g., Walker, supra (chronic diseases specifically listed at 38 C.F.R. § 3.309(a) may be subject to service connection based upon a showing of continuity of symptomatology). The Veteran's medical records are voluminous yet there is no record of any other left shoulder injury or disease, other than the inservice event. Given her reported history, the location of the arthritis, the totality of the evidence, and if affording all reasonable doubt, the Board finds that service connection is warranted for left shoulder disability, characterized as left shoulder degenerative joint disease and bursitis. Ratings Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. However, if VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Cf. McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (Board finding that veteran had disability "at some point during the processing of his claim," satisfied service connection requirement for manifestation of current disability); Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court found no basis for drawing a distinction between initial ratings and increased rating claims for applying staged ratings. Accordingly, it was held that ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. In this case, there has not been a material change in the disability level and a uniform rating is warranted. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). 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 Mitchell Court 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. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran is certainly competent to report pain, numbness, swelling and edema, weakness, other symptoms, and that his activities are restricted. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Bilateral Foot Disorder In a January 1992 rating decision, service connection was granted service connection for her bilateral foot disability, then identified as calluses of the soles of the feet. In October 2002, the Veteran was seen at the podiatry clinic with complaints of bilateral foot pain which was present with weight-bearing activities. The Veteran related that she had problems using foot inserts. Physical examination revealed that the there was lateral deviation of the right and left great toes. There was no pain on palpation to the medial bony prominence at the first metatarsophalangeal joint (MPJ) joint nor was there any pain on range of motion of the first MPJ bilaterally. There was a hyperkeratotic lesion on the sub first metatarsal head on both feet in association with the tibial sesamoid with the arch on the right foot being much greater in severity in comparison to the left foot. The Veteran also developed a heloma dura on the dorsolateral aspect of the joint of the first digit of the right foot. There was much pain on palpation along the distal course of the peroneus brevis as well as its insertion into the base of the first metatarsal of the right foot. There was also much pain on range of motion against resistance upon eversion of the right foot. There was mild pain on palpation along the course of the medial band of the plantar fascia with the pain being most prominent at the central portion of the fascia on the right foot. X-rays revealed medial dislocation of the first MPJ bilaterally and there was a bilateral bipartite tibial sesamoid. The impression was hallux abductovalgus bilaterally, peroneus brevis tendonitis of the right foot, and hammer digit syndrome of the fifth digit of the right foot. In February 2003, the Veteran was afforded a VA examination. On inspection of the right foot, there was a mild hallux valgus deformity. There was also mild pes planus. There was no inversion or eversion of the ankle. At the base of the first metatarsal, there was a 1.5 centimeter by 1.5 centimeter tender callus, and medically over the plantar aspect of the great toe, there was a 1 centimeter by 2 centimeter tender callus. There was no evidence of infection or drainage. The diagnosis was callus formation of the right foot, and mild hallux valgus deformity with bunion formation of the right foot. In May 2003, it was noted that the Veteran had undergone trigger point injections for pain. Orthotic use was recommended. In December 2003, the Veteran reported having bilateral foot pain. In November 2004, the Veteran was seen at the rheumatology clinic with various complaints, including bilateral foot pain, with pain sometimes to the great toe and sometimes to the small toe. In February 2005, she was afforded a VA examination. She reported that she had pain in both feet, particularly with prolonged standing or walking, and which was worse on the right. Examination of the right foot revealed a mild hallux valgus deformity and a mild pes planus deformity. At the base of the first metatarsal was a 1.5 centimeter callus that was tender over the medial aspect of the great toe. There was also a 1 centimeter callus on the right great toe. There was no infection, drainage, or erythema. Examination of the left foot did not reveal hallux valgus. There was a 1 centimeter callus at the base of the first metatarsal on the left that was tender. There was no infection, drainage, or erythema. There was also a .8 centimeter callus on the medial aspect of the left great toe. Range of motion of the feet was normal. The diagnosis was right hallux valgus deformity, right pes planus, callus formation on the right foot, callus formation of the right foot and left callus valgus. The Veteran's daily activities were limited as she was not able to clean her house or do yard work. There was no additional limitation with repetitive use or during flare-ups. X-rays showed mild spurs and bony erosions involving the right first metatarsophalangeal joint. Hallux valgus was present bilaterally. There was pes planus on the left. A June 2005 VA examination revealed that the Veteran had normal dorsiflexion of the feet to 10 degrees, plantar flexion to 45 degrees, and inversion and eversion which did not cause any pain. She had bilateral hallux valgus which was worse on the right with tenderness over the bunions. She was not significantly tender over the dorsum of the feet. She had slight flattening of the arch bilaterally, but no pain on manipulation of the foot and normal Achilles tracking. The diagnosis was bilateral hallux valgus. X-rays revealed hallux valgus and degenerative joint disease. In July 2012, the Veteran was afforded a VA examination. It was noted that the Veteran had flat feet, metatarsalgia, bunions, and degenerative joint disease. The Veteran had pain on use of her feet which was accentuated by use. She did not have pain on manipulation of the feet. There was no swelling on use. There were characteristic calluses of both feet related to the flatfoot condition. She also had extreme tenderness of the plantar surfaces of both feet which was not improved by orthopedic shoes or appliances. The Veteran had decreased longitudinal arch height on weight-bearing, marked deformity of the feet, and marked pronation of the feet. This condition was not improved by orthopedic shoes or appliances. Further, the weight-bearing line fell over or medial to the great toe. She did not have inward bowing of the Achilles tendon or inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation. There was no scarring. There was no evidence of plantar fasciitis or ankle abnormality. The Veteran did not have functional impairment to the extent that she would be equally well-served by an amputation. The foot conditions affected the Veteran's ability to work because she could not stay on her feet for long due to pain. The examiner opined that both feet exhibited flatfoot, metatarsalgia, bunions, and arthritis which were all related to her deformity as well as other factors such as her genetic makeup, aging, obesity, and activities of long standing. X-rays revealed stable feet with hallux valgus and pes planus. The Veteran's right foot has been assigned a 10 percent rating under Diagnostic Code 5280 while the left foot has been assigned a 10 percent rating under Diagnostic Code7819-7804. In Butts v. Brown, 5 Vet. App. 532 (1993), the Court held that the selection of the proper diagnostic code is not a question of law subject to the de novo standard of review. Accordingly, the Court held in Butts that as VA and the Board possess specialized expertise in determining the application of a particular diagnostic code to a particular condition, their determination is due greater deference. Indeed, the Court has also held that, although the reason for the change must be explained, VA and the Board may change the diagnostic codes under which a disability or disabilities are evaluated. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In that regard, the Board seeks to have the Veteran rated on the basis of the code(s) that are most advantageous to her. In this case, the diagnostic codes pertaining to foot disabilities are more appropriate than the codes pertaining to skin disorders. Thus, the Board will rate both feet under the diagnostic codes pertaining to the feet. Under 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5284 can be used to evaluate disabilities of the feet, however, assigning multiple ratings for the Veteran's bilateral foot disorders, based on the same symptoms or manifestations would constitute prohibited pyramiding. 38 C.F.R. § 4.14. Since the recent VA examination report indicated that the current diagnoses are inter-related, the Board will determine which code provides for the highest possible rating for each foot. At the outset, the diagnostic codes pertinent to the service-connected disability of each foot are: Diagnostic Code 5276 (flatfoot), Diagnostic Code 5279 (metatarsalgia), Diagnostic Code 5280 (hallux valgus), Diagnostic Code 5282 (hammertoe), and Diagnostic Code 5284 (foot injuries). 38 C.F.R. § 4.71a (2012). Out of these codes, only Diagnostic Code 5276 and 5284 provide for ratings in excess of 10 percent. A rating based on arthritis directs for the Veteran to be rated based on the joint(s) involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Under Diagnostic Code 5276, pronounced bilateral flatfoot is assigned a 50 percent rating for marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tenoachilles on manipulation, not improved by orthopedic shoes or appliances. A 30 percent rating is assigned for bilateral flatfoot for severe disability with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A review of the last examination which was ordered to address the specific criteria showed that some of the criteria for a 50 percent rating are met. For instance, the Veteran has extreme tenderness of the plantar surfaces of both feet which was not improved by orthopedic shoes or appliances; marked pronation of the feet. This condition was not improved by orthopedic shoes or appliances. She did not have inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation. Overall, the examiner described symptoms most nearly approximating a 50 percent rating, combined for both feet as a bilateral disability. Since Diagnostic Code 5284, at its maximum, provides for a 30 percent rating for each foot which combines to 50 percent per 38 C.F.R. § 4.25, a 50 percent rating combined is the maximum available. As the Veteran does not have loss of use of either foot, a higher rating of 40 percent per each foot is not for assignment. The Board further notes that there is no indication that pain or the other DeLuca factors limits functional impairment beyond what is stated in the applicable code which provides for pronounced impairment. Conclusion for Ratings In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the evidence supports a higher rating of 50 percent combined for right and left feet disabilities under Diagnostic Code 5276. In considering the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or 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 Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's bilateral foot disabilities are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably describe his disabilities. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Service connection for a psychiatric disability including PTSD is denied. Service connection for a left shoulder disability, characterized as left shoulder degenerative joint disease and bursitis, is granted. Entitlement to a 50 percent combined rating for bilateral foot disabilities is granted, subject to the law and regulations governing the payment of monetary benefits. ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs