Citation Nr: 1321970 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 09-25 747 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent prior to April 27, 2012 and in excess of 50 percent beginning April 27, 2012 for posttraumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 30 percent for residuals of a shell fragment wound of the left shoulder, multiple, with keloid scar (left shoulder disability). 3. Entitlement to an evaluation in excess of 20 percent for residuals of a gunshot wound of the right side of the neck, posterior and lateral, with keloid scar (neck disability). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active duty from May 1965 to May 1967; he was awarded the Purple Heart and the Combat Infantryman Badge. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia (RO), which denied a rating in excess of 30 percent for PTSD, a rating in excess of 30 percent for left shoulder disability, and a rating in excess of 20 percent for neck disability. An August 2012 rating decision granted a rating of 50 percent for PTSD, effective April 27, 2012, the date of an evaluation for rating purposes. The Veteran has indicated a desire to continue the appeal for a higher rating for PTSD. The issue of entitlement to TDIU is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. The evidence beginning in April 2008 more nearly approximates occupational and social impairment with reduced reliability and productivity. 2. The evidence does not more nearly approximate occupational and social impairment comparable to deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to psychiatric symptomatology during the appeal period. 3. The Veteran is assigned the maximum rating for injury to Muscle Group I of the non-dominant arm. 4. The evidence shows no more than moderately severe impairment of the neck. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 50 percent beginning April 4, 2008 for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012 3. The criteria for an evaluation in excess of 30 percent for left shoulder disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.73, Diagnostic Codes 5301, 5302, 5303 (2012). 4. The criteria for an evaluation in excess of 20 percent for neck disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.73, Diagnostic Code 5323 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012); see 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent the Veteran a letter in May 2008, prior to adjudication, which informed him of the requirements needed to establish entitlement to an increased rating. In accordance with the requirements of VCAA, the May 2008 letter informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. No additional private medical evidence was subsequently added to the claims files. The Veteran was informed in the May 2008 letter about disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. VA examinations were conducted in June 2008 and in April and May 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination reports on file are adequate for rating purposes, as they provide the current symptomatology of the Veteran's PTSD, left shoulder disability, and neck disability. There are also VA treatment reports on file. Consequently, there is sufficient medical evidence of record to make a determination on each of the issues decided in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination in this case has been met and that the case will be decided based on the evidence of record. 38 C.F.R. § 3.159(c)(4). The Board concludes that all available evidence that is pertinent to the claims decided herein has been obtained and that there is sufficient medical evidence on file on which to make a decision on the claims. The Veteran has been given ample opportunity to present evidence and argument in support of his claims. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Analysis of the Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Nevertheless, where entitlement to compensation has already been established and an increase in the disability rating is at issue the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Veteran's claims for an increased ratings were received by VA in April 2008. The relevant period for consideration in this appeal begins one year prior to that submission (i.e., in April 2007). However, there are no pertinent treatment reports dated from April 2007 to April 2008. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Pertinent to a claim for an increased rating, lay testimony is competent when it describes symptoms, which supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (holding that, in general, for the need for a VA examination to arise, a claimant would only need submit his competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation.). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). PTSD A May 1982 rating decision granted service connection for PTSD and assigned a 30 percent rating effective January 26, 1982. A claim for increase was received by VA on April 4, 2008. An October 2008 rating decision denied an increased rating for PTSD, and the Veteran timely appealed. An August 2012 rating decision granted a rating of 50 percent for PTSD, effective April 27, 2012. The Veteran continued his appeal. Under the rating schedule, a 30 percent evaluation is assignable for psychiatric disability when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent evaluation is assignable for psychiatric disability when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (for example, retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is assignable for psychiatric disability when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation for psychiatric disability is assignable with total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The global assessment of functioning (GAF) score reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 31 to 40 involves some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF of 71 to 80 is assigned when symptoms, if present, are transient and are expected reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), with no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-7 (1994). The Veteran complained on QTC psychiatric evaluation in June 2008 of insomnia, nightmares, intrusive thoughts of Vietnam, being easily startled, intermittent difficulty with concentration and memory, an increase in social withdrawal, irritability and anger. On mental status examination, the Veteran was well oriented, and no memory problem was shown. His mood and affect were appropriately anxious and sad as he discussed his exposure to traumatic events. He did not have panic attacks. His insight and judgment were good. The diagnosis was PTSD, and his GAF score was 55. The Veteran was considered capable of performing repetitive work in which there is a low stress level. VA treatment reports for September 2008 reveal complaints of insomnia, nightmares, flashbacks, intrusive thoughts, hyperstartle reflexes, avoidance, and hypervigilance. His GAF score was 57. The Veteran complained in February 2011 of nightmares and intrusive thoughts related to his prior trauma. VA treatment records from February 2011 through February 2012 contain the diagnosis of PTSD and provide a GAF score of 55. It was reported on QTC psychiatric evaluation in April 2012 that the Veteran's PTSD symptoms consisted of depressed mood, suspiciousness, sleep impairment, mild memory loss, difficulty in understanding complex commands, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran indicated that he was very careful about to whom he got close and with whom he would be social. The Veteran was married and had a good relationship with his wife; he had a fair relationship with his children and his siblings. The Veteran said that he had not worked for a number of years because of the effects of his mental condition and his medical problems. The examiner noted at one point in the evaluation that the Veteran's psychiatric disorders caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although he was generally functioning satisfactorily with normal routine behavior, self-care and conversation. Later in the evaluation report, it was noted that the Veteran's symptoms caused clinically significant distress or impairment in social, occupational or other important areas of functioning. PTSD was diagnosed, and the Veteran's GAF score was 55. A Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002); however, as the Court held in Mauerhan, without the examples noted in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating should be assigned. Id. Although the medical evidence prior to VA evaluation in April 2012 does not discuss the specific criteria in the rating schedule as clearly as the April 2012 evaluation report, the Board concludes that the psychiatric findings prior to April 2012 are equivalent in severity to the findings for which he was assigned a 50 percent rating. Moreover, his GAF score throughout the appeal period, meaning both before evaluation in April 2012 and on this evaluation, has been 55, except for one score of 57 in September 2008, which is indicative of moderate symptoms. He complained in June 2008 of multiple psychiatric symptoms, including insomnia, nightmares, intrusive thoughts of Vietnam, an increase in social withdrawal, intermittent difficulty with concentration and memory, irritability and anger. He was reported to be anxious and sad. This symptomatology is more indicative of occupational and social impairment with reduced reliability and productivity. Consequently, as the clinical evidence prior to April 2012 shows symptomatology that more nearly approximates the criteria for a 50 percent rating, an increased rating of 50 percent is warranted beginning on the date of claim, April 4, 2008. The Board finds, however, that a rating in excess of 50 percent is not warranted for PTSD throughout the appeal period. The evidence does not approach or approximate the symptomatology that causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. In fact, difficulty in adapting to stressful circumstances is the only symptom listed under the 70 percent rating which the Veteran was noted to have when he was examined in April 2012. The Board acknowledges the Veteran's subjective psychiatric complaints throughout the appeal period, such as insomnia and nightmares. The Veteran is competent to report his subjective symptoms. These lay observations are credible, but must be evaluated in light of the rating schedule described above. The lay statements have been considered in the above noted grant of a 50 percent rating for PTSD beginning in April 2008. However, the evidence of record has not shown the severity required for a higher schedular rating at any other time, as discussed above. Left Shoulder and Neck Because the left shoulder and neck disabilities are both residuals of combat trauma and are both rated under the diagnostic codes for muscle injuries, they will be discussed together. A September 1967 rating decision granted service connection for a left shoulder disability and for a neck disability, assigning a 30 percent rating for the left shoulder disability and a 20 percent rating for the neck disability, effective May 12, 1967. A claim for increase was received by VA on April 4, 2008. An October 2008 rating decision denied higher ratings for the left shoulder and neck disabilities, and the Veteran timely appealed. Muscle injuries are rated pursuant to muscle injury rating criteria. 38 C.F.R. §§ 4.55, 4.56, 4.73 (2012). For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in five anatomical regions. 38 C.F.R. § 4.55(b) (2012). The specific bodily functions of each group are listed. 38 C.F.R. § 4.73 (2012). The severity of the muscle disability is determined by application of muscle rating criteria. 38 C.F.R. § 4.56 (2012). First, an open comminuted fracture with muscle or tendon damage will be rated as severe, unless (for locations such as the wrist or over the tibia) the evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a) (2012). A through and through injury with muscle damage shall be rated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b) (2012). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c) (2012). Under Diagnostic Codes 5301 to 5323, muscle injuries disabilities are rated as slight, moderate, moderately severe, or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56(d) (2012). A moderate muscle disability is one where the injury was either through and through, or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the effect of high velocity missile, residuals of debridement, or prolonged infection. The service department record (or other evidence) would show in service treatment for the wound. There would be a consistent complaint of one or more of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, the entrance (and if present, exit) scars would be small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance, or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side would be present. A moderately severe muscle disability is one where the injury was either through and through, or a deep penetrating wound by a small high velocity missile or large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), and, if present, an inability to keep up with work requirements. Objectively, the entrance (and if present, exit) scars would indicate the track of missile through one or more muscle groups. There would be indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. A severe muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell or harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) x-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. Diagnostic Code 5301, governs injuries to Muscle Group I. Muscle Group I encompasses the extrinsic muscles of the shoulder girdle, including the trapezius, levator scapulae, and serratus magnus. Under Diagnostic Code 5301, a 10 percent rating is assigned where there is moderate impairment of the non-dominant extremity. A 20 percent rating requires moderately severe impairment. A 30 percent rating requires a showing of severe impairment. 38 C.F.R. § 4.73, Diagnostic Code 5301 (2012). The provisions of Diagnostic Code 5302 provide that the function of Muscle Group II is the depression of arm from vertically overhead to hanging at side (the extrinsic muscles of the shoulder girdle involved are the Pectoralis major II (costosternal); latissimus dorsi and teres major (teres major, although technically an intrinsic muscle, is included with latissimus dorsi). This muscle group also allows for the downward rotation of scapula using the pectoralis minor; and the rhomboid, which are also extrinsic muscles of the shoulder girdle; and acts with Group III in forward and backward swinging of the arm. 38 C.F.R. § 4.73, Diagnostic Code 5302. The provisions of Diagnostic Code 5303 provide that the function of Muscle Group III is to elevate and abduct the arm to shoulder level, and to allow forward and backward swinging of arm. This muscle group includes the pectoralis major I (clavicular) and deltoid. The function is elevation and abduction of the arm to the level of the shoulder and it acts with the trapezius and levator scapulae of Muscle Group II in forward and backward swing of the arm. 38 C.F.R. § 4.73, Diagnostic Code 5303. Both of these diagnostic codes provide a zero percent evaluation for slight muscle disability of either the dominant or non-dominant side of the body. A 20 percent rating requires moderate injury; a 20 percent rating is also assigned for moderately severe injury of the non-dominant upper extremity or severe injury of the non-dominant upper extremity. A 30 percent rating requires moderately severe injury of the dominant upper extremity. A 40 percent rating requires severe injury of the dominant upper extremity. 38 C.F.R. § 4.73, Diagnostic Codes 5302, 5303. The Veteran's neck disability is presently rated under Diagnostic Code 5323 for a Group XXIII muscle injury, which includes movements of the head, fixation of shoulder movements, and muscles of the side and back of the neck including the suboccipital and lateral vertebral and anterior vertebral muscles. A noncompensable rating is assigned for injuries that are slight, while a 10 percent rating is assigned for moderate injuries. A 20 percent rating is warranted for moderately severe injuries, and a 30 percent rating for severe injuries. 38 C.F.R. § 4.73, Diagnostic Code 5323. Under Diagnostic Code 5201, limitation of an arm at the shoulder level warrants a 20 evaluation whether it is the major or minor extremity. When motion is limited to midway between the side and shoulder level, a 30 percent evaluation is warranted for the major extremity and 20 percent for the minor extremity. When motion is limited to 25 degrees from the side, a 40 percent evaluation is warranted for the major extremity and 30 percent for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal flexion (forward elevation of the arm) and normal abduction (movement of the arm away from the side) of the shoulder are to 180 degrees. Normal internal rotation and external rotations of the shoulder are to 90 degrees. 38 C.F.R. § 4.71, Plate 1. Ankylosis of the scapulohumeral articulation (which moves as one piece), when in a favorable position, with abduction to 60 degrees, and ability to reach the mouth and head is retained, a 30 percent evaluation is warranted for the major extremity and 20 percent for the minor extremity. When in an intermediate position between favorable and unfavorable, 40 percent is warranted for the major extremity and 30 percent for the minor extremity. When in an unfavorable position, with abduction limited to 25 degrees from the side, a 50 percent is warranted for the major extremity and a 40 percent rating for the minor extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5200. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). 38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2012). 38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). 38 C.F.R. § 4.45 (2012). The Court has held that when a Diagnostic Code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Under the rating criteria, Diagnostic Code 5242 (degenerative arthritis of the spine) can be evaluated under the following general rating formula for diseases and injuries of the spine: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: A 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine thoracolumbar spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or fewer or when there is favorable ankylosis of the entire cervical spine. A 40 percent rating requires evidence of unfavorable ankylosis of the entire cervical spine. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion is zero to 45 degrees, and left and right lateral rotation is zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). According to the Veteran's service treatment records, he was hospitalized in May 1966 with a fragment wound of the left shoulder and a gunshot wound of the neck due to enemy small arms and mortar fire; there was no artery or nerve involvement. He underwent debridement and removal of foreign bodies. It was reported on VA evaluation in August 1967 that the Veteran had a well-healed scar on the posterior neck; there was full range of neck motion without neurological disability. There was a disfiguring scar on the right side of the neck, 2.5 inches long, without muscle or nerve injury. There was good range of shoulder motion, with minimal resistance encountered above the shoulder level. The diagnosis was scars, multiple, bullet and shrapnel wounds of the right side of the neck and left shoulder with disfiguring keloid scar on the right side of the neck. The Veteran was hospitalized at a VA facility in September 1967 for plastic repair of keloids with split thickness skin graft to the left shoulder. It was reported on QTC evaluation of the Veteran's neck and left shoulder in June 2008 that the Veteran's gunshot wound was reportedly through and through and that many of his wounds were surgically repaired, including with skin grafts. There were multiple keloid scars from the injuries. The Veteran occasionally experienced pain in the neck area with certain activities; he denied left shoulder pain. There was no current treatment or functional impairment. Physical examination did not reveal any neck tenderness, facial disfigurement, mastication interference, or speech interference. There was no evidence of scar ulceration, adherence, instability, inflammation, edema, tissue loss, pigmentary changes, or abnormal texture. Left shoulder and neck range of motion was normal, without additional loss on repetitive motion. Shoulder muscle strength was 5/5. X-rays showed degenerative disc disease of the cervical spine; the left shoulder was normal, without retained foreign bodies. The diagnosis was no significant residuals other than disfigured scars, with multiple left shoulder keloid scars and a right posterior neck keloid scar. The examiner concluded that the Veteran's conditions only minimally affected his ability to perform his usual occupational and daily living activities. VA treatment records for July 2008 reveal complaints of neck and shoulder pain, which did not limit function. There was full range of motion of the neck. The diagnosis was likely degenerative spinal changes. The Veteran complained in February 2011 of chronic left shoulder pain with loss of motion and strength. The Veteran complained on QTC evaluation of the neck and left shoulder in May 2012 of sharp pain and weakness in the left shoulder. He is right handed. Examination of the left shoulder revealed an injury to Muscle Group I of the shoulder girdle and arm. There was a 12 x .2 cm superficial non-linear scar and an 8 x 3 cm deep non-linear scar; there was an 8 x .2 cm scar on the neck. His neck scar did not cause any limitation of function. His left shoulder scars affected his ability to work, due to pain and an inability to lift his left shoulder. Muscle examination of the left shoulder did not show abnormality of muscle substance or function, although left shoulder abduction, Muscle Group III, was 3/5. There was no muscle atrophy. Muscle injury did not impact the Veteran's ability to work. X-rays showed degenerative joint disease of the left shoulder. The current 30 percent rating for left shoulder disability is the maximum schedular rating assigned for a severe muscle injury of the non-dominant shoulder under Diagnostic Codes 5301, 5302, and 5303. In fact, none of the rating codes for muscle injuries of a non-dominant shoulder provides a rating in excess of 30 percent. The Board would also note that the maximum schedular rating provided for limitation of motion of the non-dominant arm is 30 percent, under Diagnostic Code 5201. Although a higher rating can be assigned for unfavorable ankylosis of the non-dominant upper extremity under Diagnostic Code 5200, with abduction limited to 25 degrees from the side, the Veteran does not have ankylosis of the left upper extremity, as motion of the left shoulder was normal in June 2008 and there was no functional loss of the left shoulder in May 2012. Consequently, a rating in excess of 30 percent for left shoulder disability is not warranted. The Board also finds that a rating in excess of 20 percent is not warranted for the Veteran's neck disability under Diagnostic Code 5323, as the evidence shows no more than moderately severe impairment of the neck. Motion of the neck was normal in June 2008, and there was no functional loss of the neck in May 2012. As there is no evidence of significant loss of motion of the neck, with forward flexion of the neck limited to no more than 15 degrees or evidence of favorable ankylosis of the entire cervical spine, a higher rating is also not warranted under the general formula for rating the spine. The Board also finds that an increased rating is not warranted for either the left shoulder or neck disability under the DeLuca criteria. As noted above, the Veteran is currently assigned the maximum schedular rating for limitation of motion of the shoulder under Diagnostic Code 5201. There was no additional limitation of motion of the left shoulder or neck on repetitive range-of-motion testing in June 2008. The Board notes that the General Rating Formula already accounts for pain, which is generally a concomitant of limitation of motion. See 38 C.F.R. § 4.71a; 68 Fed. Reg. 51, 454, 51,455 (Supplementary Information). Additional Considerations The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Board finds that referral of any of the disabilities at issue for extraschedular consideration is not warranted. The Veteran's service-connected disabilities are contemplated and reasonably described by the rating criteria discussed above. Id. The Veteran does not have symptoms associated with any of these disabilities that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. Accordingly, a comparison of the Veteran's symptoms and functional impairment with the schedular criteria does not show that the Veteran's PTSD, left shoulder disability, or neck disability presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular evaluations are adequate to rate each disability. Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Therefore, referral for extraschedular consideration is not warranted. The benefit-of-the-doubt rule has been applied in granting a 50 percent rating for PTSD beginning April 4, 2008 and has been considered in rating PTSD beginning April 27, 2012 and in rating the left shoulder disability and the neck disability; however, as noted above, the preponderance of the evidence weighs against an increased rating for PTSD beginning April 27, 2012, for the left shoulder disability, and for the neck disability. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to an evaluation of 50 percent, but no higher, for PTSD beginning April 4, 2008 is granted, subject to the controlling regulations applicable to the payment of monetary benefits. An evaluation in excess of 50 percent for PTSD beginning April 27, 2012 is denied. An evaluation in excess of 30 percent for left shoulder disability is denied. An evaluation in excess of 20 percent for neck disability is denied. REMAND The Court of Appeals for Veterans Claims (Court) has held that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, if the disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Here, the record includes the Veteran noted on VA psychiatric evaluation in April 2012 that he had not worked for at least 15 years and that he was unemployable due primarily to the effects of his psychiatric condition and medical problems. Accordingly, the Veteran should be provided with appropriate notice as to how to substantiate a claim for TDIU. It would be fundamentally unfair to the Veteran to decide a claim which has not been developed and adjudicated by the RO. See Bernard v. Brown, 4 Vet. App. 384 (1993). In order to comply with precedential Court opinion, this issue, therefore, is remanded for further development. Therefore, the case is remanded for the following actions: 1. The AMC/RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his TDIU claim. Based on his response, the AMC/RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the AMC/RO. If, after making reasonable efforts to obtain named records the AMC/RO is unable to secure same, the AMC/RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the AMC/RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. The Veteran will be requested to submit an up-to-date VA Form 21-8940, Veterans Application For Increased Compensation Based On Unemployability, which will be added to the claims files. 3. The Veteran must be afforded an appropriate VA examination to determine the effects of his service-connected disabilities on his ability to obtain and maintain employment consistent with his education and occupational experience. The claims files must be made available to the examiner, and the examiner must specify in the examination report that the claims files have been reviewed. All necessary special studies or tests are to be accomplished. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to the following: Whether it is at least as likely as not that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. This opinion must be provided without consideration of his nonservice-connected disabilities, or his age. A complete rationale for all opinions must be provided. 4. The AMC/RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. Following completion of all indicated development, the AMC/RO must adjudicate the claim for entitlement to TDIU, to include consideration of all of the evidence of record. If the benefit sought on appeal remains denied, the Veteran and his representative will be provided a Supplemental Statement of the Case, which should include all pertinent law and regulations. The Veteran will then be given an appropriate opportunity to respond thereto. Thereafter, the case must be returned to the Board for the purpose of appellate disposition. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs