Citation Nr: 1322165 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 10-00 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to a disability rating in excess of 10 percent for status post Bristow procedure, left shoulder with scar. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from July 1980 to October 1984. This matter came to the Board of Veterans' Appeals (Board) from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran also filed a timely notice of disagreement to a September 2009 rating action which denied entitlement to a temporary total rating for convalescence following surgery for a service-connected right knee disability. In a statement of the case issued in February 2010, temporary total rating was awarded for the period from July through August 2009. This was not considered a complete award of the benefits sought, but the Veteran did not file a substantive appeal and that matter is not currently before the Board. See 38 C.F.R. § 20.200 (2012) (An appeal consists of a timely filed notice of disagreement in writing and after a statement of the case has been furnished, a timely filed substantive appeal.). FINDINGS OF FACT 1. Tinnitus was not manifested during service, and current tinnitus is not otherwise related to the Veteran's active service 2. The Veteran's left (minor) shoulder disability is manifested by pain and noncompensable limitation of motion, but does not result in limitation of arm motion at shoulder level or midway between the side and shoulder level, ankylosis, dislocation or nonunion of the clavicle or scapula with loose movement, arthritis, or episodes of recurrent dislocation at scapulohumeral joint with guarding at any point throughout the appeal period. CONCLUSIONS OF LAW 1. Tinnitus was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for a disability rating in excess of 10 percent for status post Bristow, left shoulder with scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5299-5203, 5201, 5202 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veteran Claims' (Court's) decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on a claim for VA benefits. In December 2008, a VCAA letter was issued to the Veteran with regard to his claim of service connection for tinnitus and an increased rating for his left shoulder disability. The letter notified the Veteran of what information and evidence is needed to substantiate his claims, what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and the evidence necessary to support a disability rating and effective date. Id.; but see VA O.G.C. Prec. Op. No. 1-2004 (Feb. 24, 2004); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also finds that VA has complied with all assistance provisions of VCAA. The evidence of record contains the Veteran's service treatment records, post-service private outpatient treatment records, and lay statements of the Veteran. There is no indication of relevant, outstanding records that would support the Veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). In May 2009, the Veteran was afforded a VA audiological examination, and an etiological opinion was proffered. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). He was also provided with an adequate VA examination that assessed the severity of his left shoulder disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's Virtual VA eFolder is an electronic record and an extension of the paper file. Review of the Veteran's eFolder revealed no further relevant evidence that has not already been associated with the claims folder. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. II. Criteria & Analysis A. Service Connection for Tinnitus Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also 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. 38 C.F.R. § 3.303 (d). The Veteran's service record, namely his DD214, reflects that that his military occupational specialty (MOS) was security specialist. On an October 1979 preliminary physical review, the Veteran denied having difficulty hearing. On October 1979 enlistment report of medical history, he responded "NO" when asked if he experienced ear trouble or hearing loss. An October 1979 enlistment examination reflects that audiometric testing was performed. At that time, pure tone thresholds, in decibels, were as follows: 15, 0, 0, 0, and 0 in the right ear and 30, 15, 0, 5, and 10 in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. A clinical evaluation of the ears was normal. No complaints of hearing problems, tinnitus, or any other ear related problems were noted during service. On August 1984 separation report of medical history, he again denied having any ear trouble or hearing loss. An August 1984 separation examination reflects that audiometric testing was performed. At that time, pure tone thresholds, in decibels, were as follows: 10, 5, 0, 0, and 0 in the right ear and 20, 5, 10, 15, and 5 in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. A clinical evaluation of the ears was normal In December 2009, the Veteran underwent a VA examination. The examiner reviewed the Veteran's claims file and noted his in-service history of military exposure. The Veteran reported that he had noise exposure as a security specialist to weapons fire and flight line operations. He reported that hearing protection was usually worn during military service. He denied occupational or recreational noise exposure. He has worked as a police dispatcher for over 10 years. He denied any significant history of ear infection/surgery, cranial trauma, or family incidence of hearing impairment. He had current complaints of ringing in the ears. He indicated that his tinnitus began with a gradual onset during military service. An audiogram revealed that puretone thresholds, in decibels, were as follows: 15, 15, 15, 10 and 10 in the right ear and 15, 20, 20, 25, and 15 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition scores were 100 percent bilaterally. The examiner diagnosed the Veteran with normal hearing and tinnitus. The examiner opined that the Veteran's current bilateral tinnitus was less likely as not caused by or a result of in-service acoustic trauma. The examiner reported that the opinion was based on conceded history of military noise exposure, as well as the service treatment records, which were silent for hearing loss, hearing threshold shift, or complaints/diagnosis of tinnitus. As detailed, service treatment records are negative for tinnitus, hearing loss, or any other ear related problems, and the Veteran's hearing was normal during audiometric testing conducted during his separation examination in August 1984. While the lack of in-service findings of complaints or diagnoses of tinnitus or any other ear problems in service does not preclude a finding of service connection, tinnitus was not reported until the Veteran filed his claim in February 2008, thus over 23years after separation from service. The Board notes that there was an absence of any subjective complaints of tinnitus for decades after discharge from service or of persistent symptoms of tinnitus between service discharge and 2008. The lack of any evidence of symptoms of tinnitus for many years between the period of active duty and the initial complaints and findings of tinnitus weighs against the claim. A prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Likewise, a VA physician reviewed the claims folder, which included service treatment records, in December 2009. As detailed, the examiner opined that the Veteran's tinnitus is not due to conceded military noise exposure. The examiner based this opinion on a thorough review of the claims folder, to include no findings of hearing loss or hearing threshold shift, or complaints/diagnosis of tinnitus. The opinion of the December 2009 VA examiner leads to a finding that the Veteran's tinnitus is less likely than not related to in-service noise exposure. The Board accepts the examiner's opinion as being the most probative medical evidence on the subject, as such was based on a review of all historical records, and contains detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). The Board has also considered the Veteran's contention that a relationship exists between his tinnitus and his noise exposure experienced during service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In this capacity, the Board finds the Veteran is competent to attest to noise exposure he experienced during service, and find his statements of noise exposure to weapons fire and flight line operations credible based on his experiences as a security specialist. The Board concedes that the Veteran had noise exposure during his period of active service. However, the Veteran is not competent to provide an opinion that his current tinnitus is due to his in-service noise exposure, as he does not have the requisite medical expertise. Although it is conceded that he had noise exposure during service, the fact remains that his hearing was normal at separation from service, there were no shifts in his hearing threshold, and tinnitus was not shown until decades after separation from service. The Veteran has claimed that tinnitus began gradually in service. He is competent to claim that a ringing in his ears began in service. However, he had previously filed claims for other disabilities in October 1984 and May 1989 and made no mention of tinnitus or other auditory problems. On VA examination in early 1985, the Veteran made no complaints of ringing in his ears; examination of the ears revealed normal findings and it was noted that no hearing loss was observed. In the claims for compensation, the Veteran mentioned several physical disabilities and at the examination complained of several physical problems, but did not mention tinnitus. He was aware of the compensation program and it would seem that if he had tinnitus that began in service he would have mentioned it to the medical examiner and/or filed a claim for compensation. However, he made no mention of tinnitus in the more than 20 years following separation from service and his initial claim of service connection. The Board does not find the claim that tinnitus had its onset in service and/or continued since then to be credible. The Board finds that the negative clinical and documentary evidence for decades following service is more probative than the remote assertions of the Veteran. The December 2009 VA examiner was aware of the Veteran's in-service noise exposure per the Veteran's statements and review of the claims folder, but nevertheless concluded that his tinnitus was not due to service. The Veteran's contentions are outweighed by the medical evidence and opinion of the VA medical examiner, which reflect that his tinnitus is not due to noise exposure in service. There is simply no evidence in the record, other than the Veteran's unsubstantiated contentions, to suggest that his tinnitus is etiologically linked to his service, including noise exposure therein. The preponderance of the probative evidence of record is against the Veteran's claim of service connection for tinnitus and the claim must be denied. B. Increased Rating for Left Shoulder Disability with Scar Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating 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. It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Court has held that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2012). Rather, to support an increased rating pain must result in functional loss, in terms of limitations in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. Service connection for a left shoulder, status post Bristow procedure was established in a May 1985 rating decision and a 10 percent disability evaluation pursuant to 38 C.F.R. § 4.71a , DC 5299-5203 was assigned, effective October 2, 1984. The Veteran's 10 percent disability rating protected as it has been continuously rated as such for 20 or more years. See 38 C.F.R. § 3.951(b). Regulations provide that, when the disability being rated is not specifically provided for in the rating schedule, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Further, the provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. The Veteran's service-connected left shoulder disability has been rated analogously as impairment of the clavicle or scapula under Diagnostic Code 5203. DC 5203 provides that a veteran will receive a 10 percent disability rating when he has, in either the major or minor shoulder, malunion of the clavicle or scapula, or nonunion without loose movement. 38 C.F.R. § 4.71a, DC 5203. A veteran will receive the maximum 20 percent rating, for either the major or minor shoulder, only when he has nonunion of the clavicle or scapula with loose movement, or dislocation of the clavicle or scapula. 38 C.F.R. § 4.71a, DC 5203. In his November 2008 informal claim, the Veteran requested an increased in the disability rating due to the "worsening condition" of his left shoulder disability. The Board notes review of the entirety of the Veteran's claims file and the May 2009 VA examination report, as well as the lay statements of the Veteran. In consideration of the applicable rating criteria of the shoulder, the Board finds that the objective medical evidence does not support a disability rating in excess of 10 percent for left shoulder disability. In consideration of Diagnostic Code 5203, the objective medical evidence of record does not reflect nonunion of the clavicle or scapula with loose movement, and does not reflect dislocation of the clavicle. An October 2008 Radiology consultation from Baptist Hospital revealed that there were chronic post-surgical changes of the left scapula/glenoid. On May 2009 VA examination, there was no effusion, edema, erythema, tenderness, palpable deformities or instability found. The diagnosis was left shoulder post-surgery with stability. Thus, based on such objective findings, the Board finds that a 20 percent disability rating is not warranted for dislocation or nonunion with loose movement. A 20 percent disability rating is not warranted for a minor extremity pursuant to Diagnostic Code 5201, as the objective evidence does not show limitation of motion at shoulder level. On May 2009 VA examination, there was some pain associated with range of motion with gravity and against resistance. There was no other gross swelling or deformity noted. Forward flexion was 0 to 180 degrees, abduction was 0 to 180 degrees, external rotation was 0 to 40 degrees, and he was unable to rotate fully to 90 degrees. He had normal internal rotation at 0 to 90 degrees. Limitation to range of motion was by pain and his surgical procedure. On repetitive motion, there was some mild pain, but there was no fatigue, weakness, lack of endurance, or incoordination note. The examiner reported that additional limitation due to flare-ups could not be determined without resorting to mere speculation. There was no discomfort or difficulty with range of motion testing. Even in consideration of the Veteran's pain, such objective findings do not reflect limitation of motion at shoulder level or midway between the side and shoulder level of the minor arm. The rating schedule provides that arthritis due to trauma, substantiated by X-ray findings, should be rated under the criteria for degenerative arthritis. 38 C.F.R. § 4.71a, Codes 5010 (Arthritis Due to Trauma), 5003 (Degenerative Arthritis). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate Codes for the specific joint or joints involved. A rating of 20 percent is available when there is arthritis in more than one major joint or 2 or more groups of minor joints with occasional incapacitating exacerbations. Code 5003, 38 C.F.R. § 4.71a. Here arthritis was not shown on the October 2008 private x-ray report. Also, on May 2009 VA examination, the Veteran denied having any incapacitating episodes in the past year. A rating under DCs 5010 or 5003 is not warranted. In light of such clinical observations, the Board finds that the Veteran's left shoulder disability, a minor extremity, manifests no higher than a 10 percent rating under the provisions of 38 C.F.R. §§ 4.3 , 4.7, 4.71a (Diagnostic Code 5010). The Veteran is not entitled to an increased rating under any other diagnostic code as he has no ankylosis of the shoulder (Diagnostic Code 5200) or impairment of the humerus to include episodes of recurrent dislocation at scapulohumeral joint with guarding, or malunion of the hinders with moderate or marked deformity. (Diagnostic Code 5202). The Board has also considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206-07. These factors have been taken into consideration in contemplation of the 10 percent evaluation. As detailed by the May 2009 VA examination, on repetitive motion, there was some mild pain, but there was no fatigue, weakness, lack of endurance, or incoordination notes. The examiner reported that additional limitation due to flare-ups could not be determined without resorting to mere speculation. There was no discomfort or difficulty with range of motion testing. Additionally, in regards to any functional impairment, the Veteran reported that there were no incapacitating episodes or recommended bedrest in the past year. There was no impediment to the activities of daily living. He reported that he was a police dispatcher for the police department. His job required sitting, answering the telephone, being right-handed caused him to use his left hand to answer the phone that caused some aching pain along with discomfort. In consideration of the statements of the Veteran, the Board finds that the currently assigned 10 percent disability rating adequately compensates him for any pain and functional loss. To the extent that additional functional loss is shown, it does not rise to the level that would enable a finding that the overall disability picture more nearly approximates the next-higher 20-percent evaluation. In this regard, the objective evidence of record is of greater probative weight than the Veteran's belief that he is entitled to a higher disability rating. The Board has given consideration as to whether a separate compensable rating is warranted for his left shoulder scar. On May 2009 VA examination, there was evidence of a well-healed surgical incision of the anterior portion of the left shoulder. There was a vertical incision that was 11 cm in length and 3 to 5 mm wide. The scar was nontender. There was no evidence of underlying depression. There was no limitation to the underlying function. There was no change in pigmentation noted. There was no swelling, tenderness, or deformity. There was no tissue loss, no keloid formation and nonadherence to the underlying tissues. In light of the objective findings and there is no evidence or allegation of any symptomatology associated with the scar, or indication that the scar results in any limited function, assignment of a separate, compensable rating for the left shoulder scar is not warranted. See 38 C.F.R. § 4.118, DC 7803 to 7805. The Board again notes that the Veteran's own assertions, and those of his representative, have been considered. However, as noted, the Board finds that the lay assertions made in support of his claim for higher rating are not entitled to more weight than the objective findings rendered by trained medical professionals in evaluating the Veteran's left shoulder disability. See 38 C.F.R. § 3.159 (a)(1); see Bostain v. West, 11 Vet. App. 124, 127 (1998); also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ('a layperson is generally not capable of opining on matters requiring medical knowledge'). As indicated above, the preponderance of the evidence is against a rating in excess of 10 percent for the left shoulder disability with scar at any point throughout the appeal period. See Hart, supra. Extraschedular Considerations The Veteran's service-connected left shoulder disability with scar does not warrant referral for extra-schedular consideration for any period. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R.§ 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VA O.G.C. Prec. Op. No. 6-96, published at 61 Fed. Reg. 66749 (1996). During his May 2009 VA examination, the Veteran reported that he was a police dispatcher for the police department. His job required sitting, answering the telephone, being right-handed caused him to use his left hand to answer the phone that caused some aching pain along with discomfort. However, he denied having any incapacitating episodes or recommended bedrest in the past year. There was no impediment to the activities of daily living. Moreover, the Veteran's left shoulder symptomatology is contemplated by the rating schedule. For these reasons, the Board finds that while the Veteran's disability may have an effect on his professional and personal life, the evidence does not reflect impairment of his earning capacity to warrant an extraschedular rating for the disability at issue herein. The disability rating assigned squarely contemplates the symptomatology associated with his left shoulder disability. Thun v. Peake, 22 Vet. App. 111 (2008). Additionally, the objective evidence does not reflect frequent periods of hospitalization due to his left shoulder disability with scar. Accordingly, the Board finds that the impairment resulting from the Veteran's left shoulder disability with scar is appropriately compensated by the currently assigned schedular rating and 38 C.F.R. § 3.321 is inapplicable. Total Rating for Compensation Based on Individual Unemployability (TDIU) The Court has held that TDIU is an element of all claims for an initial rating where unemployability is raised. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2012). In this case there is no evidence that the Veteran's service-connected left shoulder disability with scar has caused unemployability. During the May 2009 VA examination, the Veteran reported that he was employed as a police dispatcher with the police department for the past 10 years. There have been no reports that the employment was marginal or paid less than the poverty rate. As there is no evidence of unemployability further consideration of entitlement to TDIU is not required. ORDER Entitlement to service connection for tinnitus is denied. Entitlement to a disability rating in excess of 10 percent for status post Bristow, left shoulder with scar is denied. ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs