Citation Nr: 1322985 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 09-48 404 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for left elbow disorder, to include as secondary to the service-connected left shoulder disability. 2. Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to a service-connected left shoulder disability or a service-connected right hand disability. 3. Entitlement to an evaluation in excess of 10 percent prior to July 31, 2013, for the service-connected residuals of a left shoulder injury. 4. Entitlement to an evaluation in excess of 20 percent beginning on July 31, 2013, for the service-connected residuals of a left shoulder injury. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1974 to October 1978. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the RO. In an October 2008 rating decision, the RO in Togus, Maine continued a 10 percent evaluation for the service-connected residuals of a left shoulder injury. The Veteran appealed. In a December 2009 rating decision, the RO in Indianapolis, Indiana denied the Veteran's claims of service connection for left elbow disorder and for bilateral carpal tunnel syndrome in addition declining to reopen a previously denied claim of service connection for hepatitis C. The Veteran appealed. In May 2012, the Board determined that new and material evidence had been submitted to reopen the previously denied claim of service connection for hepatitis C and remanded the reopened claim as well as the claims for service connection for left elbow disorder and bilateral carpal tunnel syndrome and for increased rating for the service-connected left shoulder disability to the RO (via the Appeals Management Center (AMC)) for additional development. The Board instructed that the Veteran should be afforded a VA examinations in conjunction with his claims. A review of the claims folder shows that requested actions have been accomplished, and no further action is required in compliance with the Board's remand directive. Stegall v. West, 11 Vet. App. 268, 271 (1998). Based on the findings contained in a July 2012 VA examination report, the AMC, in a November 2012 rating decision, awarded service connection for hepatitis C and assigned a 10 percent evaluation, effective on July 10, 2006. As the award of service connection marks the award of the full benefit sought and the Veteran has not yet appealed the assigned evaluation or effective date, the matter is no longer on appeal. In the November 2012 rating decision, the RO increased the rating assigned for the service-connected left shoulder disability from 10 to 20 percent disabling, effective on July 31, 2012 (the date of the VA examination). Since the Veteran is presumed to seek the maximum available benefit for a disability, the claims for increased ratings remain on appeal unless otherwise withdrawn. AB v. Brown, 6 Vet. App. 35, 38 (1993). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issue of service connection for a left elbow disorder is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran is not shown to have manifested complaints or findings referable to bilateral carpal tunnel syndrome in service or for many years thereafter. 2. The currently demonstrated bilateral carpal tunnel syndrome is not shown to be due to any event or incident of the Veteran's period of active service or to have been caused or aggravated by the service-connected bilateral shoulder or right hand disability. 3. For the period of the appeal prior to July 31, 2012, the service-connected left shoulder disability is shown to have been manifested by limited motion and degenerative changes and productive of a functional loss due to pain that more closely resembles no more than limitation of motion of the arm to midway between the side and shoulder level. 4. For the period of the appeal beginning on July 31, 2012, the service-connected left shoulder disability is not shown to be manifested by ankylosis or limitation of movement or functional loss due to pain with motion of the arm limited to 25 degrees from the side. CONCLUSIONS OF LAW 1. The Veteran's disability manifested by bilateral carpal tunnel syndrome is not due to disease or injury that was incurred in or aggravated by active service; nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1131, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The schedular criteria for the assignment of an evaluation of 20 percent, but no higher for the service-connected residuals of a left shoulder injury for the period of the appeal prior to July 31, 2012 have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a including Diagnostic Codes 5003, 5201, and 5202. 3. The schedular criteria for the assignment of an evaluation in excess of 20 percent for the service-connected residuals of a left shoulder injury period of the appeal beginning on July 31, 2012 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a including Diagnostic Codes 5003, 5201, and 5202. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, as well as what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). Importantly, the VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom., Hartman v. Nicholson, 483 F.3d 1311 (2007). VA sent letters to the Veteran in June 2008 and February 2009 that addressed the notice elements concerning his claims. The letters informed the Veteran of what evidence is required to substantiate the claim, and apprised the Veteran as to his and VA's respective duties for obtaining evidence. VA also informed the Veteran how it determined the disability rating and the effective date for the award of benefits if service connection was to be awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that all notices required by VCAA and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. In addition to its duty to notify, or inform, the Veteran with regard to his claim, VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the available record includes service treatment records, service personnel records, post-service VA medical treatment reports, and the Veteran's own statements. To the extent that any more recent records may remain outstanding, there is no indication that they are necessary for a fully informed adjudication of the Veteran's claims. The Board finds that the notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to the matters have been requested or obtained. There is no evidence that any additional relevant treatment records exist, and the Veteran has not so alleged. VA provided the Veteran with joint examinations in August 2008 and July 2012, in which the examiners identified the nature and severity of the Veteran's left shoulder disability, and the examiners reported the clinical findings from the examination. The Board acknowledges that the examiner in the August 2008 VA examination report failed to discuss whether there was any additional functional loss as required when considering musculoskeletal disabilities. See 38 C.F.R. §§ 4.40 , 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995) (holding that remand is required where VA examination did not indicate consideration of factors cited in 38 C.F.R. §§ 4.40, 4.45, 4.59). These factors, as well as the other clinical findings sufficient to evaluate the Veteran's disability claim were addressed in the July 2012 VA examination. The Board therefore concludes that the July 2012 examination is adequate for adjudication purposes. See 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was also provided with VA neurologic examinations in July 2009 and in July 2012 to determine the nature and etiology of the Veteran's claimed left elbow disorder and bilateral carpal tunnel syndrome. The claims folder was not available for review in July 2009, and pursuant to the Board's May 2012 remand directives, the Veteran was provided with the July 2012 VA examination. The report of the July 2012 examination reflects that the examiner reviewed the Veteran's complete claims file, to include his service treatment records and past medical history. The examiner recorded his current complaints, conducted appropriate physical examinations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board therefore concludes that the examination is adequate for adjudication purposes. See 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. at 303. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to VCAA. See 38 U.S.C.A. §§ 5102 and 5103; 38 C.F.R. §§ 3.159(b), 20.1102; Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, a disability that is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered part of the original condition. Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists, and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. A disability which is aggravated by a service-connected disorder may be service connected, but compensation is only available for the degree to which that condition was made worse by the service-connected condition - only to the degree that the aggravation is shown. 38 C.F.R. § 3.310. In such a situation, VA law requires that the medical evidence must show a baseline level of severity of the nonservice-connected disease or injury, which is established by medical evidence created before the onset of aggravation. Id. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran alleges entitlement to service connection for bilateral carpal tunnel syndrome. Specifically, he asserts that his carpal tunnel syndrome is secondary to his service-connected disabilities affecting his upper extremities. Although the Veteran does not assert (nor does the evidence of record show) that his current diagnosed bilateral carpal tunnel syndrome is directly related to service, the Board will address the claim of service connection on both a direct and secondary basis. The Board notes that in order to support an award of service connection on direct basis there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and medical nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. With respect to element (1), the medical evidence of record demonstrates that the Veteran has bilateral carpal tunnel syndrome. See private treatment records dated in September 2009 as well as the reports of the July 2009 and July 2012 VA neurologic examinations. It is clear that element (1), current disability, is satisfied. With respect to element (2), in-service disease or injury, the service treatment records do not show that he complained of, sought treatment for, or was diagnosed with any wrist problems. These records do show that the Veteran fractured his right fifth metatarsal in December 1977 and received medical treatment in August 1978 for his left shoulder after he fell out of a moving vehicle and landed hard on his left shoulder. The report of his September 1978 examination prior to separation shows that the Veteran received normal neurologic and upper extremity evaluations. It was noted that he continued to complain of left shoulder pain from a traumatic injury a month earlier, but he was currently "ok." The service treatment records prior to the Veteran's separation dated in September 1978 and October 1978 continue to show that the Veteran complained of left shoulder pain with decreased motion, but none of these records show complaints or finding referable to problems involving either wrist. The Board observes that service connection has been awarded for the residuals of a left shoulder injury and residuals of fractured right fifth metatarsal. The first notation of bilateral carpal tunnel syndrome comes when the Veteran filed his claim of service connection in November 2008. Thus, the Board finds that the Veteran did not manifest bilateral carpal tunnel syndrome in service, at separation, or until decades after his discharge from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition, the clinical evidence does not reflect, nor has the Veteran's provided lay statements to the effect that he has experienced symptoms of bilateral carpal tunnel syndrome since service. Significantly, it was not until 2008, more than 40 years after the Veteran's discharge from service that he was initially complained of and sought treatment for symptoms associated with bilateral carpal tunnel syndrome. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (to the effect that service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). To the extent that the evidence of record does not show that the Veteran's bilateral carpal tunnel syndrome had an onset during his periods of service or within the first year after his separation from service. Element (2), an in-service disease or injury, has not been satisfied. The record does show that the Veteran has been awarded service connection for the residuals of a fractured right fifth metatarsal and residuals of a left shoulder injury and secondary service connection for current right shoulder disability. With respect to element (3), nexus or relationship with service, there is no favorable medical nexus opinion of record that supports a direct medical link between the current diagnosis of bilateral carpal tunnel syndrome and the Veteran's period of service. The report of a July 2012 VA neurologic examination includes an opinion by a VA examiner that strongly weighs against such a nexus. The July 2012 VA examiner opined that it was less likely than not that the Veteran's bilateral carpal tunnel syndrome was incurred in or caused by his period of service since there was no objective evidence of carpal tunnel syndrome until 2009. With respect to the Veteran's assertions that his bilateral carpal tunnel syndrome was caused or aggravated by his service-connected disabilities affecting his upper extremities, in order to satisfy element (3), there must be evidence of a nexus evidence establishing a connection between the service-connected disability and the claimed disorder. See Wallin, 11 Vet. App. at 512. There is no medical opinion of record that serves to link the claimed bilateral carpal tunnel syndrome to his service-connected disabilities. The July 2012 VA examiner stated that, based on a review of the medical evidence of record, including the Veteran's reported history, the bilateral carpal tunnel syndrome was less likely than not proximately caused by his service-connected disabilities. In support of this medical conclusion, the VA examiner noted that none of the Veteran's service-connected disabilities are known risk-factors for the development of carpal tunnel syndrome. Rather, the VA examiner noted that the Veteran's diagnosed diabetes mellitus and his obesity were identified as known risk factors for the development of carpal tunnel syndrome. The Board has also considered the Veteran's assertion that his bilateral carpal tunnel syndrome is proximately caused or aggravated by his service-connected disabilities. The Veteran is capable of observing his symptoms, but he is not competent (i.e., professionally qualified) to offer an opinion as to a relationship between his carpal tunnel syndrome and his service-connected disabilities. See Buchanan, 451 F.3d at 1336; Davidson, 581 F.3d. at 1315; see also Jandreau, 492 F.3d at 1377. Notably, the diagnosis of a neurologic disorder requires diagnostic testing and medical expertise to determine its very nature, which extends beyond capabilities of a lay person. See id. Accordingly, element (3), a nexus or relationship between the current diagnosed disorder and injury in service, including his service-connected disabilities, has not been satisfied, and the Veteran's service-connection claim must fail on this basis. The benefit of the doubt rule is not for application because the evidence is not in relative equipoise. Increased Rating Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged 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. Hart v. Mansfield, 21 Vet. App 505 (2007). 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Any reasonable doubt will be resolved in favor of granting the veteran's claim. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. § 3.102. The medical evidence of record confirms that the Veteran is right handed, and his left shoulder is his nondominant extremity. The Veteran's disability due to residuals of left shoulder injury was previously evaluated under Diagnostic Code 5024-5003, and his disability is currently rated under Diagnostic Code 5003-5202. The application of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based upon such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When the limitation of motion of the specific joint involved is noncompensable, a 10 percent evaluation applies for each major joint or group of minor joints affected. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5202 for (non-dominant) shoulder, a 20 percent evaluation is assigned in cases of malunion of the humerus with either moderate or marked deformity; or recurrent dislocation of the humerus at the scapulohumeral joint, with either infrequent episodes and guarding of movement at the shoulder level, or frequent episodes and guarding of all arm movements. A 40 percent evaluation is assigned in cases of fibrous union the humerus. A 50 percent evaluation contemplates nonunion of the humerus (false flail joint). A 70 percent evaluation is warranted for loss of the head of the humerus (flail shoulder). Other applicable diagnostic codes include 5200 and 5201. Under Diagnostic Code 5200 for (non-dominant) shoulder, a 20 percent evaluation is assigned for favorable ankylosis of scapulohumeral articulation, with abduction to 60 degrees and the ability to reach the mouth and head. A 30 percent evaluation is warranted in cases of intermediate ankylosis of scapulohumeral articulation, between favorable and unfavorable. A 40 percent evaluation is in order in cases of unfavorable ankylosis of scapulohumeral articulation, with abduction limited to 25 degrees from the side. Under Diagnostic Code 5201 for (non-dominant) shoulder, a 20 percent evaluation is warranted for limitation of motion of the arm at the shoulder level and at midway between the side and shoulder level. A 30 percent evaluation contemplates limitation of motion of the arm to 25 degrees from the side. Normal range of motion in the shoulder is from zero to 180 degrees of forward elevation (flexion) and 0 to 180 degrees of shoulder abduction. See 38 C.F.R. § 4.71a, Plate I. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform 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. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case, the Veteran seeks a higher evaluation for his service-connected left shoulder disability. Historically, the Veteran injured his left shoulder after he fell out of a moving truck and landed hard on his left shoulder. The Veteran's disability has been evaluated as 10 percent disabling prior to July 31, 2013, and thereafter as 20 percent disabling. The Veteran contends that the severity of his left shoulder disability is worse than that reflected by his currently assigned disability ratings. He reports that his disability is manifested by symptoms of constant pain, weakness, and feelings of instability that cause him functional impairment. During the course of the appeal period, the records shows that the Veteran's left shoulder disability has been evaluated twice by VA and has received VA and private treatment for the symptomatology. The Veteran underwent his first VA examination in August 2008 to evaluate the severity of his service-connected left shoulder disability. In that examination report, the examiner noted that the Veteran complained of pain and weakness in his left shoulder and reported having audible popping from the shoulder joint. Reportedly, he experiences constant pain on a daily basis, which increases in intensity with activity. The Veteran reported having pain that became progressively worse over time. The Veteran felt that his disability caused him functional impairment as it affected his mobility and his ability to engage in recreational activities. The evaluation revealed objective findings of painful motion, tenderness, weakness and abnormal movement in the left shoulder. The Veteran had range of motion manifested by forward flexion limited to 105 degrees and with abduction limited to 70 degrees. The examiner noted that the Veteran had pain and tenderness about the posterior aspect of the shoulder and with any motion of the shoulder. He had weakness and decreased range of motion as result of pain and feelings of instability. The examiner did not provide an opinion as to what degree, if any, of additional limitation of motion was due functional loss from pain, weakness, and tenderness. There was no evidence of ankylosis. The X-ray studies showed no evidence of acute fracture or dislocation, but there was evidence of mild degenerative changes that were consistent with his age. The Veteran was assessed with degenerative joint disease of the glenohumeral joint with sclerosis and greater wear of the glenoid. Subsequent VA and private treatment records showed that the Veteran continued to seek treatment for pain and limitation of motion in his left shoulder. The Veteran was afforded another VA examination on July 31, 2012 to evaluate the severity of his left shoulder disability. The examination report showed that the Veteran complained of ongoing pain in his left shoulder that radiated down to his elbow. The range of motion testing revealed that the Veteran had left shoulder flexion limited to 75 degrees, with pain beginning at 0 degrees and abduction limited to 75 degrees, with pain beginning at 0. There was no additional loss of motion after repetitive-use testing. The examiner found that there was objective evidence of less movement than normal and painful motion in the left shoulder. There was also objective evidence of guarding on movement. Muscle strength testing was normal, and there was no evidence of ankylosis, rotator cuff involvement, or instability of the shoulder joint. The examiner noted that the Veteran had a history of AC separation, but there was no current evidence of tenderness on palpation or findings on cross-body adduction test. The X-ray studies revealed findings of degenerative arthritis. He was diagnosed with left shoulder AC separation with mild degenerative arthritis. Here, the Veteran seeks higher evaluation for his service-connected left shoulder disability. Initially, the Board notes that, while there has been some variation in the extent of the left shoulder disability during the appeal period, the severity of the Veteran's symptomatology has been relatively constant throughout the period of this appeal; therefore, "staged" ratings are not warranted. 38 C.F.R. § 4.71a; Hart, 21 Vet. App. 505. For this reason, in resolving all reasonable doubt in the Veteran's favor, the Board finds that an increased rating of 20 percent is warranted for the initial period of appeal. The medical evidence of record does not indicate that the Veteran's symptomatology had worsened to a level more severe than 20 percent disabling at any point during this appeal period. See 38 C.F.R. § 4.1. In this regard, under the Rating Schedule, the evidence of record prior to July 31, 2012 shows that the severity of the service-connected left shoulder disability more closely approximated the criteria for a 20 percent evaluation under the provisions for degenerative arthritis with loss of arm motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5201. The August 2008 VA examination report showed that the Veteran's left shoulder disability was manifested by X-ray findings of degenerative arthritis and forward flexion limited to 105 degrees, abduction to 70 degrees, with objective evidence of painful motion tenderness, and weakness. This symptomatology is appropriately rated under Diagnostic Codes applicable to the range of motion loss as there is x-ray evidence of arthritis and a compensable degree of limitation of arm motion based on limitation of forward flexion. On its face, the finding of the limitation of forward flexion in the left arm to105 degrees does not support a compensable evaluation under the criteria associated with Diagnostic Code 5201 (with compensable ratings starting at 20 percent for limitation of motion to shoulder level or 90 degrees), but when considering the factors discussed in DeLuca, the Veteran's symptomatology more closely reflects a disability picture manifested by limitation of arm motion at shoulder level. See 38 C.F.R. § 4.7; see also 38 C.F.R. §§ 4.40, 4.45, 4.59 as applied under DeLuca, 8 Vet. App. at 204-08; 38 C.F.R. § 4.71a, Diagnostic Code 5201. In this regard, the Board notes that August 2008 VA examination does show objective evidence of painful motion, tenderness and weakness during range of motion testing. The Board acknowledges that the August 2008 VA examiner did not record to what degree, if any, of additional limitation of motion was due functional loss from pain, weakness or tenderness. However, the medical evidence does not show an actual limitation of left arm or a functional loss due to pain or other factors worse than midway between the side and shoulder level. An evaluation of 20 percent, and no higher, for the period prior to July 31, 2012 is warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5201. Although the results of the July 31, 2012 VA examination show that the Veteran had reduced limitation of left motion with forward flexion of 75 degrees, with pain starting at 0 degrees, this evidence does not support an evaluation in excess of 20 percent under the criteria for limitation of arm motion. 38 C.F.R. § 4.71a, Diagnostic Code 5201. This symptomatology, even when considering the Deluca factors, only supports a finding of limitation of arm motion to midway between the side and shoulder (or 45 degrees), which warrants a 20 percent evaluation for nondominant arm. See 38 C.F.R. § 4.7; see also 38 C.F.R. §§ 4.40, 4.45, 4.59 as applied under DeLuca, 8 Vet. App. at 204-08; 38 C.F.R. § 4.71a, Diagnostic Code 5201. In order to support a higher evaluation of 30 percent for loss of motion of non-dominate arm, the medical evidence must demonstrate that the Veteran had limitation to 25 degrees from side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board acknowledges that the July 2012 VA examination recorded that the Veteran complained of pain starting at 0 degrees, but he continued to have a range of motion to 75 degrees after repetitive testing. Again, the 20 percent rating already includes the pain that the Veteran experiences on motion as it was noted by the VA examiner and there was no evidence of additional limitation of motion due to repetitive use. See Id. There is no evidence of ankylosis. An evaluation in excess of 20 percent based on x-ray evidence of degenerative arthritis with limitation of arm motion is not warranted at any point during the under appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200 and 5201. The Board has considered that the RO recently evaluated the Veteran's left shoulder disability as 20 percent disabling under Diagnostic Code 5202, for other impairment of humerus, based on the findings of history of AC separation, the Veteran's subjective complaints of a sensation of popping in his left shoulder and the objective findings of guarding on motion, despite the July 2012 VA examination negative finding of history of recurrent dislocation. See 38 C.F.R. § 4.71a. In order to support a higher evaluation under Diagnostic Code 5202, the evidence of record must demonstrate findings of fibrous union, nonunion, or loss of head of the humerus. Here, the x-ray evidence failed to demonstrate any abnormalities of the humerus head beyond mild degenerative changes. An evaluation in excess of 20 percent based on other impairment of humerus is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5202. Moreover, the record contains no relevant evidence of muscle injury, neurological impairment, or other symptoms that fall outside the purview of C.F.R. § 4.71a, that should be considered at this time in evaluating the service-connected left shoulder disability. Regarding any other possible separate ratings, the Board acknowledges that recent VA clinical testing has yielded findings of diminished reflexes and sensation in the Veteran's upper extremities. However, as discussed, those findings have been clinically attributed to the Veteran's bilateral carpal tunnel syndrome, rather than to his shoulder disorder. In sum, the Board finds that a 20 percent disability rating, and no higher adequately addresses the severity of the service-connected left shoulder disability during this time. To the extent that a higher evaluation is asserted, the preponderance of the lay and medical evidence is against such a finding. See 38 C.F.R. § 4.1; see also Gilbert, 1 Vet. App. at 55. Extraschedular Consideration The above determinations are based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. However, the regulations also provide for exceptional cases involving compensation. Ratings shall be based, as far as practicable, upon the average impairments of earning capacity with the additional proviso that VA shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Here, the Board is cognizant of the Veteran's assertions that his left shoulder disability results in functional limitations where he is unable to lift his arm above his head. Nevertheless, the Board considers it unnecessary to refer the Veteran's left shoulder disability for an extraschedular rating as the regular schedular standards obviously address this manifestation. The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Moreover, the competent and credible evidence of record does not otherwise show that the Veteran's left shoulder disorder results in a marked functional impairment to a degree other than that addressed by VA's Rating Schedule. In this regard, the Board considers it significant that the particular regulatory criteria used to rate the Veteran's service-connected disability expressly contemplate functional loss in the assignment of a schedular evaluation. 38 C.F.R. §§ 4.59, 4.71a. Accordingly, the Board finds that the Veteran has been reasonably compensated for the impairment attributable to that disability. See Van Hoose v. Brown, 4 Vet. App. 361 (1993) (disability rating is recognition that industrial capabilities are impaired). In light of the above, the Board finds that remand for referral for consideration of an extraschedular rating is unwarranted in this instance. See 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Total Disability Rating Based Upon Individual Unemployability (TDIU) The Board also notes that this case does not raise a claim for a TDIU rating. At no point during the period under appeal has the Veteran asserted that he is unable to obtain or maintain substantially gainful employment. He has asserted that his left shoulder disability causes him functional impairment, but this does not amount to claiming unemployable. Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). ORDER Service connection for bilateral carpal tunnel syndrome is denied. An increased rating of 20 percent, but no more for the service-connected left shoulder disability for the period of the appeal prior to July 31, 2012 is granted, subject to the regulations controlling disbursement of VA monetary benefits. An increased rating in excess of 20 percent for the service-connected left shoulder disability for the period of the appeal beginning on July 31, 2012 is denied. REMAND The Veteran also seeks service connection for a left elbow disorder, to include as secondary to his service-connected left shoulder disability. Although regrettably it will result in additional delay in adjudicating this appeal, based on a review of the claims folder, the Board finds that additional development is needed prior to adjudication of this claim. The United States Court of Appeals for Veterans Claims (Court) has held that RO compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates another remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). For reasons discussed below, the Board has concluded that the development conducted does not adequately comply with the directives of the May 2012 remand. In its May 2012 remand, the Board instructed the RO to schedule the Veteran for a VA examination to address the question of whether any left elbow disorder was the proximate result of the service-connected left shoulder disability. In the previous July 2009 VA fee basis neurological examination, the examiner found that the Veteran had left ulnar neuropathy based on clinical examination and concluded that the Veteran's left ulnar neuropathy was related to the in-service injury when the Veteran fell from a truck during service and landed on his elbow, despite the lack of the complaints or treatment for left elbow problems in the service treatment records. It was unclear whether the claims file was provided to the examining physician for review, and the Board remanded the matter of a new VA examination. Pursuant to the 2012 remand directives, the Veteran was afforded another VA examination in July 2012. That examination report showed that the Veteran complained of pain in his left elbow that radiated from the lateral epicondyle to his hand. He also reported a history of peripheral neuropathy in his upper and lower extremities. The examination showed no abnormalities involving the left ulnar nerve. The examiner noted that the results of an August 2009 private electromyography (EMG) only demonstrated findings of bilateral carpal tunnel syndrome and peripheral polyneuropathy. The examiner concluded that there was no evidence of left ulnar neuropathy on physical examination or from the private EMG. The examiner then concluded that it was less likely than not that the Veteran's condition was related to his period of service or proximately due to his service-connected left shoulder disability because there was no evidence of left ulnar nerve neuropathy on clinical evaluation or in the EMG results. In the examination report, the examiner did note that the Veteran's left elbow complaints were consistent with lateral epicondylitis, a treatable musculoskeletal disorder. However, the examiner failed to address the findings of lateral epicondylitis as to whether the Veteran had any current chronic left elbow disability proximately caused by his service-connected left shoulder disability. Notably, chronic lateral epicondylitis could be analogous to other inflammations of musculoskeletal system that are ratable disabilities under the VA's Schedule for Rating Disabilities. 38 C.F.R. §4.71a, Diagnostic Codes 5019-5024. Thus, the Board finds that the 2012 VA examiner's examination is inadequate. Ultimately, it remains unclear to the Board whether the Veteran has a current diagnosed disorder manifested by complaints of left elbow pain, numbness, and weakness. The Board finds that further explanation and clarification from the July 2012 VA examiner is needed prior to adjudication of the Veteran's claim. Therefore, the claims files should be returned to the July 2012 VA examiner for an addendum opinion which adequately addresses whether the Veteran has any current diagnosed disorder involving his left elbow that is related to an injury or other event of his period of service or caused or aggravated by the service-connected left shoulder disability. See 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159(c)(4). Accordingly, this remaining matter is REMANDED for the following action: 1. The RO should take appropriate steps to seek the Veteran's assistance in obtaining any outstanding pertinent medical treatment records referable to the claimed left elbow disorder. If any identified records cannot be obtained, a memorandum should be included in the file explaining the procedures undertaken to attempt to find the records and indicating why such attempts were not fully successful. 2. The Veteran's claims files then should be forwarded to the VA examiner who performed the July 2012 VA examination (or a suitable substitute if this individual is unavailable) to review of the claims files and to provide an addendum opinion. Based on a review of the record, to include any pertinent records contained in the Veteran's Virtual VA electronic file, the examiner should opine as to whether it is at least as likely as not that the Veteran has a current disability of the left elbow that is due to an event or incident of the Veteran's period of active service or is caused or aggravated by the service-connected left shoulder disability. The examiner is asked to review all pertinent documents in the claims file in conjunction with an addendum opinion. A full rationale for all opinions and conclusions should be provided. Another VA examination of the Veteran should only be performed if deemed necessary by the person providing the opinions. 3. After completing all indicated development, the RO should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs