Citation Nr: 1323784 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 07-26 592 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an increased disability rating for cervical spine strain, with cervical disc protrusion at C3-4, currently evaluated as 30 percent disabling. 2. Entitlement to service connection for myofascial pain syndrome. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran served on active duty for training from June 1979 to August 1979. He served on inactive duty for training on September 8, 1979. He had additional National Guard service until February 1981. This matter is before the Board of Veterans' Appeals (Board) following Board Remands in November 2009, October 2010, and April 2012. This matter was originally on appeal from rating decisions dated in December 2006 and July 2008 of the Department of Veterans Affairs (VA), Regional Office (RO). These matters were remanded to the RO in November 2009, October 2010, and April 2012. Pursuant to the Board's November 2009 Remand, the Appeals Management Center (AMC) scheduled a Travel Board hearing for the Veteran. Pursuant to the Board's October 2010 Remand, the AMC obtained identified records from VA Medical Centers in Bonham and Dallas, scheduled the Veteran for appropriate VA examinations, readjudicated the Veteran's claim under the provision of the Veterans Claims Assistance Act of 2000 as discussed in more detail below, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's November 2009 and October 2010 Remands. Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). In April 2012, the issues were remanded for additional development. The Board finds that the agency of original jurisdiction substantially complied with the mandates of the February 2013 remand. See Stegall, supra. The Veteran was provided a VA examination in July 2012 and a VA medical opinion was obtained in March 2013. The Board concludes that there has been substantial compliance with the remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In June 2010, the Veteran testified at a Travel Board hearing before the undersigned. A transcript of that hearing is of record. In a February 2013 rating decision, the RO granted service connection for rotator cuff syndrome of the right shoulder and assigned a 10 percent rating from April 9, 2007. The action constituted a full grant of the benefits sought, and the claim for service connection for a right shoulder disability is no longer open for appellate review. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). FINDINGS OF FACT 1. For the entire appeal period, the service-connected cervical spine strain with disc protrusion at C3-4 is manifested by pain and a limitation of motion or functional loss due to pain with restriction of forward flexion of the cervical spine to 5 to 30 degrees and mild radiculopathy of the left and right upper extremities and there is no evidence of incapacitating episodes lasting a duration of at least 4 weeks during a 12 month period or ankylosis of the cervical spine. 2. The Veteran sustained a cervical spine injury in a motor vehicle accident on September 8, 1979 during a period of inactive duty for training and a cervical muscle strain was diagnosed. 3. The Veteran has had recurrent symptoms of neck pain since the cervical spine injury in September 1979. 4. Myofascial pain syndrome was first diagnosed during a period of inactive duty for training in January 1981 and the Veteran has had myofascial pain syndrome since the period of inactive duty for training. 5. The Board is unable to differentiate between the symptomatology attributable to the myofascial pain syndrome of the cervical spine and the symptomatology attributable to the service-connected cervical spine strain with disc protrusion at C3-4. 6. It is as likely as not that the myofascial pain syndrome of the cervical spine is due to injury during inactive duty for training. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for the assignment of an increased disability rating in excess of 30 percent for the service-connected cervical spine strain with disc protrusion at C3-4 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, 4.124a, Diagnostic Codes 5235-5243, 8715 (2012). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for myofascial pain syndrome of the cervical spine are met. 38 U.S.C.A. §§ 101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a letter dated in July 2006, prior to the initial adjudication of the claim. Additional VCAA letters were sent to the Veteran in April 2007, May 2012, and July 2012. The VCAA letters informed the Veteran of the evidence and information needed to substantiate a claim for an increased rating and informed the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf. VA informed the Veteran it had to obtain any records held by any federal agency. The letters also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letters told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the July 2006 letter explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claims on appeal. VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records were obtained and are associated with the claims folder. VA treatment records dated from 1993 to 2010 are associated with the virtual file. In April and May 2007, the Veteran informed VA that he did not have any additional evidence or information to submit in support of his claims. VA provided examinations in September 2006, May 2007, December 2010, and July 2012 to obtain medical evidence as to the current severity of the cervical spine disability. The examinations are adequate because they were performed by medical professionals based on review of claims file and a solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiners considered the Veteran's reported medical history and lay statements concerning the service-connected disability. The VA examiner described the cervical spine disability and all current manifestations and symptoms. The examination reports are accurate and fully descriptive. Neither the Veteran nor his representative has challenged the adequacy of the examinations obtained for this issue. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claim and VA met its duty to assist the Veteran. 2. Entitlement to an increased disability rating for cervical spine strain, with cervical disc protrusion at C3-4 Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40, and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. 38 C.F.R. § 4.71a. Diagnostic Code 5235, Vertebral fracture or dislocation; Diagnostic Code 5236, Sacroiliac injury and weakness; Diagnostic Code 5237, Lumbosacral or cervical strain; Diagnostic Code 5238, Spinal stenosis; Diagnostic Code 5239, Spondylolisthesis or segmental instability; Diagnostic Code 5240, Ankylosing spondylitis; Diagnostic Code 5241, Spinal fusion; and Diagnostic Code 5242, Degenerative arthritis of the spine; are rated under the following new 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 10 percent evaluation will be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical 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 is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation will be assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation will be assigned of unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation will be assigned for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 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 thoracolumbar spine is 240 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 Code 5243 provides that intervertebral disc syndrome (preoperatively or postoperatively) be rated either under the General Rating Formula for Disease and Injuries of the Spine, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under Diagnostic Code 5243, a 40 percent rating is warranted where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. Diagnostic Code 5243 defines an incapacitating episode as a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. Rating Analysis The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the assignment of a disability evaluation in excess of 30 percent for the service-connected cervical spine disability for the entire appeal period, and the appeal is denied. Under the General Rating Formula, a 40 percent evaluation will be assigned for unfavorable ankylosis of the entire cervical spine. In order for a 100 percent rating to be assigned, the evidence must establish unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242. The medical evidence of record does not document unfavorable ankylosis of the cervical spine or entire spine. The VA examinations dated in September 2006, May 2007, December 2010, and July 2012 and the treatment records establish that the Veteran has limited motion of the cervical spine, but there were no findings of ankylosis. Thus, on this basis, a higher rating is not warranted under Diagnostic Codes 5235 to 5242. The rating criteria are intended to take into account functional limitations; therefore, the provisions of 38 C.F.R. §§ 4.40, 4.45, could not provide a basis for a higher evaluation. 68 Fed. Reg. 51454-5 (Aug. 27, 2003). In any event, additional functional limitation warranting a higher evaluation is not been shown. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The VA examination reports specifically note that pain on motion was considered when range of motion was tested and the examiners noted the point that pain began. There was no evidence of additional limitation of motion due to weakness, incoordination or fatigability. See the VA examination reports dated in September 2006, May 2007, and July 2012. The July 2012 VA examination report indicates that the cervical spine functional loss was manifested by less movement, excess fatigability, and pain on movement. However, on range of motion testing, forward flexion of the cervical spine was to 30 degrees, where pain began. The VA examiner noted that repetition did not cause additional loss of motion. There are no objective findings of additional limitation of range of motion with repetition or due to weakness, excess fatigability and incoordination. The current 30 percent rating contemplates the functional loss due to pain, excess fatigability, and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Higher ratings are not warranted under Diagnostic Code 5243. The evidence does not establish that the service-connected cervical spine disability causes incapacitating episodes having a total duration of at least four weeks during the past 12 months. The VA examination reports dated in September 2006, December 2010, and July 2012 specifically indicate that the Veteran did not have any incapacitating episodes due to the cervical spine disability. There is no objective evidence of any incapacitating episodes due to the cervical spine disability. VA treatment records do not serve to document any incapacitating episodes. The medical evidence of record does not show physician-prescribed bed rest, which is the requirement for an incapacitating episode. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. Thus, the Board finds that a disability evaluation in excess of 30 percent for the cervical spine disability is not warranted under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The evidence preponderates against the claim for a disability evaluation in excess of 30 percent for the service-connected cervical spine disability for the entire appeal period, and the appeal is denied. The Board notes that separate 10 percent evaluations have been assigned for radiculopathy of each upper extremity from July 11, 2012. See the February 2013 rating decision. The criteria for rating disability of the median nerve are set forth under Diagnostic Codes 8515, 8615, and 8715. 38 C.F.R. § 4.124. Under Diagnostic Code 8515, a 10 percent rating is warranted for mild incomplete paralysis of the major or minor extremity. A 20 percent rating is warranted for moderate incomplete paralysis of the minor extremity. A 30 percent rating is warranted for moderate incomplete paralysis of the median nerve in the major extremity. A 40 percent rating is warranted for severe incomplete paralysis of the median nerve in the minor extremity. A 50 percent rating is warranted for severe incomplete paralysis of the median nerve in the major extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). Diagnostic Codes 8616 and 8716 are Diagnostic Codes that apply to neuritis and neuralgia of the median nerve. The schedular criteria are the same as those for Diagnostic Code 8515 as set forth above. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715 (2012). Complete paralysis of the median nerve is rated as 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity. This evaluation contemplates manifestations such as the hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to the palm; weakened wrist flexion; and pain with trophic disturbances. Id. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124a. The Board finds that a disability evaluation in excess of 10 percent is not warranted for the radiculopathy of either the left or right upper extremity. The medical evidence does not show findings of more than mild incomplete paralysis. The medical evidence shows that the radiculopathy is manifested by mild intermittent pain, mild paresthesias, and mild numbness in each upper extremity. See the July 2012 VA examination report. Neurological examinations were otherwise normal. 38 C.F.R. § 4.124a indicates that the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less that the type picture for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. There is no evidence of moderate, moderately-severe or severe incomplete paralysis. There is no evidence of complete paralysis. Thus, the Board finds that a rating higher than 10 percent is not warranted for the radiculopathy of the left and right upper extremities under Diagnostic Code 8715. The Court has held that a total rating based upon individual unemployability by reason of service-connected disability encompassed in a claim for increased rating or the appeal of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In a February 2013 rating decision, the RO granted the Veteran's claim for a total rating due to individual unemployability by reason of service-connected disability, effective on July 11, 2012. The Veteran was notified of this decision and did not perfect an appeal. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for service-connected cervical strain with cervical disc protrusion at C3-4. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's cervical strain with cervical disc protrusion at C3-4 are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. As discussed, the Veteran's symptoms and functional limitations due to the cervical spine disability are contemplated by the rating schedule, and the assigned schedular evaluations, therefore, are adequate. The rating criteria reasonably describe his disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. The rating criteria for spine disabilities contemplate limitation of motion of the spine and 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. The schedular rating criteria, the General Rating Formula for Diseases and Injuries of the Spine and the formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, specifically provide for disability ratings based on limitation of motion (flexion and combined ranges of motion, including ankylosis), including due to pain and other orthopedic factors which are incorporated into the schedular rating criteria (see 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59; DeLuca), other objective findings such as muscle spasm, tenderness, altered gait, abnormal spinal contour, and loss of height of vertebral body. The schedular rating criteria also provide for separate ratings for objective neurological manifestations. Hence, as the schedular rating reasonably describes the Veteran's disability picture, referral for extraschedular consideration is not warranted. 3. Service Connection for Myofascial Pain Syndrome Service Connection Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The term "veteran" is defined as a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." 38 U.S.C.A. § 101(2) (West 2002). The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24) (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). The definitional statute, 38 U.S.C.A. § 101(24), makes a clear distinction between those who have served on active duty and those who have served on active duty for training or inactive duty for training. The Court has held this statute, in effect, means that if a claim relates to period of active duty for training, a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim. Paulson v. Brown, 7 Vet. App. 466, 469-470 (1995). Active duty for training (ACDUTRA) includes full-time duty with the Army National Guard of any State under sections 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. See 38 U.S.C.A. § 101(22)(C); 38 C.F.R. § 3.6(c) (2012). Inactive duty training (INACDUTRA) includes service with the Army National Guard of any State (other than full-time duty) under section 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. See 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Presumptive periods do not apply to ACDUTRA or INACDUTRA. See Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Therefore, consideration of 38 U.S.C.A. §§ 1111 and 1131 (presumption of soundness), 3.306 (presumption of aggravation of a chronic pre-existing disease), and 38 C.F.R. §§ 3.307 and 3.309 (presumption of service incurrence for certain disease) for the periods of ACDUTRA or INACDUTRA is not appropriate. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Analysis of Service Connection The Veteran contends that the myofascial pain syndrome of the cervical spine was caused by the motor vehicle accident in INACDUTRA in September 1979. The Board finds that the evidence is in equipoise on the question of whether the diagnosed myofascial pain syndrome of the cervical spine is related to the cervical spine injury the Veteran sustained during INACDUTRA in September 1979. The service records show that the Veteran sustained a cervical spine injury in a motor vehicle accident on September 8, 1979 during a period of INACDUTRA and a cervical muscle strain was diagnosed. The medical statement and line of duty report indicates that a jeep turned over and the Veteran was inside the jeep when this occurred. It was noted that the Veteran had a possible cervical spine injury and a cervical muscle strain was diagnosed. A February 1980 service treatment record indicates that the Veteran had neck pain. The impression was acute cervical strain resolving. The Veteran was not placed on a permanent profile. A June 19, 1980 service treatment record indicates that the Veteran reported that his symptoms had worsened and he was unable to work. It was noted that the Veteran would be admitted to a hospital the following week for treatment of cervical strain. Service records show that the Veteran was hospitalized on June 24, 1980 and he was disabled from the performance of his duties from June 24 to July 2, 1980. A January 18, 1981 service treatment record indicates that the Veteran's symptoms had returned since discharge from the hospital. The impression was chronic myofascial pain. The Veteran was placed on a permanent profile on January 19, 1981 and he was discharged from the National Guard in February 1981. The record shows that the Veteran has had recurrent symptoms of neck pain since the cervical spine injury in September 1979. A February 1986 VA examination report indicates that the Veteran had complaints of intermittent neck pain. Physical examination revealed bilateral muscle spasm. The diagnosis was cervical strain, symptomatic, mild. X-ray examination was normal. Service connection for cervical strain was granted in April 1986. A 10 percent rating was assigned from December 10, 1985. A November 1986 VA examination report indicated that the Veteran reported that his neck ached all day and most of the night. The diagnosis was neck pain, no positive finding. A December 1992 VA treatment record shows a diagnosis of chronic arthromyalgia. In May 2001, a 30 percent rating was assigned to the service-connected cervical spine strain. A March 2003 VA examination report indicates that the impression was cervical spine injury in jeep accident with chronic neck pain. A September 2006 VA examination report indicates that the Veteran reported having daily, constant neck pain, pain that radiated to his arms, and numbness in both hands. The diagnosis was cervical spine disc disease. A May 2007 VA examination report indicates that the Veteran reported having continuous neck pain that radiated to the right shoulder. The examiner noted that an April 2003 EMG of the upper extremities was normal. The diagnosis was myofascial pain syndrome of the cervical spine with a normal x-ray examination and MRI. A December 2010 VA examination report notes that the Veteran reported having neck pain with radiation to the upper extremities with numbness. X-ray examination revealed minimal cervical disc protrusion at C3-4 level with no hernia ton. The diagnosis was myofascial pain syndrome. The Veteran was afforded another VA examination in July 2012. The diagnosis was cervical spine strain and cervical spine disc protrusion at C3-C4. The evidence of record shows that the Veteran sustained a cervical spine injury in a motor vehicle accident on September 8, 1979 during a period of INACDUTRA and he received medical treatment for the cervical spine injury after the accident. The Veteran's symptoms of neck pain after the cervical spine injury have been attributed to the diagnosis of cervical spine strain and the diagnosis of chronic myofascial pain. Cervical muscle strain was first diagnosed in September 1979. Chronic myofascial pain syndrome was first diagnosed in January 1981; the service treatment record notes that the Veteran's symptoms had returned since the hospitalization for treatment of the cervical spine strain. The Board is unable to differentiate between the symptomatology attributable to the myofascial pain syndrome of the cervical spine and the symptomatology attributable to the service-connected cervical spine strain with disc protrusion. The Board notes that the March 2003 VA examination report indicates that the Veteran had a cervical spine injury with chronic neck pain. The VA examination reports dated in May 2007 and December 2010 show diagnoses of myofascial pain syndrome of the cervical spine. This diagnosis is based upon the symptomatology of constant neck pain and radiating pain and examination findings of limited range of motion of the cervical spine and tenderness to palpation of the cervical spine. The September 2006 and December 2010 VA examination reports show diagnoses of cervical spine disc disease and cervical spine strain and these diagnoses are based upon the same symptomatology and manifestations. Affording the Veteran the benefit of doubt, the Board finds that it is as likely as not that the myofascial pain syndrome of the cervical spine is due to injury during INACDUTRA and is a component of the disability picture of the service-connected cervical spine strain with disc protrusion at C3-4. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for myofascial pain syndrome of the cervical spine is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER An increased disability rating in excess of 30 percent for the cervical strain with cervical disc protrusion at C3-4 is denied. Service connection for myofascial pain syndrome of the cervical spine is granted. ____________________________________________ THOMAS D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs