Citation Nr: 1324544 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 07-26 029 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial evaluation for right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) in excess of 10 percent prior to January 1, 2011. 2. Entitlement to an initial evaluation for right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) in excess of 20 percent from January 1, 2011. 3. Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU), on an extraschedular basis. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran had active service from November 1998 to November 2004. The increased rating appeals initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2005 decision by the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which, in part, granted service connection for right shoulder tendonitis, rated 10 percent disabling from November 14, 2004, the day following the Veteran's discharge from the service. 38 C.F.R. § 3.400(b)(2) (2012). The Veteran disagreed with the rating assigned giving rise to the current appeal. By rating action in October 2008, the RO assigned a 100 percent evaluation for convalescence from May 9, 2008, the date of surgery, and a 10 percent schedular evaluation from August 1, 2008. In March 2011, the Board, in part, remanded the appeal for additional development. Thereafter, by rating action in June 2011, the RO assigned a 100 percent convalescence rating following a second surgery on October 22, 2010, and subsequently assigned a 20 percent schedular evaluation effective from January 1, 2011. (See January 2012 rating action). The periods of 100 percent convalescence will not be discussed in this Board decision for increased ratings. In February 2013, the Board again remanded this appeal to the RO via the Appeals Management Center (AMC), in Washington, DC, for further development. The appeal has now been returned to the Board for appellate disposition. Jurisdiction over the appeal has been transferred to the RO in Huntington, West Virginia. The Veteran's Virtual VA paperless claims file has been reviewed in preparing this decision and remand, along with his paper claims file. At his March 2013 VA examination, the Veteran stated that he is unable to get a job because employers will not hire him due to his service-connected disabilities, to include his service-connected right shoulder disability. The Board finds that this evidence raises a TDIU claim. When a TDIU for a service-connected disability is raised in connection with an increased rating claim for that service-connected disability, the Board has jurisdiction over the issue of TDIU because it is part of the claim for increased compensation. Thus, the TDIU claim is included in the Veteran's appeal consistent with Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to a TDIU, on an extraschedular basis, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. Prior to January 1, 2011, the Veteran's service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle was manifested by, at worst, forward flexion limited to 150 degrees, abduction limited to 150 degrees, internal rotation limited to 60 degrees, and external rotation limited to 55 degrees, even when considering his pain. 2. Since January 1, 2011, the Veteran's service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle has been manifested by, at worst, forward flexion limited to 115 degrees, abduction limited to 110 degrees, internal rotation limited to 80 degrees, and external rotation limited to 80 degrees, even when considering his pain. CONCLUSIONS OF LAW 1. Prior to January 1, 2011, the criteria for an initial rating in excess of 10 percent for the service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5201 (2012). 2. Since January 1, 2011, the criteria for an initial rating in excess of 20 percent for the service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5201 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). I. VA's Duties to Notify and Assist Under applicable law, VA 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO sent the Veteran an initial duty-to-assist letter in March 2004. This letter addressed the Veteran's underlying claim of service connection for a right shoulder disorder. The increased rating claims flow downstream from an August 2005 rating decision, which initially established service connection for right shoulder tendonitis (later rated as right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle). The United States Court of Appeals for Veterans Claims (Court) held, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91(2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice provided before service connection was granted was legally sufficient, VA's duty to notify in this case is satisfied. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). VA also has a duty to assist the Veteran in the development of the appeal. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the appeal has been obtained. His STRs, VA treatment records, and private treatment records have been obtained. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorder currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. He has been afforded VA examinations, and the reports of those evaluations contain all findings needed to properly evaluate his disability. 38 C.F.R. § 4.2 (2012). The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The Board is also satisfied as to substantial compliance with its March 2011 and February 2013 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The remands included scheduling the Veteran for additional VA examinations, which he had in April 2011 and March 2013. The remands also included obtaining the Veteran's recent VA and private treatment records, which were obtained by the AMC and associated with his claims file. Finally, the remands directed the AMC to readjudicate the Veteran's appeal, which was accomplished in the January 2012 and April 2013 Supplemental Statements of the Case (SSOCs). Thus, the Board finds that there has been substantial compliance with its remand directives. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's appeal. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Increased Rating Claim Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. Separate DCs identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Where a Veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Veteran is in receipt of a 10 percent disability rating prior to January 1, 2011, and a 20 percent disability rating since January 1, 2011, under 38 C.F.R. § 4.71a, DC 5201 (previously rated under DC 5204) for his service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle. He seeks increased ratings. At the March 2013 VA medical examination, the Veteran reported that he is right-handed. Therefore, his right shoulder disability affects his major joint. DC 5201 provides that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder. Limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder. Limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder. 38 C.F.R. § 4.71a. Regarding DC 5201, the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently issued a decision, in which the Federal Circuit found that, "The plain language of section 4.71a confirms that a Veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to 'limitation of motion of' the arm." Yonek v. Shinseki, No. 10-3320, slip. op. at 4 (July 8, 2013 (U.S. Vet. App.). Normal range of motion of the shoulder is set forth in 38 C.F.R. § 4.71, Plate I (2012). Normal forward elevation, or flexion, is from 0 to 180 degrees. Normal shoulder abduction is also from 0 to 180 degrees. Normal external rotation and internal rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. Further, the provisions of 38 C.F.R. § 4.40 state that a disability affecting 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. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, at 592 (1991). Instead, in Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The Board will begin by addressing the 10 percent disability rating in effect prior to January 1, 2011. In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent prior to January 1, 2011, for his service-connected right shoulder disability. Here, there is no evidence of limitation of motion of the right arm at the shoulder level, to warrant a 20 percent rating. 38 C.F.R. § 4.71a, DC 5201. Since November 14, 2004 (the effective date of service connection), the Veteran has been treated by the VA Medical Center (VAMC) for his service-connected right shoulder disability. Specifically, at a January 2005 VA outpatient visit, the physician noted that the Veteran had decreased range of motion with pain and stiffness in his right shoulder. However, specific measurements regarding the Veteran's ranges of motion were not provided. The Veteran was afforded a VA examination in February 2005. At the examination, the Veteran's ranges of motion of the right shoulder were as follows: flexion limited to 150 degrees; abduction limited to 150 degrees; internal rotation to 60 degrees; and, external rotation to 90 degrees. The Veteran had tenderness and pain in the right shoulder. At a November 2005 VA outpatient treatment visit, the Veteran's ranges of motion of the right shoulder were as follows: flexion limited to 175 degrees; and, abduction limited to 170 degrees. The Veteran had full ranges of motion in the internal and external rotation. At an April 2007 VA outpatient visit, the physician noted that the Veteran had decreased range of motion in his right shoulder and chronic pain. However, specific measurements regarding the Veteran's ranges of motion were not provided. The Veteran was afforded another VA examination in October 2008. At the examination, the Veteran's ranges of motion of the right shoulder were not provided. However, the examiner found that the Veteran had a mild loss of motion and a mild loss of strength, along with pain, weakness, and stiffness in his right shoulder. In December 2008, the Veteran was provided another VA examination. At the examination, the Veteran's ranges of motion of the right shoulder were as follows: flexion limited to 160 degrees; abduction limited to 150 degrees; internal rotation limited to 90 degrees; and, external rotation limited to 55 degrees. The examiner found that there was no objective evidence of pain with active motion on the right side. VA outpatient notes beginning in November 2010, showed that the Veteran was instructed on various exercises to gain strength and ranges of motion in the right shoulder, and that he had started exercising at home doing just a few repetitive movements. The physical therapy notes document steady improvement in his ranges of motion and strength with decreasing pain over the next few months. The remaining VA and private treatment records do not provide contrary evidence. Based on the aforementioned evidence, the Board finds that the Veteran is not entitled to a disability rating in excess of 10 percent prior to January 1, 2011, for his service-connected right shoulder disability. As demonstrated by the aforementioned medical evidence, the record does not demonstrate that the Veteran's right shoulder disability is manifested by limitation of motion of the right arm at the shoulder level, to warrant a 20 percent rating. 38 C.F.R. § 4.71a, DC 5201. The Board will now address the 20 percent disability rating in effect since January 1, 2011. In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent since January 1, 2011, for his service-connected right shoulder disability. Here, there is no evidence of limitation of motion of the right arm midway between the side and shoulder, or limitation of motion of the right arm to 25 degrees from the side, to warrant a higher 30 percent rating for the right shoulder disability. 38 C.F.R. § 4.71a, DC 5201. Specifically, since January 1, 2011, in VA treatment records dated in January 2011 and February 2011, the Veteran's right shoulder displayed forward flexion limited to 130 degrees with pain. No other ranges of motion of the right shoulder were provided. A VA orthopedic outpatient note dated in March 2011, showed that the Veteran had full flexion and abduction and could reach behind his back to the mid thoracic level. While the Veteran had some weakness in the shoulder girdle, he denied any shoulder pain. At a VA examination in April 2011, the Veteran's ranges of motion of the right shoulder were as follows: flexion limited to 120 degrees; abduction limited to 110 degrees; internal rotation limited to 80 degrees; and, external rotation limited to 80 degrees. In March 2013, the Veteran was provided another VA examination. At the examination, the Veteran's ranges of motion of the right shoulder were as follows: flexion limited to 115 degrees, with objective evidence of painful motion beginning at 115 degrees; and, abduction limited to 110 degrees, with objective evidence of painful motion beginning at 110 degrees. The remaining VA and private treatment records do not provide contrary evidence. Based on the aforementioned evidence, the Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent since January 1, 2011, for his service-connected right shoulder disability. Here, there is no evidence of limitation of motion of the right arm midway between the side and shoulder, or limitation of motion of the right arm to 25 degrees from the side, to warrant a higher 30 percent rating for the right shoulder disability. 38 C.F.R. § 4.71a, DC 5201. In forming this decision, the Board has considered the Veteran's complaints of pain in the right shoulder. However, the lay and objective medical evidence does not show that his symptoms result in additional functional limitation to the extent that the Veteran's disability warrants higher disability ratings under DC 5201. 38 C.F.R. § 4.71a. Specifically, at the February 2005 VA examination, the Veteran had tenderness and pain in the right shoulder. Nothing further was documented. At the October 2008 VA examination, the VA examiner indicated that the Veteran's right shoulder was not manifested by flare-ups, and there were no functional limitations on his standing or walking. The Veteran did have pain, weakness, decreased muscle strength, fatigue, and stiffness of his right shoulder. At the December 2008 VA examination, the VA examiner determined that there was no objective evidence of pain following repetitive motion. He also found that there were no additional limitations after three repetitions of ranges of motion of the right shoulder. Although the Veteran was examined by VA in April 2011, the VA examiner did not provide an estimate as to whether there was any additional functional impairment due to the factors set forth in DeLuca. Specifically, the examiner indicated that there was objective evidence of pain on repetitive motion, but that he was unable to test the Veteran to determine whether there was any additional range of motion loss due to his significant pain. Accordingly, the Board remanded for an additional VA examination and medical opinion on this issue to be obtained. The Veteran was afforded another VA examination in March 2013. At the examination, the Veteran reported flare-ups of the right shoulder, specifically when he was lifting 20 pounds or more or lifting the right arm overhead. The examiner determined that the Veteran did not have additional limitation in ranges of motion of the right shoulder following repetitive-use testing. The examiner found that the Veteran also did not have any functional loss and/or functional impairment of the right shoulder. The examiner reasoned that the Veteran was able to perform three repetitions of motion with no reduction of degrees. The Veteran demonstrated heavy breathing and appeared to experience some discomfort during the examination. However, the examiner found that the Veteran's ranges of motion did not change following the repetitive motion and he was able to put his shirt back on without difficulty. The examiner stated that the Veteran has learned to adapt and has changed his training towards an occupation that would limit any activity (i.e., heavy lifting) that would flare-up his right shoulder. The examiner indicated that if the Veteran was subjected to any constant heavy lifting of items overhead or at shoulder level with no breaks in a regular work day, then he would likely have significant limited functional ability due to overuse and pain produced from overuse. However, in summary, the March 2013 VA examiner found that the Veteran did not have any functional loss and/or functional impairment of the right shoulder. Given that the Veteran was able to achieve the aforementioned ranges of motion of the right shoulder on examination despite the presence of pain, the Board finds that additional compensation for pain is not warranted. Indeed, pain alone does not constitute a functional loss under VA regulations. See Mitchell, 25 Vet. App. at 32. An award of a higher rating cannot be based on speculation of the additional functional loss in terms of degrees during such flare-ups. Thus, the Board finds that the Veteran's painful limitation of motion and additional functional impairment meets the impairment contemplated by the current scheduler disability ratings throughout the entire appeal period and does not more nearly approximate functional impairment commensurate with a higher disability rating. Even when considering the Veteran's pain and functional impairment following repetitive motion, the evidence of record does not establish that he has the requisite limitation of motion of the right shoulder to warrant higher disability ratings. Accordingly, the evidence of record does not support the assignment of higher disability ratings for the right shoulder disability based on additional functional limitation following repetitive use or flare-ups of the joint. The Board has considered other DCs in an effort to determine whether the Veteran might be entitled to higher disability ratings under another Code throughout the entire appeal. In this regard, DC 5200 provides that ankylosis of the scapulohumeral articulation is to be rated as follows: favorable ankylosis, with abduction to 60 degrees and can reach mouth and head, is rated as 30 percent for the major shoulder; intermediate ankylosis, between favorable and unfavorable, is rated as 40 percent for the major shoulder; and, unfavorable ankylosis with abduction limited to 25 degrees from side, is rated as 50 percent for the major shoulder. A Note provides that the scapula and humerus move as one piece. 38 C.F.R. § 4.71a, DC 5200. Throughout the entire appeal, the Veteran's right shoulder has not been ankylosed, as the Veteran had ranges of motion, albeit limited, in the right shoulder. Further, the March 2013 VA examiner specifically found that the Veteran's right shoulder joint was not ankloysed. The remaining medical evidence of record does not provide contrary evidence to that described above. 38 C.F.R. § 4.71a, DC 5200. DC 5202 provides ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the major shoulder. Malunion of the humerus with marked deformity is rated as 30 percent for the major shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, are rated as 20 percent for the major shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 30 percent for the major shoulder. Fibrous union of the humerus is rated as 50 percent for the major shoulder. Nonunion of humerus (false flail joint) is rated as 60 percent for the major shoulder. Loss of head of the humerus (flail shoulder) is rated as 80 percent for the major shoulder. 38 C.F.R. § 4.71a, DC 5202. DC 5203 also provides ratings for other impairment of the clavicle or scapula. Nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder. Dislocation of the clavicle or scapula with loose movement is also rated as 20 percent for the major shoulder. 38 C.F.R. § 4.71a, DC 5203. Here, the March 2013 VA examiner specifically found that the Veteran's right shoulder was not manifested by malunion, nonunion, or recurrent dislocations. The remaining medical evidence of record does not provide contrary evidence to that described above. 38 C.F.R. § 4.71a, DCs 5202, 5203. Thus, the Board finds that there are no other Codes under which the Veteran would be entitled to a higher disability rating at any time during the appeal. The Board notes that the Veteran is currently in receipt of a separate disability rating for his right shoulder scars. This rating was granted in the April 2013 rating decision, and to date, the Veteran did not appeal this grant. Therefore, the Board does not need to discuss in this decision whether the Veteran is entitled to a separate compensable disability rating for his related scars of the right shoulder. Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant even further staged ratings. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating an appeal, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that his disability is worse than the assigned ratings, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. In sum, the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent prior to January 1, 2011, and in excess of 20 percent since January 1, 2011, for the service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle, at any time during the appeal period. Thus, the appeal is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). III. Extraschedular Consideration The above determination is based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). However, the regulations also provide for exceptional cases involving compensation. Pursuant to 38 C.F.R. § 3.321(b)(1) (2012), the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service is authorized to approve an extraschedular evaluation if 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). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). 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). If the evidence raises the question of entitlement to an extraschedular rating, 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 a Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the claimant's disability level and symptomatology, then a Veteran'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"). Here, because the schedular ratings for the Veteran's right shoulder disability fully address his symptoms, which include mainly pain and limitation of motion, referral to the VA Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of an extraschedular evaluation is not warranted. The evidence of record does not establish that his right shoulder disability prevents him from being employed or requires frequent hospitalizations. Regarding employability, in particular, at his March 2013 VA examination, the Veteran stated that he is unable to get a job because employers will not hire him due to his service-connected disabilities, to include his service-connected right shoulder disability. However, the March 2013 VA examiner, following a review of the claims file and a physical examination of the Veteran, determined that the Veteran could perform sedentary employment with his service-connected right shoulder disability. The examiner noted that the Veteran would have difficulty with overhead reaching and heavy lifting, but this would not prevent him from performing sedentary employment. The examiner also reasoned that the Veteran started automobile mechanic school in June 2011, and was able to finish his education, despite his right shoulder difficulties. The examiner noted that the Veteran reported he could not find a job after graduating, so he returned to business school in September 2012. There are no other medical opinions in the claims file regarding the Veteran's right shoulder disability and his employability. Further, the Veteran's TDIU claim is being remanded for further development below, and thus, the total effect of the Veteran's service-connected disabilities, to include his right shoulder disability, will be considered. Therefore, the Board finds that there is no evidence that the Veteran's service-connected disability causes impairment that is not contemplated by the schedular rating criteria or that renders impractical the application of the regular schedular standards. See Thun, 22 Vet. App. at 111. Accordingly, referral of this case for consideration of an extraschedular rating is not warranted. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). ORDER Prior to January 1, 2011, an initial disability rating in excess of 10 percent for the service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) is denied. Since January 1, 2011, an initial disability rating in excess of 20 percent for the service-connected right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle (previously rated as tendonitis) is denied. REMAND Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the TDIU claim can be properly adjudicated. Initially, the Veteran has not been provided with a proper duty-to-assist notice letter. The Veteran must be provided with this requisite notice upon remand. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; see Dingess, 19 Vet. App. at 473. Second, a remand is required in order to afford the Veteran a VA examination to determine whether his service-connected disabilities currently preclude him from performing substantially gainful employment. The evidence of record documents that the Veteran is currently unemployed, and the Veteran asserts that his current unemployment is due to his service-connected disabilities. Although the Veteran has been afforded VA examinations, a medical opinion regarding the total effect of his service-connected disabilities on his employability has not yet been obtained. In the case of a disability compensation claim, VA's duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Here, a VA examination is necessary in order to provide a current assessment of the Veteran's employability. Additionally, the most recent outpatient treatment records from the St. Louis, Missouri, VAMC are dated since August 2011. The most recent outpatient treatment records from the Orlando, Florida, VAMC are dated since February 2013. On remand, all pertinent records since these dates should be obtained and added to the claims file. Upon remand, all private treatment records contained in the claims file should also be updated. See 38 U.S.C.A. § 5103A(a)(1), (b)(1), (c)(1); Loving v. Nicholson, 19 Vet. App. 96, 101-03 (2005). Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran a duty-to-assist notice letter pursuant to 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), which includes, but is not limited to, an explanation as to what information or evidence is needed to substantiate his TDIU claim currently on appeal. Additionally, this letter should comply with the case of Dingess, 19 Vet. App. at 473. 2. Obtain all pertinent VA outpatient treatment records from the St. Louis, Missouri, VAMC since August 2011 that have not been secured for inclusion in the record. Obtain all pertinent VA outpatient treatment records from the Orlando, Florida, VAMC since February 2013 that have not been secured for inclusion in the record. Ensure that the Veteran has not been recently treated by any other local VAMCs. If no additional medical records are located, a written statement to that effect should be requested for incorporation into the record. 3. Obtain and update all private treatment records currently contained in the claims file. If no additional medical records are located, a written statement to that effect should be requested for incorporation into the record. 4. Schedule the Veteran for a VA examination in order to assist in evaluating the effect of his service-connected disabilities (right shoulder impingement syndrome with post-op acromioplasty and excision of the distal clavicle; mechanical low back pain; tinnitus; hearing loss; right shoulder scars; multiple scars from the residuals of leishmaniasis; and, left shoulder tendonitis) on his employability. Properly notify the Veteran of the examination by sending notice of the details of the examination to the Veteran at his correct address. Send the notice with sufficient time in advance to allow the Veteran to attend the examination. Specifically, the VA examiner is directed to provide a medical opinion concerning the extent of the social and industrial impairment resulting solely from the Veteran's service-connected disabilities. The medical opinion must address whether his service-connected disabilities alone are so disabling as to render him unemployable. A pertinent medical, education, and employment history should be taken. The VA examiner should also consider whether the Veteran is currently receiving Workers' Compensation or SSA disability benefits. The Veteran's age and the effects of non-service-connected disabilities cannot be factors for consideration in making the determination. However, the effects of treatments and medications used to treat the service-connected disabilities must be considered in the opinion. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file itself, must be made available to the examiner. All necessary studies and tests shall be conducted. If the examiner determines that a decision cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. The Veteran is hereby notified that it is his responsibility to report for the examination(s) scheduled in connection with this REMAND at whatever location it is scheduled and to cooperate in the development of his case. The consequences of failure to report for a VA examination may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. The RO/AMC should then determine whether the Veteran's TDIU claim should be referred to the Director of VA Compensation and Pension for extraschedular consideration. 6. After the above actions have been completed, readjudicate the Veteran's claim. If the claim remains denied, issue to the Veteran and his representative a Supplemental Statement of the Case (SSOC). Afford them the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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 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). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs