Citation Nr: 1324980 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 08-37 748 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to an initial compensable rating for hypertension. 2. Entitlement to an initial increased rating for degenerative joint disease, left shoulder, rated 10 percent disabling from February 26, 2009, and as noncompensably disabling prior to that date. 3. Entitlement to an initial increased rating for degenerative joint disease, right shoulder, currently rated 10 percent disabling from February 26, 2009, and as noncompensably disabling prior to that date. 4. Entitlement to an initial increased rating for lumbar spine L5-S1 degenerative disc disease, currently rated 10 percent disabling from February 26, 2009, and as noncompensably disabling prior to that date. 5. Entitlement to an initial increased rating for degenerative joint disease, left knee, currently rated 10 percent disabling from February 26, 2009, and as noncompensably disabling prior to that date. 6. Entitlement to an initial increased rating for degenerative joint disease, right knee, currently rated 10 percent disabling from February 26, 2009, and as noncompensably disabling prior to that date. 7. Entitlement to an initial compensable rating for degenerative joint disease, left hand and wrist. 8. Entitlement to a total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from June 1999 to June 2007. This matter came to the Board of Veterans' Appeals (Board) from an April 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In the April 2008 rating decision, the RO granted entitlement to service connection for lumbar spine L5-S1 degenerative disc disease, bilateral shoulder, bilateral knee, left hand and wrist, degenerative joint disease, assigning a single 10 percent disability rating, effective June 5, 2007; and, granted entitlement to service connection for hypertension, assigning a noncompensable rating, effective June 5, 2007. In a March 2010 rating decision, the RO assigned a 10 percent disability rating to degenerative disc disease, lumbar spine L5-S1; assigned a 10 percent disability rating to degenerative joint disease, right shoulder; assigned a 10 percent disability to degenerative joint disease, left shoulder; assigned a 10 percent disability rating to degenerative joint disease, right knee; assigned a 10 percent disability rating to degenerative joint disease, left knee, all effective February 26, 2009. To summarize, prior to February 26, 2009, the Veteran was in receipt of one single 10 percent rating contemplating his arthritis of the spine, shoulders, knees, left hand and left wrist. As of February 26, 2009, each of these disabilities was assigned a 10 percent evaluation. Thus, for all of the arthritis-based claims, the Board's analysis will consider whether a separate compensable 10 percent evaluation is appropriate for the period prior to February 26, 2009, as well as whether a rating in excess of 10 percent is warranted from that point forward. In an April 2011 rating decision, the RO granted entitlement to service connection for posttraumatic stress disorder (PTSD) with depressive symptoms, assigning a noncompensable rating, effective June 5, 2007, assigning a 30 percent disability rating, effective June 16, 2009, and assigning a 50 percent disability rating, effective June 10, 2010. The grant of service connection for PTSD with depressive symptoms constituted a full award of the benefit sought on appeal as to that issue. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Neither the Veteran nor his representative submitted a jurisdiction-conferring notice of disagreement as to the down-stream elements of effective date or compensation level within the applicable time period. Thus, those issues are not currently in appellate status. Id. In March 2009, the Veteran testified at a Board hearing before a Veterans Law Judge who is no longer employed by the Board. The transcript is of record. The Veteran elected to testify at another Board hearing. Thus, in March 2013, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; the transcript is of record. The Board acknowledges that a total disability rating due to individual unemployability (TDIU) as a result of service-connected disability was denied by the RO in a February 2013 rating decision. To date, the Veteran has not filed a notice of disagreement. However, the Court held in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a claim of entitlement to a TDIU is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial ratings assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. The Veteran continues to assert that he is unemployed due to his service-connected disabilities. Pursuant to Rice, the issue of entitlement to a TDIU is currently before the Board since the issue of unemployability is raised by the record. The issues of entitlement to initial increased ratings for lumbar spine L5-S1 degenerative disc disease, right knee, left knee, and left hand and wrist, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if any further action is required on his part. FINDINGS OF FACT 1. For the period prior to December 16, 2012, the Veteran's hypertension was not manifested by diastolic pressure predominantly 100 or more, or by systolic pressure predominantly 160 or more. 2. For the period from December 16, 2012, the Veteran's hypertension has not been manifested by diastolic pressure predominantly 110 or more, or by systolic pressure predominantly 200 or more. 3. From June 5, 2007, the Veteran's major left shoulder is manifested by infrequent episodes of recurrent dislocation at scapulohumeral joint with guarding of movement only at shoulder level, with no limitation of motion midway between side and shoulder level. 4. For the period prior to February 26, 2009, the Veteran's minor right shoulder is not manifested by limitation of motion or functional loss. 5. From February 26, 2009, the Veteran's minor right shoulder is not manifested by limitation of motion at shoulder level, impairment of the humerus, nonunion or dislocation of the clavicle or scapula. CONCLUSIONS OF LAW 1. For the period prior to December 16, 2012, the criteria for entitlement to a compensable disability rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). 2. For the period from December 16, 2012, the criteria for entitlement to a 10 percent disability rating, but no higher, for hypertension have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). 3. For the period from June 5, 2007, the criteria for a separate 20 percent disability rating for degenerative joint disease, left shoulder, have been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5201, 5202, 5203 (2012). 4. For the period prior to February 26, 2009, the criteria for a separate compensable rating for right shoulder disability have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 50003, 5201, 5203 (2012). 5. For the period from February 26, 2009, the criteria for a disability rating in excess of 10 percent disability rating for degenerative joint disease, right shoulder, have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5201, 5202, 5203 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claims arise from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Here, the Veteran was sent a letter in October 2007 that provided information as to what evidence was required to substantiate the claim(s) and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him 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 Board finds that VA has complied with all assistance provisions of VCAA with regard to the hypertension and bilateral shoulder issues. His service treatment records and VA outpatient treatment records have been associated with the claims folder and Virtual VA. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The Veteran was afforded VA examinations in conjunction with his hypertension and bilateral shoulder claims, which will be discussed below. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims for initial increased ratings for hypertension and shoulder disabilities. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Hypertension The Veteran's hypertension is rated noncompensably disabling pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension). Such diagnostic code provides a 60 percent rating if the diastolic pressure is predominantly 130 or more, a 40 percent rating if the diastolic pressure is predominantly 120 or more, a 20 percent rating if the diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more, a 10 percent rating if the diastolic pressure is predominantly 100 or more or systolic pressure is predominantly 160 or more, or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Initially, it is noted that the medical evidence of record reflects that the Veteran requires continuous medication for control of his hypertension. In March 2008, the Veteran underwent a VA examination. It was noted that he was treating his hypertension with 20 milligrams of Lisinopril per day. His blood pressure readings were: 118/83, 123/80, and 136/90. A March 2008 VA outpatient treatment record reflects a blood pressure reading of 130/88. An April 2008 VA outpatient treatment record reflects a blood pressure reading of 118/84. A July 2008 VA outpatient treatment record reflects a blood pressure reading of 113/85. VA outpatient treatment records dated in August 2008 reflect blood pressure readings of 122/71 and 121/64. A December 2008 VA outpatient treatment record reflects a blood pressure reading of 86/54. The examiner noted that he has hypertension but was now hypotensive with his current combination of medications. His physician reduced his Lisinopril from 20 milligrams to 10 milligrams per day. A January 2009 VA outpatient treatment record reflects a blood pressure reading of 88/62. An April 2009 VA outpatient treatment record reflects a blood pressure reading of 127/79. VA outpatient treatment records dated in June 2009 reflect blood pressure readings of 122/78, 103/63, and 115/78. A July 2009 VA outpatient treatment record reflects a blood pressure reading of 114/84. An August 2009 VA outpatient treatment record reflects a blood pressure reading of 114/78. VA outpatient treatment records dated in September 2009 reflects that he was taking 10 milligrams of Lisinopril per day. An October 2009 VA outpatient treatment record reflects a blood pressure reading of 126/88. VA outpatient treatment records dated in June 2010 reflects that he was taking 10 milligrams of Lisinopril per day. An August 2012 VA outpatient treatment record reflects a blood pressure reading of 113/73. An October 2012 VA outpatient treatment record reflects a blood pressure reading of 119/77. In December 2012, the Veteran underwent a VA examination. It was noted that he had been taking anti-hypertension medications since service and at the time of the examination he was taking Lisinopril 10 milligrams a day. His blood pressure readings were: 122/80, 120/80, and 124/82. VA outpatient treatment records dated in December 2012 reflect blood pressure readings of 127/84, 146/103, 131/83, 140/87, 133/103, 128/84, 139/91, 145/85, 131/81, and 137/91. The Veteran's hypertension is currently rated noncompensably disabling as while the medical evidence of record reflects that his hypertension requires continuous medication for control, none of the readings taken prior to December 16, 2012 reflect a diastolic pressure of 100 or more, and there has been no showing of systolic pressure predominantly 160 or more. On December 16, 2012, however, blood pressure readings of 146/103 and 133/103 were recorded. While the Board does not necessarily find that these readings constitute diastolic pressure predominantly 100 or more, in light of the fact that two of the diastolic readings in December 2012 were recorded in excess of 100 and the fact that he continues to take medication to control his hypertension, the Board finds that a 10 percent rating is warranted from December 16, 2012. There is otherwise no support for a disability rating in excess of 10 percent from December 16, 2012, as the medical evidence does not demonstrate that the Veteran's hypertension more nearly approximates diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more, as contemplated by a 20 percent rating under Diagnostic Code 7101. 38 C.F.R. § 4.104, Diagnostic Code 7101. Accordingly, a compensable rating is not warranted prior to December 16, 2012, but a 10 percent rating is warranted from December 16, 2012. Shoulders As detailed in the Introduction, service connection was initially established for lumbar spine L5-S1 degenerative disc disease, bilateral shoulder, bilateral knee, left hand and wrist, degenerative joint disease, and a single 10 percent disability rating was assigned, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010, arthritis, due to trauma, substantiated by x-ray findings, which is rated as degenerative arthritis pursuant to Diagnostic Code 5003, effective June 5, 2007. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The single 10 percent rating was assigned as the March 2008 VA examination reflected no limitation of motion affecting the shoulder, knees, spine and left hand/wrist, but minimal degenerative joint disease was detected on x-ray examination. Thus a single 10 percent rating was assigned in contemplation of x-ray evidence of involvement of 2 or more major joints. The Veteran perfected an appeal with regard to the disability rating assigned. Thereafter, separate 10 percent disability ratings were assigned to the right and left shoulders, effective February 26, 2009. The evidence of record reflects that the Veteran is left-handed. Disabilities of the shoulder and arm are evaluated under rating criteria that contemplate ankylosis of scapulohumeral articulation (Diagnostic Codes 5200), limitation of motion of the arm (Diagnostic Code 5201), other impairment of the humerus (Diagnostic Code 5202), or impairment of the clavicle or scapula (Diagnostic Code 5203). Normal range of motion of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5200 rates ankylosis of the scapulohumeral joint. Where arm limitation of motion is limited to 25 degrees from the side, a 30 percent evaluation is assigned for the minor side and a 40 percent evaluation is assigned for the major side, under Diagnostic Code 5201. Limitation of motion midway between the side and shoulder level contemplates a 20 percent evaluation for the minor side and a 30 percent evaluation for the major side, and limitation of motion at shoulder level contemplates a 20 percent evaluation for both the major and minor side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under Diagnostic Code 5202, for impairment of the humerus, a 20 percent rating is granted when there is malunion, with moderate deformity, for the minor and major arms; a 20 percent rating is warranted when there is marked deformity of the minor arm and a 30 percent rating is warranted when there is marked deformity of the major arm. Also under Diagnostic Code 5202, for recurrent dislocations of the minor/major arm at the scapulohumeral joint, a 20 percent rating is granted with infrequent episodes, and guarding of movement only at shoulder level; a 20 percent rating is granted for the minor arm and a 30 percent rating is granted for the major arm when there are frequent episodes and guarding of all arm movements. For fibrous union of the minor arm a 40 percent rating is assigned, whereas a 50 percent rating is assigned for the major arm. A 50 percent rating is warranted for nonunion (false flail joint) of the minor arm and a 60 percent rating is warranted for the major arm. A 70 percent rating is warranted for loss of head of (flail shoulder) for the minor arm and an 80 percent rating is warranted for the major arm. 38 C.F.R. § 4.71a, Diagnostic Code 5202. Under Diagnostic Code 5203, for impairment of the clavicle or scapula in both the minor and major arms, a 10 percent rating is granted for malunion or nonunion without loose movement and a 20 percent rating is granted for nonunion with loose movement or for dislocation. The medical evidence of record reflects that during service the Veteran injured both shoulders. He underwent left shoulder surgery in February 2007 for a left rotator tear. Later that same year he underwent right shoulder surgery for a rotator tear and scar tissue. A March 4, 2008 VA examination report reflects the Veteran's complaints of pain and stiffness in the shoulders. On physical examination of the shoulders, range of motion of the shoulders was normal, albeit with pain on left shoulder abduction from 140 to 180 degrees, and internal rotation from 20 to 80 degrees. There was minimal degenerative joint disease in the right shoulder and minimal symmetrical degenerative joint disease in the left shoulder. On March 25, 2008, the Veteran sought VA emergency room treatment complaining of left shoulder pain. While moving a car seat he felt his shoulder pop out from the socket and then pop back in. He was able to move his left arm but range of motion was limited due to pain. On physical examination, there were no fractures or dislocation. The assessment was left shoulder injury, muscle sprain versus ligament injury versus rotator cuff injury. He was given a splint and pain medication. A May 2008 VA treatment record reflects that the Veteran had done well post February 2007 surgery until the injury on March 25, 2008. He reported pain since that time with apprehension about a dislocation. On physical examination, he had full range of motion of his left shoulder. There was no subluxation of the shoulder and he had tenderness over the front portion of the shoulder, rotator cuff, and biceps tendon region. He was given an injection of xylocaine. A July 2008 VA treatment record reflects the Veteran's complaints that his left shoulder pops occasionally. On examination, he had fairly good range of motion of both shoulders. No crepitus could be felt in the left shoulder. X-rays and MRI were reviewed which showed no significant surgical pathology. There was no evidence of any Bankart lesion or rotator cuff tendon tear. The left subacromial bursa was injected with xylocaine for symptomatic relief. In August 2008, the Veteran complained of left shoulder pain. He reported relief of pain and increased range of motion following the July 2008 injection. It was noted that he was taking a Morphine Sustained Release and he was noticing decreased pain in his shoulders. On February 26, 2009, the Veteran underwent a VA examination that reflected complaints of pain in the right shoulder, but not as bad as the left shoulder. With regard to the left shoulder, he complained of pain in the shoulder 70 percent of the time and he has flare-ups of throbbing pain about once per week. On physical examination, left flexion was from 0 to 160 degrees, left abduction was from 0 to 170 degrees. There was pain with active motion on the left side. Range of motion of the right shoulder was normal. There was pain following repetitive motion but no additional limitations after three repetitions of range of motion. The examiner diagnosed mild degenerative joint disease with mild biceps tendinitis right shoulder and chronic rotator cuff tendinitis and secondary degenerative joint disease left shoulder. A July 2009 entry reflects that via telephone contact, the Veteran reported knee/shoulder pain for the prior 1 to 2 weeks but since then not continuously. An October 2009 VA treatment record reflects complaints of right shoulder pain, with no specific findings or diagnosis. A December 2010 entry reflects the examiner's notation that his MRIs of the shoulders show tendinosis of the rotator cuff. In January 2011, the Veteran reported to the orthopedic clinic with complaints of bilateral shoulder pain, left greater than right. He denied any injury. On examination, he had full range of motion with limited external rotation on left shoulder. In March 2011, he complained of bilateral shoulder pain, left greater than right. On another occasion in March 2011, he indicated that he had experienced no dislocation episodes in either shoulder since his operations had been performed. He had full active range of motion of both shoulders. On December 16, 2011, he reported a worsening of his left shoulder pain over the last few months, worse than before. The Veteran reported the pain medication was not working and he was taking more than recommended. On examination of the left shoulder, there was no tenderness to palpation and no active abduction. In December 7, 2012, the Veteran underwent a VA examination. With regard to the left shoulder, he complained that he was unable to reach up well. As a consequence, he had trouble adjusting the shower head and trouble reaching up to shelves above the shoulder. Limited range of motion slowed him down doing yard work. His shoulder joint tended to "pop out" when significant lifting or force is applied so he could not perform heavier work at home or elsewhere. With regard to his right shoulder, the Veteran reported that his right shoulder was functioning well. On physical examination, right shoulder flexion and abduction was normal, with no objective evidence of painful motion. Left shoulder flexion was to 170 degrees and painful motion began at 160 degrees. Left shoulder abduction was to 145 degrees and painful motion began at 130 degrees. He was able to perform repetitive-use testing with three repetitions. Following repetitive motion, right shoulder range of motion was normal, with flexion to 180 degrees and abduction to 180 degrees; and, left shoulder flexion was to 170 degrees and abduction was to 145 degrees. He did not have additional limitation on range of motion of the shoulder and arm following repetitive-use testing. With regard to functional loss or impairment, the examiner noted less movement than normal in the left shoulder and pain on movement in both shoulders. He had localized tenderness or pain on palpation of joints/soft tissue/biceps tendon of the left shoulder. There was no guarding of the shoulders. On muscle strength testing, shoulder abduction and forward flexion were normal in both shoulders. There was no ankylosis of the glenohumeral articulation. Hawkins' impingement test and empty can test were negative. On external rotation/infraspinatus strength test, it was positive indicative of weakness of the left shoulder. Lift-off subscapularis test was negative. There was a history of mechanical symptoms (clicking, catching, etc.) affecting the left shoulder. The examiner noted infrequent episodes of recurrent dislocation (subluxation) of the glenohumeral joint of the left shoulder. Crank apprehension and relocation test was positive in the left shoulder, which was indicative of shoulder instability. There was laxity of the clavicle or scapula of both shoulders but no dislocation; nonunion; or, malunion. There was tenderness on palpation of the AC joint on the left shoulder. Cross-body adduction test was positive on the left shoulder which was indicative of acromioclavicular joint pathology. He had effective function of the shoulders. The examiner noted that there was no degenerative or traumatic arthritis documented and the imaging was done post-operatively. The examiner diagnosed tendinosis of supraspinatus and subscapularis tendons, right shoulder; partial tear of glenoid labrum, left shoulder; and, limited motion, left shoulder. Initially, the Board finds that a separate rating is warranted for the Veteran's left shoulder disability from June 5, 2007. Indeed, a March 2008 VA examination included x-ray findings of minimal symmetrical degenerative joint disease in the left shoulder and complaints of pain on range of motion, albeit with normal range of motion. This alone is sufficient to warrant a 10 percent evaluation- however, the Board finds that an even higher rating, of 20 percent, is warranted throughout the rating period on appeal. Indeed, a May 2008 treatment report reflects the Veteran's complaints of apprehension about left shoulder dislocation ever since his 2007 surgery. In a July 2008 VA record he reported that the left shoulder popped occasionally. Finally, a December 2012 VA examination indicated infrequently recurrent dislocations of the left shoulder. Thus, for these reasons, a 20 percent evaluation under Diagnostic Code 5202 is warranted throughout the rating period on appeal. There is no showing of frequent dislocation, or of flail shoulder, false flail joint, or fibrous union of the humerus such as to warrant higher evaluations under that diagnostic code. With respect to the right shoulder, the Board finds that for the period prior to February 26, 2009, a separate compensable rating is not warranted, as the March 2008 VA examination report reflects normal range of motion without any complaints of pain on motion nor any indication of functional loss. Likewise, the subsequent VA treatment records do not reflect any complaints or treatment related to the right shoulder. For the period from February 26, 2009, the Board finds that disability ratings in excess of 10 percent are not warranted for the right shoulder disability. With regard to the right shoulder, the VA examination reports and VA treatment records do reflect pain. However, the bulk of his complaints referred to the left shoulder. As detailed above, on examination in February 2009, range of motion of the right shoulder was normal. Thereafter, VA treatment records reflect complaints of pain in the right shoulder, but with no specific objective findings to support a rating in excess of 10 percent. The December 2012 VA examination report also reflects normal range of motion. While he had pain on movement in the right shoulder, further testing was negative. Considering the DeLuca factors and the evidence of record, the Board finds that the current 10 percent rating more than adequately compensates the Veteran for any functional loss due to pain affecting the right shoulder. DeLuca, 8 Vet. App. at 204-7. Again, the VA examiners have found no loss of motion affecting the right shoulder, only pain on movement. With regard to the left shoulder, for the period prior to December 7, 2012, the clinical evidence of record is against a finding that the Veteran's left shoulder motion was limited at shoulder level. As noted previously, the February 2009 VA examination report reflected flexion to 160 degrees and abduction to 170 degrees with pain but no additional limitations after three repetitions of range of motion. The evidence does not show limitation of motion at shoulder level to warrant a 20 percent rating. Thereafter, VA treatment records reflect complaints of pain but with a full range of motion on testing in January and March 2011. On examination in December 2012, his flexion was to 170 degrees with pain at 160 degrees and abduction was to 145 degrees with pain at 130 degrees, albeit with no additional limitation on range of motion following repetitive-use testing. Thus, while a 20 percent rating would not be warranted for limitation of motion at shoulder level, the examiner also noted mechanical symptoms affecting the left shoulder, infrequent episodes of recurrent dislocation of the glenohumeral joint of the left shoulder, shoulder instability, and acromioclavicular joint pathology. The Board finds that a 20 percent rating is warranted pursuant to Diagnostic Code 5202 for infrequent episodes of recurrent dislocation with guarding of movement at the shoulder level. A higher rating is not warranted as frequent episodes of recurrent dislocation has not been shown. In contemplation of the DeLuca factors and the evidence of record, the Board finds that the respective 10 percent rating and 20 percent rating assigned to the left shoulder more than adequately compensates the Veteran for any functional loss due to pain affecting the shoulder. DeLuca, 8 Vet. App. at 204-7. The Board has also considered whether there is another applicable diagnostic code which would provide the Veteran with a higher rating based on his symptoms but finds that there is not. The evidence of record is against a finding that the Veteran's left shoulder disability is manifested by fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus; therefore higher ratings under Diagnostic Code 5202 is not warranted. In addition, the evidence of record does not reflect that he has ankylosis of scapulohumeral articulation; therefore, a rating under Diagnostic Code 5200 is not warranted. Thus, the Board concludes that a separate 20 percent rating is warranted for left shoulder disability, effective June 5, 2007. With regard to the right shoulder, the Board finds that a separate compensable rating is not warranted for the period prior to February 26, 2009, and a rating in excess of 10 percent is not warranted from February 26, 2009. Extraschedular consideration (A claim for a TDIU is discussed in the Remand below.) The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are adequate with respect to the Veteran's hypertension and bilateral shoulder disabilities. The diagnostic criteria adequately describe the severity and symptomatology of these disorders. Indeed, there is no indication that the Veteran experiences symptoms that are outside the range of that contemplated by the relevant diagnostic codes. Accordingly, referral for extraschedular consideration is not for application here. ORDER For the period prior to December 16, 2012, a compensable rating for hypertension is denied. From December 16, 2012, a 10 percent rating for hypertension is granted, subject to laws and regulations governing payment of VA monetary benefits. From June 5, 2007, a 20 percent rating for left shoulder disability is granted, subject to laws and regulations governing payment of VA monetary benefits. For the period prior to February 26, 2009, a separate compensable rating for right shoulder disability is denied. For the period from February 26, 2009, a disability rating in excess of 10 percent for right shoulder disability is denied. REMAND In March 2008, the Veteran underwent a VA general examination and in February 2009 he was afforded a VA joints examination to assess the nature and severity of his lumbar spine, bilateral knees, and left hand/wrist disabilities. While he was afforded a VA examination to assess the severity of his shoulders in December 2012, such examination did not include assessment of his lumbar spine, bilateral knees, and left hand/wrist disabilities. At both the March 2009 and March 2013 Board hearings, the Veteran testified as to the symptomatology associated with these disabilities and he continues to undergo treatment pertaining to the back and knees. In light of the fact that the most recent examination was conducted over 4 years ago, and as the clinical and lay evidence suggests a worsening of symptomatology, the Veteran should be afforded a VA examination to assess the severity of his lumbar spine, bilateral knee, and left hand/wrist disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). TDIU During the pendency of the appeal, the Court held that a TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In September 2011, the Veteran filed a claim for a TDIU, submitting a VA Form 21-8940 in support of his claim. He asserted that he last worked as a mechanic in a full-time capacity on June 5, 2008, and that he stopped working due to his PTSD and shoulders. The RO denied entitlement to a TDIU in a February 2013 rating decision which the Veteran did not appeal. At the March 2013 hearing, the Veteran testified that he has been unemployed since June 2008 due to his shoulder, lumbar spine, and left hand/wrist disabilities As there is evidence of unemployability as of June 2008, the Veteran is presumed to be seeking the highest rating possible, and there is evidence of medical disabilities. Thus, given the evidence of medical disabilities, the claim for the highest rating possible, and evidence of unemployability, the record raises a claim for a TDIU under Roberson and Rice and the issue is properly before the Board as part of the appeal for increased ratings for lumbar spine, bilateral knee, bilateral shoulder, and left hand/wrist disabilities. Moreover, the Veteran's disabilities do currently meet the percentage requirements for a TDIU pursuant to 38 C.F.R. § 4.16(a). The Court has held that in the case of a claim for total rating based on individual unemployability, the duty to assist requires that VA obtain an examination including an opinion on what effect the Veteran's service-connected disabilities have on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). The record does contain a December 2012 VA opinion indicating that his PTSD has significant impact on his individual unemployability and that his left shoulder has an important impact. His other disabilities, including his right shoulder, bilateral knees, lumbar spine, and left hand/wrist have a minor impact on his ability to work. An opinion should be obtained as to the combined effect of his service-connected disabilities on employment. Finally, the evidence of record reflects that the Veteran has undergone VA vocational rehabilitation. The Veteran's vocational rehabilitation folder should be associated with the claims folder. VA outpatient treatment records In light of these matters being remanded, associate updated treatment records from the Reno, Nevada VA Medical Center (VAMC) for the period from January 24, 2013. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following actions: 1. Associate updated treatment records from the Reno VAMC with the claims folder or Virtual VA for the period from January 24, 2013. 2. Associate the Veteran's Vocational Rehabilitation folder with the claims folder or Virtual VA. If such efforts prove unsuccessful, documentation to that effect should be added to the claims folder. 3. Schedule the Veteran for a VA orthopedic examination with a physician with appropriate expertise to assess the current severity of his lumbar spine, bilateral knee, and left hand/wrist disabilities. It is imperative that the claims file be made available to and reviewed by the examiner in connection with the examination. All clinical and special test findings should be clearly reported, and pertinent orthopedic and neurological findings should be reported. With regard to the right and left knees, the examiner should report the ranges of right and left knee flexion and extension in degrees. The examiner should determine whether the right and left knee disabilities are manifested by weakened movement, excess fatigability, incoordination, flare-ups or pain. Such inquiry should not be limited to muscles or nerves. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, pain or flare-ups. If there is pain on motion, the examiner should report the point in the range of motion when the pain becomes apparent. The examiner should also report whether there is instability or subluxation and express an opinion as to the severity of such instability or subluxation. With regard to the lumbar spine, the examination should include range of motion studies. With regard to range of motion testing, the examiner should report at what point (in degrees) pain is elicited as well as whether there is any other functional loss due to weakened movement, excess fatigability or incoordination. The examiner should specifically state if ankylosis and muscle spasm are present. The examiner should also estimate any additional loss of function during periods of flare-up, expressed in degrees of lost motion. The examiner should report any specific information as to the frequency and duration of incapacitating episodes in the past 12 months, and a description of all neurologic manifestations, to include, but not limited to, radiating pain into an extremity, and bowel or bladder impairment. With regard to the left hand/wrist, the examiner should identify all disabilities associated with the left hand/wrist. Range of motion testing of the hand and wrist should be accomplished and the examiner should report, in degrees, the point at which pain is demonstrated. To the extent possible the functional impairment due to incoordination, weakened movement and excess fatigability on use should be assessed in terms of additional degrees of limitation of motion. The examiner should indicate the extent of any left hand/wrist incoordination, weakened movement and excess fatigability on use should be described. To the extent possible the functional impairment due to incoordination, weakened movement and excess fatigability on use should be assessed in terms of muscle damage from atrophy or disuse resulting from the left hand/wrist injury. The examiner should identify what muscle group is so affected. If this is not possible, the examiner should so state. Any favorable or unfavorable ankylosis should be documented. The examiner should provide an opinion concerning the combined effect of the impact of the Veteran's service-connected disabilities (PTSD, lumbar spine disability, left shoulder disability, right shoulder disability, left knee disability, right knee disability, left hand/wrist disability, hypertension, and erectile dysfunction) on his ability to maintain gainful employment for which his education and occupational experience would otherwise qualify him, and provide supporting rationale for this opinion. 4. Thereafter, readjudicate the issues of entitlement to initial increased ratings for lumbar spine disability, bilateral knee disabilities, and left hand/wrist disability, and adjudicate entitlement to a TDIU. If any of the benefits sought on appeal are not granted in full, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran and his representative have the right to submit additional evidence and argument on the 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs